Patient Review Instrument (PRI)

A Patient Review Instrument (PRI) is a medical evaluation tool that identifies whether or not an individual is eligible for skilled nursing care placement.

As part of the PRI, the "Screen" is required. The PRI and Screen is used to determine the level of care and appropriateness of placement. It will also factor into the reimbursement the facility will receive for providing care. Basically, the rule of thumb is: the more care or complexity of care that the patient requires, the higher the reimbursement the facility will receive from Medicare and Medicaid.

The eight-page PRI form is completed by certified trained evaluators, usually a registered nurse. If the patient is in a hospital the hospital staff will complete the PRI. If your patient is not hospitalized, we can complete the PRI and Screen for you right in your own home. Geriatric care managers, some home health care agencies and nurses are excellent sources to obtain a PRI and Screen. A PRI and Screen is valid in NY State for 90 days - as long as the patient's health status has not changed due to hospitalization. A PRI and Screen can be "updated" every 90 days, as needed.

The "Screen" part of the document validates that the individual qualifies for long term care placement and that community-based services or a lower level of placement is not appropriate. The Screen also identifies individuals who have mental health illnesses, mental retardation or psychiatric histories. If these conditions exist, further assessment is required to assure appropriate placement. Unfortunately, a PRI and Screen does not document Alzheimer or dementia-type illnesses.

The PRI and information documented on this form can rule in or rule out eligibility to nursing facilities and is a crucial component used by professionals advocating for and facilitating nursing home placement. Therefore, it is imperative that we understand what the PRI assesses and how the nursing home staff will evaluate the client for admission.

There may be barriers that hamper our ability for successful placement that are beyond our control such as lack of bed availability especially if the client suffers from dementia or has a medical condition that requires complex nursing care. Another obstacle in placement is that many nursing homes are accepting a majority of short term rehabilitation or sub-acute residents, which places the long term client at a disadvantage, sometimes producing a longer waiting period to secure a bed.

The PRI determines the level of care and staff time necessary to appropriately care for the resident by documenting three indicators. These indicators are: Eating, transferring,and toileting.

A CATEGORY defines a specific medical condition, medical treatment, or if the client is physically and/or verbally aggressive.

When completed, the PRI and Screen is numerically socred. The SCORE reflects how much assistance, independence, or supervision the resident requires with activities of daily living (ADL's) which are: Eating, transferring, and toileting.

A RESOURCE UTILIZATION GROUP (RUG) is attained by combining the Category and Activities of Daily LIving (ADL) score. As stated above, the PRI consists of a numerical score for activities of daily living (ADL's ) and a Category for one, or more, of five health categories which then determines the RUG. This information is translated into a "letter" and a "number" SCORE. Example: PA 3, PD 8.

The client's level of independence is assessed in three areas of daily living - a score is given for each of these functions and added together to obtain a numerical tally of between 3 and 10. This score is based on how the individual was able to perform these tasks 60 percent of the time during the previous four weeks prior to evaluation or since admission to the hospital. An individual with a lower score is more independent than the client with a higher score.

The three areas that are evaluated and scored are:

Considers how the individual consumes food, maintains nutrition, their level of independence with eating, their need for verbal cuing or assistance with opening containers or cutting food. The client is observed to determine their requirements for level of assistance so that the meal will be consumed. If a resident requires being totally fed by staff or if nutrition is given by parental or tube feeding this is documented as well.

Is defined as the act of moving between positions, to/from bed or standing. The individual is evaluated to determine how much physical assistance is required or if transfers are independent. The person may only require intermittent supervision or the assistance of one nurses aid for guidance, safety, steadiness. Physical assistance may be provided on a continual basis, or the resident may be totally dependent, requiring two people to lift and transfer them. Perhaps medical equipment, such as a hoyer lift will be required to facilitate transfers if the person is entirely bed-bound.

Described as the ability to get to and from a toilet, bedpan or commode, ability to transfer on/off the toilet, maintain personal hygiene and appropriately adjust clothing. The evaluator is assessing if the person is continent or incontinent, requires assistance or supervision in toileting activities, is not taken to the bathroom and is diapered or perhaps is incontinent but on a toileting and bowel regime.

Once the ADL is tallied, the individual is assigned one of five special-needs groups, depending on the score and medical conditions:

This qualifier is defined as an individual who requires restorative physical or occupational therapy with the prognosis of improvement. The therapy must be five times per week for at least 2.5 hours per week.

Does not meet the above criteria and has an ADL score of 5 or more and presents with one or more of the following: stage 4 decubitus, comatose, suctioning, nasal gastric feeding, parental feeding, quadriplegia or multiple sclerosis.

Does not qualify for either of the above categories and the individual's ADL score is less than 5 with one of medical condition delineated in the Special Care category OR does not meet the criteria for Special Care and may have one or more of the following conditions: dehydration, internal bleeding, stasis ulcer, daily oxygen, terminal illness, wound care, chemotherapy, blood transfusions, dialysis, urinary tract infection, one or more MD visits per week, or cerebral palsy.

Does not meet the criteria for Clinically Complex and exhibits either verbally, disruptive infantile, socially inappropriate, disruptive or physically aggressive behavior. This behavior must be documented to have occurred one time per week during the past four weeks.

The individual is classified in this group if he or she does not meet the criteria for any of the previous groups. Generally, this is the custodial client who presents a challenge for appropriate placement.

Once all of the scores and groups have been identified, the RUG (Resource Utilization Group) is determined.

Finally, we have the PRI - what is the next step in the process? The PRI is now scrutinized by the nursing home staff, perhaps an admissions screening team, the Director of Nursing Services, the physical and occupational therapist, or even the Medical Director. In some circumstances, the nursing home may require that the client be evaluated by a member of the nursing home staff to assure that the PRI is correct. If the client resides in the community, additional medical information (i.e., chest x-rays, blood work, proof that the client is free from communicable diseases) may be required.

What is documented on the PRI can be difficult to reverse. As previously stated, often the evaluator is interviewing the client for the first time. Due to time constraints the interview may be of short duration with the emphasis on the medical notes in the patient's chart. Timing of the PRI is critical for an accurate portrayal of the hospitalized patient. Frequently, medical conditions can significantly alter the physical and mental status of the individual. Usually, for a number of reasons, the hospital staff is looking to expedite discharge and the family is pressured to accept a nursing facility bed that is not conveniently located or may not have the appropriate level of care the client requires.

From "Demystifying the Patient Review Instrument" by Barbara Wolford
in NYSBA Elder Law Attorney, Winter 2003, Vol. 13, No. 1

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