MDS 3.0: What Leadership Needs to Know especially prepared for CANPFA Ann Spenard RN, MSN
History of the MDS and RAI Process The Resident Assessment Instrument (RAI) was part of a set of reforms enacted by Congress in the Omnibus Budget Reconciliation Act of 1987 (OBRA 87). These were the most sweeping reforms to nursing homes regulation since the onset of the federal payment for nursing home care with the passage of Medicare and Medicaid programs in the mid 1960 s.
History of the MDS and RAI Process (Continued) In 1983 Congress asked the National Academy of Science and Institute of Medicine to examine nursing home quality and report on how to improve nursing home regulations. After two and a half years of study one of the central recommendations was the development of a uniform comprehensive resident assessment system.
History of the MDS and RAI Process (Continued) The development of the RAI involved the work of 18 clinical work groups. The MDS was scheduled for launch in October 1990 and was fully implemented by spring of 1991. Development of MDS 2.0 started in early 1993.
History of the MDS and RAI Process (Continued) MDS 2.0 launched in October 1995. A major overhaul of the MDS 2.0 manual was published in December 2002. Quarterly updates as indicated.
PPS Balanced Budget Act (BBA) of 1997 included implementation of a Medicare Prospective Payment System (PPS) for skilled nursing facilities. The PPS system replaced the retrospective costbased system for skilled nursing homes under Part A. The final rule was published May 12, 1998.
Why MDS 3.0? Response to changes in nursing home care. Change in resident characteristics. Advances in resident assessment methods. Provider and consumer concerns about the performance of MDS 2.0.
MDS 3.0 Development CMS contracted with RAND Corp. and Harvard University to draft the revisions and nationally test MDS 3.0. The major goals of MDS 3.0: Increase the relevance of items. Improve accuracy and validity of the tool. Increase user satisfaction. Increase residents voices by increasing resident interviews.
MDS 3.0 Development (Continued) In 2005, CMS initiated a national nursing home staff time measurement (STM) study, named the Staff Time and Resource Intensity Verification (STRIVE) Project. This was the first nationwide time study since 1997. Based on this analysis CMS developed the RUG-IV classification system incorporated into MDS 3.0.
Resource Utilization Groups (RUGs) Over half the state Medicaid programs use the MDS for case mix payment. With MDS 3.0 state agencies have the option to continue the use of RUG-III or adopt RUG-IV. CMS has provided alternate RUG-IV versions with 47, 57 and 66 groups. States that currently use the RUG-III system can continue to utilize the 34, 44, or 53 groups.
RUG-IV The RUG-IV classification system has eight major classification categories: 1. Rehabilitation plus extensive services 2. Rehabilitation 3. Extensive services 4. Special care high 5. Special care low 6. Clinically complex 7. Behavioral symptoms and cognitive performance problems 8. Reduced physical function
RUG-IV (Continued) RUG-IV categories are further categorized: All categories (with the exception of extensive services) categorized by intensity of the resident s ADLs. Special care high and low and clinically complex categories categorized by the presence of depression. Behavioral symptoms and cognitive performance problems and reduced physical function categorized by the provision of restorative nursing services.
Components of MDS 3.0 SECTION BY SECTION
The MDS 3.0 Manual Intent. The reasons for including this set of assessment items in the MDS. Item display. In order to facilitate accurate resident assessment using the MDS, each assessment section is accompanied by screen shots which display the item from the MDS 3.0 item set.
The MDS 3.0 Manual1 Item Rationale. The purpose of assessing this aspect of a resident s clinical or functional status. Health-related Quality of Life. How the condition, impairment, improvement or decline being assessed can affect a resident s quality of life, along with the importance of staff understanding the relationship of the clinical or functional issue to quality of life.
The MDS 3.0 Manual2 Planning for Care. How assessment of the condition, impairment, improvement or decline being assessed can contribute to appropriate care planning. Steps for Assessment. Sources of information and methods for determining the correct response for coding each MDS item. Coding Instructions. The proper method of recording each response, with explanations of individual response categories.
The MDS 3.0 Manual3 Coding Tips and Special Populations. Clarifications, issues of note and conditions to be considered when coding individual MDS items. Examples. Case examples of appropriate coding for most, if not all, MDS sections/items.
Major Changes to MDS 3.0
Interviews One of the major changes in the MDS 3.0 is the number of resident interviews. Each section that requires an interview, will be indicated by a symbol (a small black box with an ear in it). MDS 3.0 allows for a staff assessment if the resident is unable to complete the interview.
Time Frames Throughout the MDS 3.0 the look-back period is 7 days UNLESS otherwise stated. Interviews should be completed as close to the assessment reference date as possible to gather the most complete and accurate information.
Section C Screening question to determine if a resident interview should be attempted: Brief Interview for Mental Status (BIMS) If an interview is not possible, a staff assessment of the resident s mental status is conducted. Other assessments: Delirium Acute onset of mental change
Section D Assessment for resident interview PHQ-9 (Patient Health questionnaire) If an interview is not possible, a staff assessment of the resident s mood is conducted.
Section F Interview for daily preferences and activity preferences. Make every effort to complete this interview with the resident, but you may complete the interview with a family member or significant other. Complete the staff assessment of daily activities preferences if unable to complete interview with resident, family or significant other.
Section G G0110 is very similar to section G1 in MDS 2.0. Major differences include the addition of code 7 (activity occurred 2 or fewer times). Instructions for a rule of 3. (see flow diagram) Change in definition of independent and total dependence.
Section G Includes balance during transitions and walking. Functional limitations. Mobility devices. Functional rehabilitation.
Section I Much more comprehensive list of active diagnoses. The term active diagnosis requires two parts: A documented diagnosis in the past 60 days. Once you have this then you need to determine if the diagnosis is active Active diagnoses are those that have a direct relationship to the resident s functional status, cognitive status, mood or behavior, medical treatments, nursing monitoring or risk of death during the look-back period.
Section J New pain interview including a pain intensity scale Other health conditions including assessment for dyspnea. Fall history Prior to admission Falls since admission Number of falls since admission and type of injury
Section M This section is completely re-structured. Pressure Ulcers (PUs): Is the resident at risk for PU? Does resident have an unhealed PU? Current number of unhealed PU s per stage. Dimensions of unhealed stage 3 or 4 ulcer or eschar.
Section M (Continued) Worsening of PU since prior assessment Healed pressure ulcer Present upon admission Number of venous and arterial ulcers Other ulcers, wounds and skin problems Skin and ulcer treatments
Section O Look back is different: 14 days for special treatments and programs. Two assessments for each question: While NOT a resident While a resident
Section O (Continued) Influenza and pneumococcal vaccine Therapies (7 day look back) Individual Minutes (no units or rounding) Concurrent Minutes (with one other resident) Group Minutes Definitions differ for Medicare A and Medicare B Days (the number of days therapy was administered for at least 15 minutes) Therapy start date Therapy end date (enter dashes if the therapy is still in progress. No coding changes to restorative nursing programs
Section P MDS 3.0 created a section specifically for physical restraints. Evaluations of two areas: In Bed Bed rails, trunk restraint, limb restraint, other Used in chair or out of bed Trunk restraint, limb restraint, chair prevents rising, other When coding a restraint you must evaluate the effect of the device on the resident.
Section Q Components include: Participation in assessment Resident s overall expectation Discharge plan Return to the community (must be asked on each assessment unless it is determined that a discharge to the community is not feasible). Referral
Section V 20 Care Area Assessment (CAA) replace the RAPs from MDS 2.0. Each CAA is comprised of: Introduction A list of items and responses from the MDS that are considered triggers for the issue or condition (CAT) A list of resources that nursing homes can use in performing the assessment/review of the particular issue or condition
CAAs in MDS 3.0 Delirium Cognitive loss/dementia Visual function Communication ADL functional/rehabilitation potential Pain (new) Urinary Incontinence and Indwelling Catheter Return to the community (new) Psychosocial well-being Mood State Behavioral Symptoms Activities Falls Nutritional Status Feeding Tubes Dehydration/fluid maintenance Dental Care Pressure ulcer Psychotropic drug use Physical restraints
CAAs in MDS 3.0 CAAs are required for comprehensive assessments. not required for Medicare assessments. Use the CAA process to guide your assessment and then chart your thinking. Nursing homes should assess the resident in the area triggered using current, evidence-based or expert endorsed research and clinical practice guidelines/resources.
CAAs in MDS 3.0 (Continued) CMS has provided a set of CAA tools in Appendix C of the manual. These forms are a resource and are NOT mandated.
Section X and Section Z Section X applies only when submitting a correction request. Section Z Medicare Part A billing Medicare non therapy Part A billing State Medicaid billing (if required) Alternate state Medicaid billing (if required) Insurance billing
How Does a NH Prepare for MDS 3.0? Become familiar with all the new forms and the coding methodology. Plan on going to a comprehensive education program that reviews the comprehensive full MDS 3.0 item-by item. Purchase or download the MDS 3.0 manual when available. READ (and re-read) the manual!
How Does a NH Prepare for MDS 3.0? Talk to your software vendor. Determine which departments will complete sections. Make sure all members of the team who are going to complete the MDS 3.0 get educated Educate residents. Practice prior to October 1 st. The entire interdisciplinary team should be included. Determine systems to be instituted after October 1 st.
Operational Changes to Consider with MDS 3.0 The number of interviews that need to be completed: Who will completed them, how will they be divided? How will staff get training to complete the interviews? How will staff manage their time/tasks to complete the interviews?
Operational Changes to Consider with MDS 3.02 Discharge assessments: Need to be completed for all residents who are out of the facility for greater than 24 hours (even if not admitted to the hospital) Exceptions for those on therapeutic leaves. This assessment includes all of the interview sections. On paper this form is 27 pages.
Operational Changes to Consider with MDS 3.03 How will the MDS get completed in your facility? Paper with a data entry person? Directly into the computer? Many skip patterns in this tool, this may be the easier method. If direct entry, do you have enough computers that are networked to allow direct entry into the MDS.
Operational Changes to Consider with MDS 3.04 Time for all staff to complete the MDS: How many admissions do you have per month? How many discharges or residents out of the facility for greater than 24 hours per month? How many residents are covered under Medicare per month? How many comprehensive assessments per month?
Operational Changes to Consider with MDS 3.05 When completing the Care Area Assessments, what tools will you use? How can you integrate these tools into assessments to eliminate duplication of work? Does your facility have many non-english speaking residents? If so, how are you going to meet the needs of these residents so interviews can be completed and the residents voice can be heard?
Questions
Contact Information Ann M. Spenard Qualidigm aspenard@qualidigm.org 1-860-613-4183