The purpose of this program is to ensure that nursing home placements for DMHAS clients (or DMHAS-eligible clients) are necessary, appropriate, and safe.  Preadmission Screening Resident Review (PASRR) is an integral part of the program.   

The program focuses on two specific goals: (1) Reducing inappropriate admissions of DMHAS clients to nursing homes; and (2) Transitioning nursing home residents with a mental illness back to the community with support services. To accomplish these goals, DMHAS funds Nurse Clinicians, and Case Managers located at agencies identified below, who work directly with community providers, nursing home staff, and hospital discharge planners. There is ongoing collaboration with the state's Money Follows the Person Demonstration Project and the Medicaid Home and Community-based Waiver for Persons with Serious Mental Illness (WISE) Program.

• Diverting individuals from emergency rooms and avoiding unnecessary acute care hospitalizations for psychiatric reasons
• Transitioning individuals living in nursing facilities back into the community
• Providing outreach, education and  engagement regarding community based options to individuals residing in nursing facilities with serious and persistent mental illness
• Providing consultation to professional staff regarding Behavioral Health options to nursing facility discharge teams
• Liaison support to DMHAS LMHAs and individuals who are in the process of diversion/transition as well with DSS Money Follows the Person and Mental Health Waiver staff
• Assessment for Level of care needs and determining the most appropriate community based option i.e. skilled nursing facility or State Hospital bed
• Maintaining an updated, working knowledge of community based resources for individuals living with mental illness and substance use issues
• Diabetes education regarding self-administration and healthy lifestyle choices
• Crisis intervention and consultation with other providers and local police
• Education regarding Mindfulness-Based alternative interventions to reduce psychiatric symptoms and cravings for substances
• Substance abuse counseling and resource education and connection
• Assistance with linkage and support for MAT