MDS 3.0 – Just the Basics

Presented by:

Cathie ColemanNHA, 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 ProcessWhile 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

MDS

CATs

CAAs

Care Plans

Evaluate

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 AssessmentsComprehensive assessment:

Includes MDS plus care area assessments (CAA)

ARD (assessment reference date) must be set before the 14th day of admission

The day of admission is counted as day 1

Must be completed by day 14

OBRA Assessments

Annual AssessmentComprehensive 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 14th day after the ARD

OBRA AssessmentsSignificant Change in Status

AssessmentComprehensive 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 AssessmentNot 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 AssessmentsEntry 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 AssessmentsMedicare 60 day assessments:

ARD: 57-59

Grace days: 60-63

Pays for days 61 through 90

PPS AssessmentsMedicare 90 day assessments:

ARD days 87-89

Grace days: 90-93

Pays for days 91 through 100

RAI Process ComponentsCare 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

Investigate

Care planimplement

evaluate

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 ColemanNHA, RAC-CT, ACC

Email: cathclmn@aol.com

Phone: 248-437-7450