MDS 3.0 Just the Basics Presented by: Cathie Coleman NHA, RAC-CT, ACC
The RAI Process Helps staff assess a resident s strengths and needs, leading to an individualized care plan Assists staff with evaluating goal achievement and revising care plans Promotes a holistic view of residents as individuals for whom quality of life and quality of care are mutually significant and necessary Interdisciplinary use of the RAI promotes this emphasis on quality of care and quality of life
The RAI Process While we recognize that there are often unavoidable declines, particularly in the last stages of life, all necessary resources and disciplines must be used to ensure that residents achieve the highest level of functioning possible (quality of care) and maintain their sense of individuality (quality of life)
What is the RAI? A facility must make a comprehensive assessment of a resident s needs, using that resident assessment instrument (RAI) specified by the state Resident Assessment Instrument the facility must conduct initially and periodically an assessment that is: Comprehensive Accurate Standardized Reproducible assessment of each resident s functional capacity
RAI Process Evaluate MDS Care Plans CATs CAAs
RAI Process Components Minimum Data Set (MDS) Core set of standardized screening, clinical, physical, functional, and psychosocial status items that form the foundation of the comprehensive, functional status assessment
Assessments Each set of assessments is created for different purposes and are completed on different timetables. Likewise, the data generated from these assessments is used differently depending on the type(s) of assessment conducted.
Types of Assessment Assessment designated to meet two distinct and separate requirements: OBRA--Omnibus Budget Reconciliation Act of 87 PPS Prospective Payment System for Medicare Part A
OBRA ASSESSMENTS Admission Assessments Comprehensive assessment: Includes MDS plus care area assessments (CAA) ARD (assessment reference date) must be set before the 14 th day of admission The day of admission is counted as day 1 Must be completed by day 14
OBRA Assessments Annual Assessment Comprehensive assessment: Includes MDS plus CAAs ARD must be set within 366 days of the ARD from the prior OBRA comprehensive assessment ARD must be set within 92 days of the prior OBRA assessment Completed on or before the 14 th day after the ARD
OBRA Assessments Significant Change in Status Assessment Comprehensive assessment: Includes MDS plus CAAs Required when a terminally ill resident enrolls in a hospice program Required when a resident receiving hospice care revokes hospice privileges Final decision based on judgment of the interdisciplinary team (IDT) The ARD must be within 14 days after determination that a significant change occurred
OBRA Assessments Quarterly Assessment Not a comprehensive assessment: Includes a subset of MDS items A review of the most current comprehensive assessment CAAs are not required The ARD must be set on or before day 92 after the prior OBRA assessment Must be completed within 14 days after the ARD
OBRA Assessments Entry Record---OBRA Tracking record: Includes a subset of MDS items CAAs are not required Two types: 1. Admission 2. Reentry May not be combined with an assessment Required every time a person is admitted or readmitted to a nursing home Completed 7 days after admission or reentry
OBRA Assessments Discharge Assessments: OBRA tracking record: Includes a subset of MDS items CAAs are not required Two types: 1. Discharge return anticipated 2. Discharge return not anticipated
Discharge Assessment Must be completed when the resident has a hospital observation stay longer than 24 hrs Must be completed when the resident is discharged from the facility Must be completed when the resident is admitted to an acute care hospital Will determine the OBRA and/or PPS assessment required when the resident returns to the facility Completed within 14 days after discharge date
OBRA Assessments Death in Facility record OBRA tracking record: Includes a subset of MDS items CAAs are not required May not be combined with any other assessment type Must be completed within 14 days after the resident s death
PPS Assessments Medicare five-day assessment: The first Medicare assessment completed Conducted when resident is: First admitted for a SNF Part A stay Readmitted following discharge---return not anticipated ARD: 1-5---Grace days: 6-8 Pays for days 1-14 of a Medicare Part A stay
PPS Assessments Readmission/Return assessment: Conducted just as a Medicare five-day assessment Exceptions specific for readmission/return assessments Discharged---return anticipated to the hospital during a SNF Part A stay Readmitted to the SNF continuing to require and receive SNF Part A services
PPS Assessments Medicare 14-day assessment: ARD: 13-14 Grace days: 15-18 Pays for days 15 through 30
PPS Assessments Medicare 30 Day assessment: ARD: 27-29 Grace days: 30-33 Pays for days 31 through 60
PPS Assessments Medicare 60 day assessments: ARD: 57-59 Grace days: 60-63 Pays for days 61 through 90
PPS Assessments Medicare 90 day assessments: ARD days 87-89 Grace days: 90-93 Pays for days 91 through 100
RAI Process Components Care Area Triggers (CATs) Specific MDS responses (flags) that either alone or in a combination identify residents who have or are at risk for developing functional problems and require further assessment in 20 care areas
Types of CAT Triggers 1. Potential Problems Warrants Additional Assessment Example---presence of a pressure ulcer or use of a trunk restraint, both of which indicate the need for further review to determine what type of intervention is appropriate or whether underlying behavioral symptoms can be minimized or eliminated by treatment of the underlying cause (e.g. agitation or depression)
Types of CAT Triggers 2. Broad screening Triggers A big net with a fair number of false positives Examples include factors related to delirium or dehydration. At the same time, experience has shown that many residents who have these problems were not identified prior to having triggered for review. Thus careful consideration of these triggered conditions is warranted
Types of CAT Triggers 3. Prevention of Problems Identifies risk Examples include risk factors for falling or developing a pressure ulcer
Types of CAT Triggers 4. Rehabilitation Potential Identifies rehab potential and strengths For example, MDS item responses indicating, Resident believes he or she is capable of increased independence in a least some ADLs may focus the assessment and care plan on functional areas most important to the resident or on the area with the highest potential for improvement
CAAs Authority and Approach OBRA 1987 care mandate Holistic approach Expected to involve the interdisciplinary team Facilities should experiment and be creative to establish desired outcome
RAI Process Components Care Area Assessments (CAAs) Identify areas of concern That warrant intervention Impact on resident function If there is identified risk of decline, then minimize decline to avoid functional complications Palliative care
20 Care Areas General Information List of MDS response items Team still decides whether or not to care plan No specific toll mandated as long as tools are current or evidence-based or expert-endorsed research, clinical practice guidelines and resources Resources to be available upon request
CAAs Documentation must include: Nature of problem Underlying causes Contributing factors Complications Risk Factors Justification Referrals Sources
Step 1: Triggering the CAAs Links assessment areas to other assessment areas and to protocols Captures potential problems and screening issues Team still deems if a real problem exists Automated process saves time and lends easily to individual care plans
Step 2: Assessment of Triggered Condition In-depth resident-specific assessment Information gleaned used to supplement clinical judgment and stimulate creative thinking
Step 3: Decision-making and Documentation Team decision to care plan Documentation: Why address or not address What conditions effect ADLs Why is resident at risk and that improvement is possible or decline minimized How could resident benefit from consultation
And Don t Forget If the decision is not to care plan, document why you determined that the triggered condition is not a problem Also documentation and findings can appear anywhere in the medical record Location must be identified in CAA Summary (Section V) Facilities are responsible for assessing areas that are relevant, regardless of whether the affected areas are included in the RAI (e.g. orthostatic hypotension)
Elaborate and cumbersome Process???? Completely unnecessary KISS Method: KEEP IT SIMPLE STUPID
RAI Process Components CAA Summary (Section V) Provides location for documentation of triggered care areas and decisions whether to proceed to care planning or not
Comprehensive Care Plans The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident s medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment The plan of care must deal with the relationship of items or services ordered to be provided (or withheld) to the facility s responsibility for fulfilling other requirements in these regulations
A Comprehensive Care Plan must be: Developed within 7 days after the completion of the comprehensive assessment Prepared by an interdisciplinary team, that includes the attending physician, a nurse responsible for the resident, and other appropriate staff in disciplines as determined by the resident s needs, and to the extent practicable, the participation of the resident, the resident s family or the resident s legal representative Periodically reviewed and revised by a team of qualified persons after each assessment
Care Plans Must Be On-going Focused Problem Dated Outcome-Oriented Assign Responsibility Set priorities
Care Planning Areas Functional Status Rehabilitation/Restorative Issues Health Maintenance Daily Care Needs/ Risks Discharge Potential Strengths
Care Plans are Important Links assessment to: Standards of care Reimbursement Successful survey information Provider a blueprint for action that includes: Identification of problems Specific, reasonable and measurable goals A framework for action including deadlines for achievement
Acute Care Plan Problems Short term issues May correspond with course of antibiotics Mechanism to determine when to review is needed Responsibility needs to clear Usually only 30 day review
Chronic Care Plan Problems Ongoing problems May correspond to CAA categories Target dates usually correspond with quarterly MDS/Care Conference
Care Plan Components Problem / Need Statement---always resident related and specific---not a diagnosis but can be related to diagnosis Goals always resident related Interventions / Approaches
Goals Achievable Measurable Realistic Target Dates Resident-Centered Flow from the Problem Statement
Approaches/Interventions Instructions for care Staff behavior Related to staff, volunteers, family, friends The who, what, where, when and how to assist the residents in achieving their goal
Problem Identification Process Assess evaluate Investigate implement Care plan
RAI Process Components Utilization Guidelines Provide instructions for when and how to use the RAI Include instructions for completion of RAI as well as structured frameworks for synthesizing MDS and other clinical information
Questions? Cathie Coleman NHA, RAC-CT, ACC Email: cathclmn@aol.com Phone: 248-437-7450