Countdown to MDS Section GG: Collaboration Between Nursing and Therapy

Countdown to MDS Section GG: Collaboration Between Nursing and Therapy Presented in Collaboration with NASL: Joanne M. Wisely, MA CCC/SLP, VP Legislative Advocacy Genesis Rehab Services/Respiratory Health Services Jane Moffett, RN Executive Vice-President, Casamba Amy Franklin RN, RAC-MT, DNS-MT, QCP-MT AANAC Curriculum Development Specialist 1 Copyright 2016 Faculty Disclosure I have no financial relationships to disclose I have no conflicts of interests to disclose I will not promote any commercial products or services 2 Copyright 2016 1

Requirements for Successful Completion 1.0 contact hour 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 3 Copyright 2016 Learning Objectives Detail tasks that facility management need to consider in preparation for the October 1 deadline. Explain how implementation of the new section GG will impact workflow and IDT team collaboration Describe the best practices and considerations around who from the IDT team should complete section GG 4 Copyright 2016 2

Section GG Functional Abilities and Goals Starts 10-1-16 5 Copyright 2016 IMPACT ACT 2014 Must have a means of comparing, measuring outcomes and a systematic means of data collection of the Medicare Beneficiary across all Post Acute Care (PAC) settings: Skilled Nursing Homes Inpatient Rehab Facility Long-term Care Hospital Home Health Care 6 Copyright 2016 3

Task for the Staff Education Administrator Integration Software Rehab Discharge Planning Interdisciplinary Team (IDT) Direct Care Staff Business Office Manager Medical Records Point Of Care MDS Rehab Orders Screens not for GG Pre-Admit-Rehab/Medical By 3 Social Work 7 Copyright 2016 A2400. Medicare Stay Dates Dictate When To Code Section GG Look-Back Is Three s 8 Copyright 2016 4

GG0130 & GG0170 Admission & Discharge Goal or Discharge Performance Helper Assistance Only required because resident's performance is unsafe or of poor quality Score according to amount of assistance provided Activities may be completed with or without assistive devices Does not include: Family, Hospice, Private Duty, Student Nurses/Nurses Aide 9 Copyright 2016 GG0130 & GG0170 Admission & Discharge Goal or Discharge Performance Usual Performance Over the course of three days Compare prior function from the current illness or injury or exacerbation Think about each Self-Care/Mobility item as separate when completing Admission and Discharge Performance and Discharge Goal Established through IDT collaboration 10 Copyright 2016 5

New: Safety & Quality of Performance Scale 11 Copyright 2016 6-Point Rating Scale Code 06 Independent Resident completes the activity by him/herself with no assistance from a helper. Code 05 Setup or Clean-Up Assistance Helper SETS UP or CLEANS UP; resident completes activity. Helper assists only prior to or following the activity. Code 04 Supervision or touching assistance Helper provides VERBAL CUES or TOUCHING/STEADYING assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently. 12 Copyright 2016 6

6-Point Rating Scale Code 03 Partial/Moderate Assistance Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort Code 02 Substantial/Maximal Assistance Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort. Code 01 Dependent Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity. 13 Copyright 2016 If Activity was not Attempted Code 07 Resident Refused If the resident refused to complete the activity. Code 09 Not Applicable If the resident did not perform this activity prior to the current illness, exacerbation, or injury. Code 88 Not attempted due to medical condition or safety concerns 14 Copyright 2016 7

Section GG: Functional Abilities, Goals and Discharge Performance GG130.A Eating The ability to use suitable utensils to bring food to the mouth and swallow food Once the meal is presented on a table/tray Includes modified food consistency GG130.B Oral Hygiene The ability to use suitable items to clean teeth Dentures: The ability to remove and replace from and to the mouth and manage equipment for soaking and rinsing them. GG130.C Toileting Hygiene The ability to maintain perineal hygiene, Adjust clothes before and after using the toilet, commode, bedpan, or urinal. If managing an ostomy, include wiping the opening but not managing equipment GG0130. Self-Care 15 Copyright 2016 Section GG: Functional Abilities, Goals and Discharge Performance GG0170.B Sit To Lying The ability to move from sitting on side of bed to lying flat on the bed GG0170.C Lying To Sitting On Side Of Bed The ability to safely move from lying on the back to sitting on the side of the bed With feet flat on the floor And with no back support GG0170.D Sit To Stand The ability to safely come to a standing position from sitting in a chair Or on the side of the bed GG0170. Mobility 16 Copyright 2016 8

Section GG: Functional Abilities, Goals and Discharge Performance GG0170.E Chair/Bed-to-Chair Transfer The ability to safely transfer to and from a bed to a chair (or wheelchair) GG0170.F Toilet Transfer The ability to safely get on and off a toilet or commode GG0170. Mobility 17 Copyright 2016 Section GG: Functional Abilities, Goals and Discharge Performance GG0170. J Walk 50 Feet With 2 Turns Once standing, the ability to walk at least 50 feet and make two turns GG0170.K Walk 150 Feet Once standing, the ability to walk at least 150 feet in a corridor or similar space GG0170.R Wheel 50 Feet With 2 Turns Once seated in wheelchair/scoot er (manual or motorized), can wheel at least 50 feet and make two turns GG0170.S Wheel 150 Feet Once seated in wheelchair/ scooter (manual or motorized), can wheel at least 150 feet in a corridor or similar space GG0170. Mobility 18 Copyright 2016 9

Helper Effort 2 Helpers Less Than Half More Than Half 01. Dependent Even if the resident participates Following behind with a w/c while the other helper is holding the gait belt 03. Partial/ Moderate Assist Resident performed more than half May Lift or Hold or Support Trunk or Limbs 04. Substantial/ Maximal Assist Resident performed less than half May Lift or Hold or Support Trunk or Limbs 19 Copyright 2016 Refusal vs. Medical & or Safety 20 Copyright 2016 10

THE IDT MAKING IT HAPPEN 21 Copyright 2016 MDS SECTION GG COMPLETION Does Use of a Six Point Scale Capture Usual performance of the patient Use a three day lookback Require IDT collaboration Including Rehab, as appropriate Does NOT Use the Rule of Three Use a Seven Look back Require Rehab evaluation & goals Require Rehab days and minutes 22 Copyright 2016 11

SECTION GG COLLABORATION IDT Nursing All Shifts Admission and Discharge Assessments 24/3d Routine Observations (Med Pass, Treatments, etc) COLLABORATION = USUAL PERFORMANCE 24/3d Baseline @ Admission WITH Goal for Discharge 24/3d Status @ Discharge Direct Care -All Shifts Overall Mobility Bathing, Dressing Eating Rehab Eval with Goal(s) D/C Status Mobility Self Care 23 Copyright 2016 SECTION GG COMPLETION How Does It Happen? Direct Care Staff Rehab Nursing Team Leader &/or NAC Social Service 24 Copyright 2016 12

SECTION GG COMPLETION How Does It Happen? CONSIDERATIONS Efficient & Accurate Processes How to meet 3 day deadlines? Team members always available? Team members educated to Usual vs. Rule of Three? Nursing documentation addresses mobility & self-care? Evaluation info from Rehab? OPTIONS Change or Create. MDS Information Capture? Stand Up Meeting? Shift Change? Medical Record Documentation? Restorative Program Documentation? Team Meetings? Electronic Communication? Data Capture Worksheet? www.aanac.org/section-gg-resources 25 Copyright 2016 All Data Used to SET THE GOAL Nursing Direct Care Rehab Social Service Assessment Findings Performance in Daily Activities Evaluation of Mobility Discharge Plan Med Pass Observations Mobility Performance with or without devices Evaluation of Self Care Home Health Care Treatment Observations Overall Need for a Helper Therapy Goal(s) for Mobility and/or Self-Care Community Discharge or Remain at Facility 26 Copyright 2016 13

SETTING THE GOAL: Scenario Nursing Overall Observations - 1, 2 & 3 Unable to complete meals without feeder assistance Assistance needed to stand and unable to walk Needs reminders and cues to follow direction Direct Care Observations- 1, 2 & 3 Needs one person assistance to transfer from bed to wheelchair Needs helper to push wheelchair Needs assistance to clean self and adjust clothes when toileting. www.aanac.org/section-gg-resources 27 Copyright 2016 SETTING THE GOAL: Scenarios PT Evaluation & Treatment on 2 & 3 OT & SLP: no eval orders on admission PT Evaluation and 1 treatment Chair to bed transfer & toilet transfer assist of two Sit to stand assist of one PT Goals Sit to stand for 60 seconds: Independent Chair to bed transfer & toilet transfer: Supervision with verbal cues 28 Copyright 2016 14

SECTION GG Setting the Goal Considerations A. What is reported as the usual performance on 1? 2? 3? B. Is the performance reported on the PT evaluation the same or different from what other caregivers report? Do A & B provide an admission baseline for this patient? Yes = Continue to Item C No = Review findings and consult with Interdisciplinary Team 29 Copyright 2016 SECTION GG Setting the Goal C. Did the patient state in the social service notes a preference and/or goal for discharge? Yes/No D. Is the patient motivated to achieve greater mobility and independence? Yes/No E. Does the patient appear to have potential for increased mobility and more independent self care? Yes/No What s the Goal? 30 Copyright 2016 15

SETTING THE GOAL WITH REHAB Section GG Goal Chair to Bed Transfer with Supervision Nursing Assessment Caregiver Observations Rehab Goal Nursing Direct Care Staff Rehab 31 Copyright 2016 SETTING THE GOAL WITHOUT REHAB Section GG Goal Chair to Bed Transfer with Assist of One Nursing Assessment Caregiver Observations X Rehab Goal Nursing Direct Care Staff X Rehab 32 Copyright 2016 16

SAME PATIENT & DIFFERENT GOALS? Reality. Rehab is not always ordered on admission Historically, Nursing Assessments do not set goals Collaboration and Cooperation Helps Do you have systems in place for rehab admission orders? Do you currently have prompt and effective communication with Rehab staff? When the Rehab Director is away, is there an designee named? Do you have a Restorative Nurse Coordinator who could help establish goals? Could you plan to practice setting Discharge Goals with Rehab before October 1? 33 Copyright 2016 34 Copyright 2016 17

Who Contributes? Therapy Nursing Team Observ. Patient & Family RNAC completes the section with input From the resident, family, direct care staff and medical record to determine the Usual performance during the 3 day observation period 35 Copyright 2016 Considerations on Collecting GG Rationale New Observation Period Different Definition Goal Setting New DC Assessment 36 Copyright 2016 18

Observation Period for GG vs G Section G 1 2 3 4 5 6 7 8 Section GG 1 2 3 4 5 6 7 8 37 Copyright 2016 Don t go back and modify this section when completing other items. It s expected that this section will be scored differently than Section G, after all both the definition and observation period are different! Medicare 1 Nursing & SNF Staff Initiate Admission assessment Observe self-care and mobility performance Notify rehab of orders Rehab Eval/Treat Medicare 2 Nursing & SNF Staff Observe self-care and mobility performance Rehab Eval/Treat Medicare 3 Nursing & SNF Staff Observe self-care and mobility performance Rehab Eval/Treat MDS Coordinator RNAC Review and discuss with team to confirm final Usual score for each item Decide on appropriate Goal(s) Complete MDS Section GG Document rationale When Do We Think GG? 38 Copyright 2016 19

Check Track Observe Discuss Check census to determine if a resident was admitted or discharged since the last IDT discussion It s even more important now to know if someone had an early planned discharge Track all residents during their 3-day assessment period First 3 days and last 3 days of Medicare coverage Observe and document the resident s USUAL self-care and mobility status during the observation period based on direct observation resident s self-report family report (but not what family did) direct care staff medical record Discuss Residents in an observation period for GG daily at stand up or IDT meetings Collect information about self-care and mobility during the past 24 hours Getting from 1 to 3 39 Copyright 2016 These items map back to the definitions 40 Copyright 2016 20

An explanation of the scoring is displayed here for quick reference 41 Copyright 2016 Remember use these codes instead of dashes if the resident refused code 07 if the item is not applicable code 09 if the activity was not attempted due to medical condition or safety concerns code 88 42 Copyright 2016 21

The definition of each item is here 43 Copyright 2016 Beginning on 1 of Medicare, collect information on each shift of the Usual performance based on direct observation resident s self-report family report direct care staff medical record 44 Copyright 2016 22

On 3, review and decide on each value AND complete section GG 45 Copyright 2016 Section GG Discharge Last 72 hours on Medicare A Team Consults Which team members will be able to contribute during the three day observation period (last three days of Medicare) Last 48 Hours on Medicare A Nursing & SNF Staff - Initiates discharge assessment - Review of current status to determine usual Rehab - Reviews end of care status to prepare for team collaboration Last 24 hours on Medicare A Discharge from Medicare MDS Coordinator/RNAC - Completes MDS Section GG Nursing & SNF Staff - Completes discharge assessment Rehab - Completes Therapy DC documentation Facility Designees - Consolidate information found during the observation period - Collaborate to determine final content/scores 46 Copyright 2016 23

This area is completed during the last 3 days of the Medicare stay 47 Copyright 2016 Template Note for Usual Performance Section GG completed today. Based on chart review, direct observation and discussion with direct care staff, patient and family over the observation period the following are the usual performance for self-care and mobility: xxx is the usual performance for Eating xxx is the usual performance for Oral hygiene xxx is the usual performance for Sit to lying xxx is the usual performance for Lying to sitting on the side of bed xxx is the usual performance for Sit to stand xxx is the usual performance for Chair/bed-to-chair transfer xxx is the usual performance for Toilet transfer xxx is the usual performance for Walk 50 ft with 2 turns xxx is the usual performance for Walk 150 ft xxx is the usual performance for Wheel 50 ft with 2 turns xxx is the usual performance for Wheel 150 ft 48 Copyright 2016 24

Not Assessed 7/19/2016 Sample Note Section GG completed today. Based on chart review, direct observation and discussion with direct care staff, patient and family over the observation period the following are the usual performance for self-care and mobility: Partial/moderate assistance for Eating Partial/moderate assistance for Oral hygiene Substantial/maximal assistance for Sit to lying Substantial/maximal assistance for Lying to sitting on the side of bed Dependent for Sit to stand Dependent for Chair/bed-to-chair transfer Dependent for Toilet transfer 49 Copyright 2016 Charting for Items That are Not Assessed These items were not assessed because the patient refused: These items were not attempted due to medical or safety reasons: These items were not assessed because they are not applicable: Be sure to address items that you will code with 07, 09 or 88 in your note. Be sure to use these codes instead of dashes. 50 Copyright 2016 25

Sample Note Not addressed Patient is short of breath on exertion with recent discharge from acute setting due to an exacerbation of CHF complicated with diabetes. The following items were not assessed due to unstable medical condition: Walk 50 ft with 2 turns Walk 150 ft Wheel 50 ft with 2 turns Wheel 150 ft 51 Copyright 2016 Sample Note for Goal(s) Expected to Improve The IDT team has determined that the resident is expected to make gains in function by discharge in the following areas Not Expected to Improve The IDT team has determined that the medically complex resident is not expected to progress to a higher level of functioning during the SNF Medicare Part A stay Expected to Decline The IDT team has determined that skilled services may slow, but not prevent, the decline of function and has set goals appropriately 52 Copyright 2016 26

Sample Goal Note The IDT team has determined that the as the CHF stabilizes, the resident is expected to make gains in function by discharge in the following areas: Increase to Supervision or touching assistance as the usual performance for Eating Increase to Partial/moderate assistance as the usual performance for Sit to stand Increase to Partial/moderate assistance as the usual performance for Chair/bed-to-chair transfer Increase to Partial/moderate assistance as the usual performance for Toilet transfer 53 Copyright 2016 Software may be capable of adding a custom charting area or assessment for GG Software may be capable of averaging answers & calculating the usual Helpful provided all of the team uses it CNA s who may be providing most of the support may not be contributors to these assessments Family and patient also don t typically contribute Carefully review any items where software averaged or calculated values for you Assessments are to be done in compliance with facility, Federal, and State requirements and accuracy of items are subject to audit Software may be capable of fetching values from Therapy software Use caution and carefully review any MDS section where any value is inserted from an external source In a 72 hour period for a patient with a RUG of V, therapy is involved for 3 ½ hours - 68 ½ hours of the patient s stay are not represented Don't assume that an automated process or import would have come to the same conclusion as your IDT team. Check everything! Can My Software Help? 54 Copyright 2016 27

55 Copyright 2016 Team Meeting to Review the Following Ask your team: Who will be the expert coder of GG and who will be the back-up? Who will help when Rehab is not treating the Patient? When should we start practicing? Usual Performance team discussion? o Not Worst or Best o Compare prior to the event o Which documents do you need? Would a Questionnaire be helpful? When will the software have your new item set available to practice? Seek your Rehab team for discharge goal setting advice A2400.B equals 10-1-16 Section GG is to be completed 56 Copyright 2016 28

NOW is the time TRAIN-TEST- TWEAK! Data in Data out (software) Clinicians MUST Assess, Evaluate & Attest Admission Performance with Goal Setting Discharge Performance Stop & Think Does the record reflect Section GG? 57 Copyright 2016 Resources QRP Manual updated April 2016 https://www.cms.gov/medicare/quality-initiatives-patient- Assessment- Instruments/NursingHomeQualityInits/Downloads/Skilled-Nursing- Facility-Quality-Reporting-Program-Quality-Measure-Specificationsfor-FY-2016-Notice-of-Proposed-Rule-Making-report.pdf Draft MDS 3.0 RAI Manual v1.14 May 2016 https://www.cms.gov/medicare/quality-initiatives-patient- Assessment- Instruments/NursinghomeQualityInits/MDS30RAIManual.html Section GG Tools Link: www.aanac.org/section-gg-resources 58 Copyright 2016 29

Hand Outs Section GG Key coding Q&A Tool DRAFT: MDS-3.0-SECTIONS-A-AND-GG- DOCUMENT Section GG Collection Data Tool Time Line 59 Copyright 2016 Contact AANAC American Association of Nurse Assessment Coordination (AANAC) 400 S. Colorado Blvd, Ste 600 Denver, CO 80246 Phone: 303.758.7647 Toll-free: 800.768.1880 Fax: 303.758.3588 Email: https://www.aanac.org/contact 60 Copyright 2016 30

Contact NASL National Association for the Support of Long Term Care (NASL) 1050 17th Street, NW, Suite 500 Washington, DC 20036-5558 Phone: 202.803.2385 Email: membership@nasl.org 61 Copyright 2016 62 Copyright 2016 31