The Michigan DCH 3877 form is a critical document used to assess individuals for potential mental illness or developmental disabilities prior to their admission to nursing facilities. This form plays a vital role in ensuring that those who may require mental health services receive appropriate evaluations and support. To begin the process of filling out the DCH 3877 form, please click the button below.
The Michigan DCH-3877 form plays a vital role in the healthcare landscape, particularly for individuals seeking admission to nursing facilities. This form is designed to assess potential residents for mental illness and developmental disabilities, ensuring that those who may need mental health services receive appropriate care. It is part of a broader process known as Preadmission Screening (PAS) and Annual Resident Review (ARR). Key updates to the DCH-3877 have been made to align with current standards, including changes in terminology and diagnostic criteria. For instance, the form now reflects the latest edition of the Diagnostic and Statistical Manual of Mental Disorders, ensuring that assessments are based on contemporary understanding of mental health. Additionally, the DCH-3877 requires completion by qualified professionals such as registered nurses or social workers, ensuring that evaluations are conducted by knowledgeable individuals. The form also includes specific screening criteria to help identify individuals who may need further evaluation, thereby facilitating timely access to necessary services. Understanding the DCH-3877 is essential for healthcare providers, as it not only impacts individual care but also complies with Medicaid requirements, ultimately contributing to the well-being of vulnerable populations.
DCH-3877, PREADMISSION SCREENING (PAS)/
ANNUAL RESIDENT REVIEW (ARR)
(Mental Illness/Intellectual Developmental
Disability/Related Conditions Identification)
Michigan Department of Health and Human Services
Level I Screening
(Revised 3-22)
SECTION 1 – LEVEL I SCREENING
PAS
ARR
Change in Condition
Hospital Exempted Discharge
SECTION 2 – PATIENT, LEGAL REPRESENTATIVE AND AGENCY INFORMATION
Patient Name (First, MI, Last)
Date of Birth (MM/DD/YY) Gender
Male
Female
Address (number, street, apt., or lot #)
City
State
Zip Code
County of Residence
Social Security Number Medicaid Beneficiary ID Number Medicare ID Number
Does this patient have a court-appointed guardian
If yes, give Name of Legal Representative
or other legal representative?
No
Yes
County in which the legal representative was appointed
Legal Representative Telephone Number
Referring Agency Name
Telephone Number
Admission Date (actual or proposed)
Nursing Facility Name (proposed or actual)
County Name
Nursing Facility Address (number and street)
Sections 3 and 4 of this form must be completed by a registered nurse, licensed bachelor, or master social worker, licensed professional counselor, psychologist, physician’s assistant, nurse practitioner or a physician.
SECTION 3 – SCREENING CRITERIA (All 6 items must be completed.)
1.
The person has a current diagnosis of
Mental Illness or
Dementia (Check
one or both)
2.
The person has received treatment for
Dementia (within
the past 24 months) (Check one or both)
3.
The person has routinely received one or more prescribed antipsychotic or
antidepressant medications within the last 14 days.
4.There is presenting evidence of mental illness or dementia, including significant disturbances in thought, conduct, emotions, or judgment. Presenting evidence may include, but is not limited to, suicidal ideations, hallucinations, delusions, serious difficulty completing tasks, or serious difficulty interacting with others.
DCH-3877 (Rev. 3-22) Previous edition obsolete.
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5.The person has a diagnosis of an intellectual/developmental disability or a related condition including, but not limited to, epilepsy, autism, or cerebral palsy and this
diagnosis manifested before the age of 22.
6.There is presenting evidence of deficits in intellectual functioning or adaptive behavior which suggests that the person may have an intellectual/developmental disability or a related condition. These deficits appear to have manifested before
the age of 22.
Note: If you checked “Yes” to items 1 and/or 2, checked the word “Mental Illness” and/or “Dementia.”
If yes, please explain
Note: The person screened shall be determined to require a comprehensive Level II OBRA evaluation if any of the above items are "Yes" UNLESS a physician, nurse practitioner or physician’s assistant certifies on form DCH-3878 that the person meets at least one of the exemption criteria.
SECTION 4 - CLINICIAN’S STATEMENT: I certify to the best of my knowledge that the above information is accurate.
Clinician Signature
Date
Name (type or print)
Degree/License
The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.
AUTHORITY: Title XIX of the Social Security Act
COMPLETION: Is voluntary, however, if NOT completed, Medicaid will not reimburse the nursing facility.
DISTRIBUTION: If any answer to items 1 – 6 in SECTION 3 is "Yes", send ONE copy to the local Community Mental Health Services Program (CMHSP), with a copy of form DCH-3878 if an exemption is requested. The nursing facility must retain the original in the patient record and provide a copy to the patient or legal representative.
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PREADMISSION SCREENING (PAS)/ANNUAL RESIDENT REVIEW (ARR)
Mental Illness/Intellectual Developmental Disability/Related Conditions Identification
Instructions for Completing Level I Screening
This form is used to identify prospective and current nursing facility residents who meet the criteria for possible mental illness or intellectual/developmental disability, or a related condition and who may be in need of mental health services.
Sections II and III must be completed by a registered nurse, licensed bachelor, or master social worker, licensed professional counselor, psychologist, physician’s assistant, nurse practitioner or physician.
Preadmission Screening or Hospital Exempted Discharge: The referral source completing the Level I Screening (DCH-3877), must complete and provide a copy to the proposed nursing facility prior to admission. Check the appropriate box in the upper right-hand corner.
Annual Resident Review or Change in Condition: This form must be completed by the nursing facility.
Check the appropriate box in the upper right-hand corner.
Section II – Screening Criteria – All 6 items in this section must be completed. The following provides additional explanation of the items.
1.Mental Illness: A current primary diagnosis of a mental disorder as defined in the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders.
Current Diagnosis means that a clinician has established a diagnosis of a mental disorder within the past 24 months. Do NOT mark “Yes” for an individual cited as having a diagnosis "by history" only.
2.Receipt of treatment for mental illness or dementia within the past 24 months means any of the following: inpatient psychiatric hospitalization; outpatient services such as psychotherapy, day program, or mental health case management; or referral for psychiatric consultation, evaluation, or prescription of psychopharmacological medications.
3.Antidepressant and antipsychotic medications mean any currently prescribed medication classified as an antidepressant or antipsychotic, plus Lithium Carbonate and Lithium Citrate.
4.Presenting evidence means the individual currently manifests symptoms of mental illness or dementia, which suggests the need for further evaluation to establish causal factors, diagnosis, and treatment recommendations. Further evaluation may need to be completed if evidence of suicidal ideation, hallucinations, delusion, serious difficulty completing tasks or serious difficulty interacting with others.
5.Intellectual/Developmental Disability/Related Condition: An individual is considered to have a severe, chronic disability that meets ALL 4 of the following conditions:
a.It is manifested before the person reaches age 22.
b.It is likely to continue indefinitely.
c.It results in substantial functional limitations in 3 or more of the following areas of major life activity: self-care, understanding and use of language, learning, mobility, self-direction, and capacity for independent living.
d.It is attributable to:
•Intellectual/Developmental Disability such that the person has significant subaverage general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period;
•cerebral palsy, epilepsy, autism; or
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•any condition other than mental illness found to be closely related to Intellectual/ Developmental Disability because this condition results in impairment in general intellectual functioning OR adaptive behavior similar to that of persons with Intellectual/Developmental Disability and requires treatment or services similar to those required for these persons.
6.Presenting evidence means the individual manifests deficits in intellectual functioning or adaptive behavior, which suggests the need for further evaluation to determine the presence of a developmental disability, causal factors, and treatment recommendations. These deficits appear to have manifested before the age of 22.
Note: When there are one or more "Yes" answers to items 1 – 6 under SECTION II, complete form DCH-3878, Mental Illness/Intellectual/Developmental Disability/Related Condition Exemption Criteria Certification only if the referring agency is seeking to establish exemption criteria for a dementia, state of coma, or hospital exempted discharge.
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Filling out the Michigan DCH-3877 form involves providing specific information about the patient and their mental health status. It is essential to ensure all sections are completed accurately, as this information may impact the patient’s eligibility for certain services. Here are the steps to fill out the form:
After completing the form, ensure that it is submitted to the appropriate parties as outlined in the instructions. Retain a copy for your records, and provide copies to the necessary agencies and the patient or their representative.
The Michigan DCH-3877 form is designed to identify individuals who may have mental illness or developmental disabilities. It is primarily used for prospective and current residents of nursing facilities to assess their need for mental health services. This assessment is crucial for ensuring that individuals receive appropriate care and support based on their needs.
The DCH-3877 form must be completed by qualified professionals, including registered nurses, certified or registered social workers, psychologists, physician assistants, or physicians. This requirement ensures that the assessment is conducted by someone with the necessary expertise to evaluate mental health and developmental issues accurately.
The form should be completed during two key situations: during the preadmission screening process when an individual is being admitted to a nursing facility and during the annual resident review for those already in a facility. Completing the form at these times helps to ensure that all residents receive the appropriate evaluations and services.
The DCH-3877 form consists of several sections, including:
Each section plays a vital role in gathering comprehensive information about the individual's mental health status and needs.
If any of the items in the screening criteria are answered "YES," the individual may require a more comprehensive Level II screening. In such cases, the DCH-3878 form must also be completed to establish exemption criteria, if applicable. This process helps ensure that individuals receive the necessary evaluations and services tailored to their needs.
Providers can order the DCH-3877 form from the Michigan Department of Community Health, specifically from the Forms Distribution office. Alternatively, the form is available for download from the MDCH website. This accessibility ensures that providers can easily obtain the forms needed for their assessments.
The recent revisions to the DCH-3877 form included several important updates:
These changes reflect the ongoing efforts to improve the clarity and effectiveness of the assessment process.
Once completed, the original DCH-3877 form should be retained in the patient's record at the nursing facility. Additionally, a copy must be sent to the local Community Mental Health Services Program (CMHSP). If applicable, a copy of the DCH-3878 form should also be attached. This distribution ensures that all relevant parties are informed about the individual's needs and care requirements.
Inaccurate Patient Information: Many individuals fail to provide accurate or complete patient details, such as the full name, date of birth, or Social Security number. Missing or incorrect information can delay processing and lead to complications in care.
Improper Signature: The clinician's signature must be included. Some forget to sign or fail to provide the necessary credentials. Without a valid signature, the form may be rejected, requiring resubmission.
Neglecting Screening Criteria: Respondents often overlook the importance of answering all screening criteria accurately. Each question must be addressed, and failing to do so can result in an incomplete assessment of the patient's needs.
Submitting Without Review: Submitting the form without a thorough review is a common mistake. Errors can go unnoticed, leading to potential delays in services. A careful review ensures all necessary information is correct and complete.
The Michigan DCH 3877 form is an essential document used in the preadmission screening process for individuals seeking admission to nursing facilities. It identifies those who may require mental health services due to mental illness or developmental disabilities. Several other forms and documents often accompany the DCH 3877 to ensure comprehensive evaluation and compliance with regulations. Below is a list of related forms that may be necessary in conjunction with the DCH 3877.
Understanding and preparing these forms alongside the DCH 3877 can streamline the admission process and ensure compliance with state regulations. It is crucial for providers to be familiar with these documents to facilitate appropriate care and support for patients entering nursing facilities.
The DCH-3877 form is similar to the DCH-3878 form, which is used for certifying exemption criteria related to mental illness and developmental disabilities. Both forms are part of the Preadmission Screening and Annual Resident Review process. While the DCH-3877 identifies individuals who may require further evaluation, the DCH-3878 is specifically for certifying whether a patient meets certain exemption criteria, such as being in a coma or having dementia. This distinction is crucial for determining the next steps in care and services.
Another related document is the CMS-1500 form, commonly used for billing purposes in healthcare. Like the DCH-3877, the CMS-1500 requires accurate patient information and details regarding the services provided. Both forms must be completed by qualified professionals, ensuring that the information is reliable and meets regulatory standards. However, while the DCH-3877 focuses on screening for mental health needs, the CMS-1500 is primarily concerned with payment and reimbursement processes.
The DCH-3877 also bears similarities to the MDS (Minimum Data Set) assessment used in nursing facilities. Both documents aim to assess patient needs and care requirements, ensuring that individuals receive appropriate services. The MDS includes a broader scope of health and functional status, while the DCH-3877 specifically targets mental health and developmental disability criteria. Each form plays a vital role in the comprehensive care planning process for residents.
The PASRR Level II form is another document that relates closely to the DCH-3877. This form is used when an individual is identified as needing a more in-depth evaluation following the initial screening. Both forms are part of the same regulatory framework designed to ensure that individuals with mental health issues receive necessary assessments. The PASRR Level II form delves deeper into the individual's needs, while the DCH-3877 serves as the initial screening tool.
The Medicaid Application form is also comparable to the DCH-3877 in that both require detailed patient information and eligibility criteria. The Medicaid Application assesses financial eligibility for services, while the DCH-3877 evaluates mental health needs. Both forms are crucial for determining access to necessary healthcare services, ensuring that individuals receive the support they require.
Additionally, the Mental Health Assessment form serves a similar purpose to the DCH-3877. This document is used to evaluate an individual's mental health status and treatment needs. Like the DCH-3877, it must be completed by qualified professionals and includes specific criteria to assess mental health conditions. Both forms aim to identify individuals who may benefit from mental health services and facilitate appropriate care interventions.
Lastly, the Client Intake Form is akin to the DCH-3877, as it gathers essential information about a patient’s background and needs. This form is often used in various healthcare settings to initiate the care process. While the Client Intake Form may cover a broader range of health concerns, the DCH-3877 focuses specifically on mental illness and developmental disabilities, ensuring targeted support for those populations.
When filling out the Michigan DCH-3877 form, there are several important dos and don'ts to keep in mind. Adhering to these guidelines can help ensure that the form is completed correctly and efficiently.
Understanding the Michigan DCH 3877 form is crucial for healthcare providers involved in the screening of potential nursing facility residents. However, several misconceptions can lead to confusion. Here are eight common misconceptions about the DCH 3877 form, along with clarifications for each:
This is incorrect. The DCH 3877 is used to identify individuals who may require further evaluation for mental illness or developmental disabilities, even if they do not yet have a formal diagnosis.
While physicians play an important role, the form can also be completed by registered nurses, certified social workers, psychologists, or physician assistants, broadening the pool of qualified individuals who can assist in the screening process.
Even if a patient has a diagnosis, the DCH 3877 form is still essential. It serves as a formal mechanism to assess the need for mental health services and ensure that appropriate care is provided.
Completion of the form is required for Medicaid reimbursement, but it does not guarantee it. The form must be filled out accurately and the criteria met for reimbursement to occur.
This form is also utilized for annual resident reviews. It is not limited to admissions; it plays a role in ongoing assessments of residents in nursing facilities.
All screening criteria outlined in the DCH 3877 must be answered. If any of the criteria indicate a potential issue, further evaluation is required.
This form is still relevant and actively used in Michigan. Revisions were made to ensure it reflects current standards and practices, so providers should use the latest version.
Providers are required to retain the original form in the patient’s record. This is crucial for documentation and future reference, especially for ongoing care and assessments.
By addressing these misconceptions, providers can better navigate the requirements of the DCH 3877 form and ensure that they are delivering the best possible care to their patients.
Key Takeaways for Filling Out and Using the Michigan DCH-3877 Form