MDS Essentials: Introduction to RAI and MDS Process 1 Faculty Disclosures I have no financial relationships to disclose I have no conflicts of interests to disclose I will not promote any commercial products or services All Planning Committee members, content reviewers, authors, and presenters have been evaluated for conflicts of interest and there are not any to disclose. 1
Educational Activity Completion and CE Disclosure Requirements for Successful Completion 1.25 contact hours will be awarded for this continuing nursing education activity. Criteria for successful completion includes attendance for at least 80% of the entire event. Partial credit may not be awarded. Approval of this continuing education activity does not imply endorsement by AANAC or ANCC (American Nurses Credential Center) of any commercial products or services. American Association of Post-Acute Care Nursing (AAPACN)* is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center s Commission on Accreditation. *AAPACN d/b/a American Association of Nurse Assessment Coordination (AANAC) Learning Objectives 1. Interpret the regulatory mandate for the Minimum Data Set (MDS) 2. Differentiate the various functions of the MDS and their application in nursing homes 3. Describe the components of the Resident Assessment Instrument (RAI) process 4. Demonstrate awareness of key aspects of RAIspecific lingo 5. Explain the process for accurate and timely completion of the MDS 6. Describe how the RAI process is linked to resident care and positive outcomes 4 2
The Minimum Data Set (MDS) Page numbers in the following section indicate the related page number on the Comprehensive MDS item set 5 Minimum Data Set Paper form or software version Must be submitted electronically to national MDS database known as QIES ASAP Core set of resident-specific screening, clinical, and functional status items Screening tool rather than an assessment Complex completion instructions and processes involved 6 3
Minimum Data Set Item Set Set of MDS items required depending on the reason for doing the assessment Nursing Home Comprehensive (NC) item set Contains the most items, used for clinical assessment Subsets of the NC items set Quarterly clinical assessment Discharge assessments Payment assessments Entry and Death records 7 Minimum Data Set Sections A Z: Topics Mandated by Law A. Identification Information B. Hearing, Speech, and Vision C. Cognitive Patterns D. Mood E. Behavior F. Preferences G. Functional Status GG. Functional Abilities and Goals H. Bladder and Bowel I. Active Diagnoses J. Health Conditions K. Swallow/Nutrition L. Oral/Dental M. Skin N. Medications O. Special Treatments P. Physical Restraints and Alarms Q. Participation/Goals V. CAAs/Signatures X. Correction Request Z. Assessment Admin 8 4
Minimum Data Set Items Each section is further divided into specific items Example, Section E, Behavior (p. 11) Item E0100, Potential Indicators of Psychosis Item E0200, Behavioral Symptoms Item E0300, Overall Presence of Behavioral Symptoms Item E0500, Impact on Resident Item E0600, Impact on Others Item E0800, Rejection of Care 9 Minimum Data Set After each item label, list of answer options, such as: OR 10 5
Minimum Data Set Further subdivided into more questions and the answer options: 11 Coding conventions Minimum Data Set Answer Options Check all that apply, such as E0100, or Select code and enter it into box, such as A0310 (p. 1), or Enter ID numbers, such as A0100 (p. 1) or A0600 (p. 2) Key Concept: Read coding instructions for each item 12 6
Resident Assessment Instrument (RAI) 13 Resident Assessment Instrument (RAI) Regulatory Mandate Nursing Home Reform Act of 1987 known as OBRA 87 Standardized, periodic functional status assessments required for all nursing home residents To improve quality of assessment Spotlighting resident-specific problems Targeting care planning Goal: Improving resident care and outcomes 14 7
Resident Assessment Instrument Process of Investigation Parallels nursing process Components Minimum Data Set (MDS) Core set of screening, clinical, and functional status items Care Area Triggers (CATs) MDS items that alert staff to possible problems, needs, strengths Triggers need a complete assessment of the issue that meets standards of practice 15 Resident Assessment Instrument Process of Investigation Care Area Assessments (CAAs) 20 care areas (p. 42) Complete assessments of issues identified by the MDS Identify causes, contributing factors, risk factors related to the problem Care Plan Working action plan that targets specific problems, needs, strengths and preferences including those identified by the MDS and CAAs 16 8
Resident Assessment Instrument Assessment Requirement Comprehensive assessment MDS + CAAs Required at least every 366 days Quarterly assessment Subset of comprehensive assessment Required at least every 92 days Unscheduled comprehensive assessments Significant Change in Status Assessment Significant Correction of Prior Assessment 17 Resident Assessment Instrument Assessment Requirement OBRA-required clinical assessments Required for all residents of nursing home facilities and units in facilities that are Medicare and/or Medicaid certified regardless of payer 18 9
Resident Assessment Instrument (RAI) User s Manual 19 CHAPTER 1 Overview Components of the MDS Layout of the RAI Manual Protecting the Privacy of the MDS Data 20 10
CHAPTER 1: Excerpt (p. 1-7) Monitoring the Quality of Care. MDS assessment data are also used to monitor the quality of care in the nation s nursing homes. MDS-based quality measures (QMs) were developed by researchers to assist: 1. State Survey and Certification staff in identifying potential care problems in a nursing home 2. Nursing home providers with quality improvement activities/efforts 3. Nursing home consumers in understanding the quality of care provided by a nursing home 4. CMS with long-term quality monitoring and program planning. CMS continuously evaluates the usefulness of the QMs, which may be modified in the future to enhance their effectiveness 21 CHAPTER 2 RAI Requirements Responsibility for Completing Assessments Assessment Types and Definitions Required OBRA Assessments Skilled Nursing Facility Medicare Prospective Payment System Assessments Combining Assessments Determining Item Set for an MDS Record 22 11
Chapter 2 Excerpt (pp. 2-6, 2-7) Federal regulatory requirement [42 CFR 483.20(d)] requires nursing homes to maintain all assessments completed within previous 15 months in the active clinical record. Applies to all MDS assessment types regardless of the form of storage (i.e., electronic or hard copy) The 15-month period for maintaining assessment data may not restart with each readmission to the facility 23 Chapter 2 Excerpt (p. 2-22) SIGNIFICANT CHANGE = major decline or improvement in resident s status 1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting ; 2. Impacts more than one area of the resident s health status; and 3. Requires interdisciplinary review and/or revision of care plan 24 12
CHAPTER 3 Item-By-Item Guide to MDS 3.0 Sections A-Z Intent Rationale Coding instructions Examples Tips and special population 25 CHAPTER 3: Excerpt (p. L-1) 26 13
CHAPTER 4 Care Area Assessments Background and rationale Other considerations regarding the use of CAAs When is the RAI not enough? The RAI and Care Planning The Twenty Care Areas 27 CHAPTER 4: Excerpt (p. 4-4) CATs provide a flag for the IDT members, indicating that the triggered care area needs to be assessed more completely prior to making care planning decisions. Further assessment of a triggered care area may identify causes, risk factors, and complications associated with the care area condition. The plan of care then addresses these factors with the goal of promoting the resident s highest practicable level of functioning: (1) improvement where possible or (2) maintenance and prevention of avoidable declines 28 14
CHAPTER 5 Submission and Correction of the MDS Assessment Transmitting MDS Data Validation Edits MDS Correction Policy Correcting MDS records that have not yet been accepted into the QIES ASAP system Correcting MDS records that have been accepted into the QIES ASAP System 29 CHAPTER 5: Excerpt (p. 5-7) It is important to remember that the electronic record submitted to and accepted into the QIES ASAP system is the legal assessment. Corrections made to the electronic record after QIES ASAP acceptance or to the paper copy maintained in the medical record are not recognized as proper corrections. It is the responsibility of the provider to ensure that any corrections made to a record are submitted to the QIES ASAP system in accordance with the MDS Correction Policy 30 15
CHAPTER 6 Medicare Skilled Nursing Facility Prospective Payment System Resource Utilization Groups (RUG-IV) Relationship between assessment and claim RUG-IV 66-Group Model Calculation worksheet SNF PPS Policies Non-compliance with the SNF PPS Schedule 31 CHAPTER 6: Excerpt (6-25) 32 16
Chapter 6 excerpt (p. 6-39) 33 APPENDIX A Glossary Common Acronyms 34 17
APPENDIX A - Glossary excerpt 35 APPENDIX A Common Acronyms Excerpt 36 18
APPENDIX B State Agency and CMS Regional Office State RAI Contact information Located in the Downloads section on CMS s MDS 3.0 RAI Manual Web page: http://www.cms.gov/medicare/quality-initiatives- Patient-Assessment- Instruments/NursingHomeQualityInits/MDS30RAI Manual.html 37 APPENDIX C Care Area Assessment Resources Provided as a courtesy CMS does not endorse or mandate use of this resource Facilities must use resource(s) that are current, evidenced-based or expert-endorsed research and clinical practice guidelines 38 19
Appendix C Example 39 APPENDIX D Interviewing to increase resident voice in MDS Assessment Approaches and techniques to make interviews more effective 40 20
APPENDIX D: Excerpt (p. D-1) Find a quiet, private area where you are not likely to be interrupted or overheard. This is important for several reasons: Background noise should be minimized Some items are personal, and the resident will be more comfortable answering in private. The interviewer is in a better position to respond to issues that arise Decrease available distractions 41 APPENDIX E PHQ-9 Scoring Rules Instructions for administering the BIMS in writing 42 21
APPENDIX E: Excerpt 43 APPENDIX F MDS item Matrix APPENDIX G References APPENDIX H MDS Forms 44 22
Skilled Nursing Facility Prospective Payment System (SNF PPS) 45 SNF Prospective Payment System Regulatory Mandate Federal law mandated switch from cost-based to case-mix reimbursement in 1998 Cost-based = pay facility whatever it spends on the resident s care Case-mix prospective reimbursement = predict cost of care using resident-specific information from MDS and pay facility based on that 46 23
SNF Prospective Payment System Calculating Payment Nursing Home PPS (NP) item set Specific items reflecting resident s acuity used to help quantify the cost of care and services, such as Functional status Functional abilities and goals Health conditions Diagnoses Certain treatments, procedures 47 SNF Prospective Payment System Calculating Payment Completed assessment classifies resident into one of 66 categories known as Resource Utilization Groups (RUGs) Residents in a specific RUG share a common projected cost of care Specific diagnoses, treatments, etc. may be very different A daily payment rate is assigned to each group 48 24
SNF Prospective Payment System Assessment Requirement Law mandates set schedule for SNF PPS assessments to periodically recalculate RUG At approximately day 5, 14, 30, 60, and 90 as long as Medicare Part A is the payer Recalculation of RUG also required offschedule under specific circumstances This schedule is in addition and parallel to the OBRA-required clinical assessments 49 Quality Measures (QMs) 50 25
Quality Measures Intended to reflect quality of care in the nursing home CMS pulls data specific to particular conditions and problems from a national database - examples Rate of UTIs in a facility comes from I2300 Decline in ADLs computed from comparing G0110 data on successive assessments 51 Quality Measures Long list of QMs, scores periodically updated Complex formulas and calculations involved Quality Measures info and User s Manual: https://www.cms.gov/medicare/quality-initiatives- Patient-Assessmentinstruments/NursingHomeQualityInits/NHQIQuality Measures.html 52 26
Quality Measures Publicly Reported QMs Takes facility-specific resident care information directly to consumers To publicize the differences in quality to assist consumers in selection of a facility Nursing Home Compare website www.medicare.gov/nursinghomecompare/ search.html 53 Quality Measures CASPER Reporting System Certification and Survey Provider Enhanced Reporting (CASPER) system Produces QM reports for facility to use in quality improvement efforts Surveyors also use similar list of QMs as part of the survey process 54 27
MDS and Survey Outcomes 55 Survey Outcomes All nursing facilities participating in Medicare and/or Medicaid program are required to have a Life Safety and Standard Annual Survey Additional surveys MDS/Staffing Focus Survey Dementia Focus Survey Complaint Survey Must apply RAI guidelines and understand the Interpretative guidelines found in the State Operations Manual (SOM Appendix PP) 56 28
483.20 RESIDENT ASSESSMENTS (12 TAGS) New Tag Tag Title CFR 483.20(f)(5) F842 Resident Records Identifiable Information 483.70(i)(1)-(5) F635 Admission Physician Orders for Immediate Care 483.20(a) F636 Comprehensive Assessments & Timing 483.20(b)(1)(2)(i)(iii) F637 Comprehensive Assmt After Significant Change 483.20(b)(2)(ii) F638 Quarterly Assessment At Least Every 3 Months 483.20(c) F641 Accuracy of Assessments 483.20(g) F642 Coordination/Certification of Assessment 483.20(h)-(j) F639 Use, Maintain 15 Months of Resident Assessments 483.20(d) F644 Coordination of PASARR and Assessments 483.20(e)(1)(2) F645 PASARR Screening for MD & ID 483.20(k)(1)-(3) F646 MD/ID Significant Change Notification 483.20(k)(4) F640 Encoding/Transmitting Resident Assessment 483.20(f)(1)-(4) 57 Survey Outcomes Interpretive Guidelines F641 483.20(g) Accuracy of Assessment The assessment must accurately reflect the resident s status. Intent 483.20(g) To assure that each resident receives an accurate assessment, reflective of the resident s status at the time of the assessment, by staff that are qualified to assess relevant care areas and knowledgeable about the resident s status, needs, strengths, and areas of decline. Guidelines 483.20(g) Accuracy of assessment means that the appropriate, qualified health professional correctly document the resident s medical, functional, and psychosocial problems and identify resident strengths to maintain or improve medical status, functional abilities, and psychosocial status using the appropriate Resident Assessment Instrument (RAI) (i.e. comprehensive, quarterly, SCSA) 58 29
Achieving MDS Accuracy 59 Achieving MDS Accuracy : THE authoritative resource for all official instructions and information Chapters 1: Overview 2: Timing and scheduling of assessments 3: Item-by-item coding instructions 4: Care Area Assessments and care planning 5: MDS correction policy and transmission 6: RUG-IV calculations 8 Appendices 60 30
Achieving MDS Accuracy Download from CMS website http://www.cms.gov/medicare/quality-initiatives- Patient-Assessment- Instruments/NursingHomeQualityInits/MDS30RAIMan ual.html 61 AANAC s Web Page www.aanac.org/information-resources/mds30/ 62 31
Achieving MDS Accuracy Chapter 3 Process based on the standard format for the instructions for each item Background included for each item Intent/reason for including item on MDS Rationale/purpose for assessing the topic How the topic of the item affects quality of life How assessment of the topic can contribute to appropriate care planning 63 Achieving MDS Accuracy Chapter 3 Item-specific coding instructions Steps for assessment: Sources for information and methods for determining the correct code Specific coding instructions with explanation of individual response options Coding tips/clarifications, issues of note, conditions to be considered Case examples 64 32
B0700. Makes Self Understood Item Rationale Health-related Quality of Life Problems making self understood can be very frustrating for the resident and can contribute to social isolation and mood and behavior disorders Unaddressed communication problems can be inappropriately mistaken for confusion or cognitive impairment 65 B0700. Makes Self Understood Planning for Care Ability to make self understood can be optimized by not rushing the resident, breaking longer questions into parts and waiting for reply, and maintaining eye contact (if appropriate) If a resident has difficulty making self understood: Identify the underlying cause or causes Identify the best methods to facilitate communication for that resident 66 33
B0700. Makes Self Understood Steps for Assessment 1. Assess using the resident s preferred language 2. Interact with resident. Be sure he/she can hear you or have access to his or her preferred method for communication. If the resident seems unable to communicate, offer alternatives such as writing, pointing or using cue cards 3. Observe his/her interactions with others in different settings and circumstances 4. Consult with the primary nurse assistant (over all shifts), if available, the resident s family, and speech-language pathologist 67 B0700. Makes Self Understood Coding Instructions Code 0, understood: if the resident expresses requests and ideas clearly Code 1, usually understood: if the resident has difficulty communicating some words or finishing thoughts but is able if prompted or given time. He or she may have delayed responses or may require some prompting to make self understood Code 2, sometimes understood: if the resident has limited ability but is able to express concrete requests regarding at least basic needs (e.g., food, drink, sleep, toilet) Code 3, rarely or never understood: if, at best, the resident s understanding is limited to staff interpretation of highly individual, resident-specific sounds or body language (e.g., indicated presence of pain or need to toilet) 68 34
Achieving MDS Accuracy Timeframe for Data Collection Based on Assessment Reference Date (ARD), item A2300 (p. 5) Last date for collecting data for the particular MDS Most items look-back 7 days: ARD plus the 6 days preceding it (example next slide) This is the observation period or look-back period (these terms are synonymous) Using the wrong dates or not using every day in the look-back is likely to result in accuracy problems 69 Achieving MDS Accuracy Timeframe for Data Collection Look-back period ARD + 6 previous calendar days 1 2 3 4 5 6 ARD 70 35
Achieving MDS Accuracy Who Takes Part in MDS Process? A registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals (42CFR483.20[h]) It must be an RN who signs item Z0500A certifying completion of all of the MDS items (483.20([I]) This is not verifying accuracy of the items 71 Achieving MDS Accuracy Who Takes Part in MDS Process? The determination of appropriate participation of health professionals must be based on the physical, mental and psychosocial condition of each resident. This includes an appropriate level of involvement of physicians, nurses, rehabilitation therapists, activities professionals, medical social workers, dietitians, and other professionals, such as developmental disabilities specialists, in assessing the resident, and in correcting resident assessments. Involvement of other disciplines is dependent upon resident status and needs (SOM guidelines, F641) 72 36
Achieving MDS Accuracy How is Accuracy Validated? Chart documentation that supports the MDS coding Any surveyor or auditor reading the chart should come up with the same coding decision that the person coding the MDS did 73 74 37
Please continue with MDS Essentials: Sections A, B, C, H and I 75 Questions Please submit questions to: The New to MDS Community 76 38