Nursing Home and Assisted Living Outreach Services

Nursing Home and Assisted Living Outreach Services

Nursing Home and Assisted Living Outreach Services provide mental health services to individuals in Nursing Homes and Assisted Living settings.  Services are provided as a convenience for clients to assist in overcoming barriers to receiving services in one of our Family Clinics, such as mobility challenges.  Outreach services also assist facility staff in effectively helping clients to manage successfully in the least restrictive setting possible.

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Client must have active Medicaid.  May also have Medicaid/Medicare, but we are unable to provide outreach services to those with Medicare only.

Client must be willing to participate in mental health services.

Client must have a valid mental health need.


Referrals from nursing homes are generally made by a social worker at the facility.

Referrals for clients in Assisted Living generally come from New Choice Waiver or Aging Waiver case managers.

Referrals may be sent to :

To make a referral:

Please provide a face sheet, med list, and PASRR (if applicable).

Pre-Admission Screening/Resident Review (PASRR)

PASRR stands for Pre-Admission Screening/ Resident Review and is an assessment that is required by law when a referral is made to a nursing home for an individual who has a mental illness.  This federal law was enacted for three purposes:

    • To ensure that people with mental illnesses in Medicaid-funded nursing homes are being adequately diagnosed and treated
    • To ensure that those with mental illness or a developmental disability only (and no substantial physical problems), are not being warehoused in nursing homes
    • To ensure that the federal government is not paying for long term care of the mentally ill or developmentally disabled in nursing homes that do not meet nursing facility criteria

Meet our PASRR Evaluators.