MDS-RCA Training - Maine.gov · Quality Indicators 2 MDS-RCA Training: ... MDS-RCA Training: RUG...

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MDS-RCA Training Aug 2015 9/1/2015 1 MDS-RCA Training Case Mix Team Office of MaineCare Services August 2015 1 MDS-RCA Training: Agenda History of MDS-RCA Purpose: Definitions Schedule of Assessments Case Mix Index, RUGs Accuracy and Sanctions MDS-RCA Assessment Tool Correction Policy Quality Indicators 2 MDS-RCA Training: History In 1994 a workgroup made up of providers, Muskie School and DHHS representatives was established to provide recommendations for development of: o MDS-RCA form design and content o Classification system o Case Mix payment system o Quality Indicators 3

Transcript of MDS-RCA Training - Maine.gov · Quality Indicators 2 MDS-RCA Training: ... MDS-RCA Training: RUG...

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MDS-RCA Training

Case Mix TeamOffice of MaineCare ServicesAugust 2015

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MDS-RCA Training: Agenda

History of MDS-RCAPurpose:DefinitionsSchedule of AssessmentsCase Mix Index, RUGsAccuracy and SanctionsMDS-RCA Assessment ToolCorrection PolicyQuality Indicators

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MDS-RCA Training: History

In 1994 a workgroup made up ofproviders, Muskie School and DHHSrepresentatives was established toprovide recommendations fordevelopment of:

o MDS-RCA form design and contento Classification systemo Case Mix payment systemo Quality Indicators

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MDS-RCA Training: History

1995 Time StudyTwenty five facilities, with a total of 626residents, participated in this time study.This included the following residents:

o In small facilitieso With head injurieso With Alzheimer’s Diseaseo With Mental illness

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MDS-RCA Training: History

1999 Time Study

Thirty-two Facilities, with a total of 735residents, participated in another time study.Facilities were selected according to:

o Overall populationo Presence of complex residentso Presence of residents with mental health

issueso Presence of residents with Alzheimer’s or

other Dementiao Presence of elderly population

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MDS-RCA Training: History

1999 Time Study Results

o Residents were more dependent inADL’s

o There was an increase in residents withAlzheimer’s and other Dementias.

o There was an increase in wanderingand intimidating behaviors.

o There was an increase in the amount oftime needed to care for these residents

o The Case Mix Grouper needed to berevised

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MDS-RCA Training: Purpose

Who, What, Where, Why and,When…

of Case Mix

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MDS-RCA Training: Purpose

So… Who completes the MDS-RCA?

…The MDS-RCA Coordinator

with help from:

The resident

Personal Support Specialists

CRMA

family

clinical records

Social Services

dietary, activities and other staff8

MDS-RCA Training: Purpose

And… What is Case Mix?

Case Mix is a system of reimbursement thatpays facilities according to the amount oftime spent providing care to residents.

Residents are grouped according to theamount of time needed to provide their care

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MDS-RCA Training: Purpose

And… Where is the assessment done?

MDS-RCA assessment is completed in thefacility

All residents

Regardless of payer source

The MDS-RCA cannot be completed if theresident is not in the facility. For example, ifin the hospital or on a therapeutic leave

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MDS-RCA Training: Purpose

And… Why do we need to do MDS-RCAAssessments?

1. To provide information to guide staff indeveloping a realistic individualized ServicePlan.2. To place a resident into a paymentgroup within the Case Mix System.3. To provide information that determinesthe Quality Indicators.4. To show an accurate picture of theresident’s condition, the type and amountof care needed 11

MDS-RCA Training: Purpose

So… Why do we need to do MDS-RCAAssessments? (cont.)

5. Improve equity of payment toproviders

6. Provide incentives to facilities foraccepting residents with higher careneeds

7. Strengthens the quality of care andquality of life for residents.

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MDS-RCA Training: Purpose

Schedule of Assessments:

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MDS-RCA Training: Purpose

When to complete a Significant ChangeMDS-RCA assessment:

• Resident has experienced a “majorchange”

• Not self-limited• Impacts more than one area of the

resident’s clinical status• Requires review and/or changes to the

service plan• Improvement or decline• Completed by the end of the 14th day

following the documented determination14

MDS-RCA Training: Timeliness and Accuracy

Timeliness

MaineCare Benefits Manual, Chapter III, Section97, §7060.1:

“The Department will sanction providers for failureto complete assessments completely, accuratelyand on a timely basis.”

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MDS-RCA Training: Timeliness and Accuracy

Accuracy

Each assessment must be conducted orcoordinated by staff trained in the completion ofthe MDS-RCA.

Documentation is required to support thetime periods and information coded on theMDS-RCA. (MBM, chapter III, Section 97,Appendix C, §7030.3)

Penalty for Falsification: The provider may besanctioned whenever an individual willfully andknowingly certifies (or causes anotherindividual to certify) a material and falsestatement in a resident assessment.

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MDS-RCA Training: Case Mix Review

Case Mix Quality Assurance Review

About every 6 months, a Case Mix nursereviews a number of MDS-RCAassessments and resident records to checkthe accuracy of the MDS-RCAassessments.

Insufficient, inaccurate or lack ofdocumentation to support informationcoded on the MDS-RCA may lead to anerror.

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MDS-RCA Training

Poor Documentation could mean…

Lower payment than the facility couldbe receiving, OR

Overpayment which could lead to re-payment to the State (Sanctions). This isdue to either overstating the care aresident received or insufficientdocumentation to support the care thatwas coded.

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MDS-RCA Training: Sanctions

Sanctions:

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MDS-RCA Training: Purpose

Case Mix Resident ClassificationGroups and Weights

There are a total of 15 case mixclassification or RUG (ResourceUtilization Groups) groups, includingone default group used when aresident cannot be classified into oneof the other 14 classification groups.

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MDS-RCA Training: Case Mix Review

5 categories:

• Impaired Cognition• Clinically Complex• Behavioral Health• Physical• Default or Not Classified

The Department assigns each casemix classification group a specificcase mix weight, as follows…

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MDS-RCA Training: Purpose

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MDS-RCA Training: RUG Groups

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ADL Function Self-PerformanceMDS-RCACode

ADLScore

1. Bed Mobility (G1aa)

2. Transfer (G1ba)

3. Locomotion (G1ca)

4. Dressing (G1da)

5. Eating (G1ea)

6. Toilet Use (G1fa)

7. Personal Hygiene (G1ga)

Independent 0 0

Supervision 1 1

Limited Assistance 2 2

Extensiveassistance

3 3

Total Dependence 4 4

Activity did notoccur

8 4

The ADL index score is determined as follows:

MDS-RCA Training: RUG Groups

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Impaired Cognition Groups

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MDS-RCA Training: RUG Groups

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Clinically Complex Groups

MDS-RCA Training: RUG Groups

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Behavioral Health Groups

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Physical and Default groups

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MDS-RCA Training: Purpose

Documentation errors vs. Payment errors

• A Payment error counts towards the final“error rate” presented at the time of theexit interview.

• A Documentation or clinical error does notcount towards the final error rate.

• Both types of errors must be corrected

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MDS-RCA Training: Assessment Tool

MDS-RCA Assessment Tool

Section by Section

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MDS-RCA Training: Assessment Tool

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Section AA: IdentificationInformation.

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MDS-RCA Training: Assessment Tool

Face Sheet: Background InformationCompleted at the time of the resident’sinitial admission to the facility.

Section AB: Demographic InformationSection AC: Customary RoutineSection AD: Face Sheet Signatures and

dates

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MDS-RCA Training: Assessment Tool

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Section A: Identification and Background information

MDS-RCA Training: Assessment Tool

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Section B: Cognitive Patterns

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MDS-RCA Training: Assessment Tool

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MDS-RCA Training: Assessment Tool

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MDS-RCA Training: Assessment Tool

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MDS-RCA Training: Assessment Tool

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Section E: Mood and Behavior Patterns (cont)

MDS-RCA Training: Assessment Tool

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ADL SELF-PERFORMANCEMeasures what theresident actually did(not what he or shemight be capable ofdoing) within eachADL category overthe last 7 days.

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MDS-RCA Training: Assessment Tool

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MDS-RCA Training: Assessment Tool

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Note: this section has a 14-day look back period.

0 - Continent – Complete control

1 - Usually Continent – Bladder,incontinent episodes occur once aweek or less. Bowel incontinentepisodes occur less than once aweek.

2 - Occasionally Incontinent –Bladder incontinent episode occurtwo or more times a week but notdaily. Bowel incontinent episodesoccur once a week.

3 - Frequently Incontinent –Bladder, tended to be incontinentdaily, but some control present (e.g.,on day shift) Bowel, 2-3 times aweek.

4 - Incontinent – Bladderincontinent episodes occur multipletimes daily. Bowel incontinence isall (or almost all) of the time.

A. Mr. Q was taken to the toilet afterevery meal, before bed, and onceduring the night. He was never foundwet.

B. Mr. R had an indwelling catheter inplace during the entire 14-dayassessment period. He was neverfound wet.

C. Although she is generally continentof urine, every once in a while (aboutonce in two weeks) Mrs. T doesn’tmake it to the bathroom in time afterreceiving her daily diuretic pill

D. Late in the day when she is tired,Mrs. A sometimes (but not all days)has more episodes of urinaryincontinence.

POP QUIZ !

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MDS-RCA Training: Assessment Tool

Section I: Diagnosis

All diseases and conditions must have physiciandocumented diagnosis in the clinical record.

Do not include conditions that have been resolved orno longer affect the resident’s functioning or serviceplan.

Diabetes with daily insulin injectionsAphasiaCerebral palsyHemiparesis/hemiplegiaMultiple sclerosis (MS)QuadriplegiaExplicit terminal prognosis (6 months or less)

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Thesediagnosescontributeto theClinicallyComplexRUGgroups

MDS-RCA Training: Assessment Tool

Section J covers Health Conditions andPossible Medication Side Effects…

A lot of territory!

J1. Problem conditions J2. Extrapyramidal signs and symptoms J3 and 4. Pain Symptoms and location J5 and 6. Pain interference and management J7. Accidents J8. Fall risk

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MDS-RCA Training: Assessment Tool

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Delusions and Hallucinations are bothItems that can contribute to the BehavioralHealth RUG groups. Descriptivedocumentation required

Section J. Health Conditions and Possible Medication Side Effects

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MDS-RCA Training: Assessment Tool

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Section K: Oral and Nutritional Status

MDS-RCA Training: Assessment Tool

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Section L: Oral / Dental Status

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If M1b is checked, itwill contribute to aclinically complexRUG group

Section M: Skin Condition

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MDS-RCA Training: Assessment Tool

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Section M: Skin Condition

If M2a, b, c, or d iscoded greater than0, this item willcontribute to aclinically complexRUG group

MDS-RCA Training: Assessment Tool

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Section N: Activity Pursuit Patterns

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Section O: Medications

This item cancontribute to theclinically complexRUG group, incombination witha diagnosis ofDiabetes

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MDS-RCA Training: Assessment Tool

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Section P: Special Treatments and Procedures

These items willcontribute to theclinically complexRUG group

MDS-RCA Training: Assessment Tool

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Section P: Special Treatments and Procedures (cont.)

These items will contribute to aBehavioral Health RUG group if three(3) or more items in P2A – P2J arechecked

MDS-RCA Training: Assessment Tool

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Section P: Special Treatments and Procedures (cont)

These items will contribute to aClinically Complex RUG group

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MDS-RCA Training: Assessment Tool

P4. Rehab / Restorative care

P5. Skill Training

P6. Adherence With Treatments/TherapiesPrograms

P7. General Hospital Stays

P8. Emergency Room (ER) Visit(s)

P9. Physician Visits

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Section P: Special Treatments and Procedures (cont)

MDS-RCA Training: Assessment Tool

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Section P: Special Treatments and Procedures (cont)

Note: Code the number of days the physician changedthe resident’s orders, not including order renewals withoutChange or clarification of orders.

This item will contribute to the ClinicallyComplex RUG group if coded as 4 or more

MDS-RCA Training: Assessment Tool

P11. Abnormal Lab Values

P12. Psychiatric Hospital Stay(s)

P13. Outpatient Surgery

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Section P: Special Treatments and Procedures (cont)

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MDS-RCA Training: Assessment Tool

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Section Q: Service Planning

Note: this item refers toResident self-identified goals

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Section R: Discharge Potential

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Section S: Assessment Information and Signatures

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MDS-RCA Training: Assessment Tool

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Section T: Preventive Health

Note: 12 month look back period for preventivehealth measures.

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Section U: Medications list

MDS-RCA Training: Discharge Tracking Tool

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MDS-RCA Training: Assessment Tool

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CorrectionRequest Form:Prior RecordSection

MDS-RCA Training: Corrections

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CorrectionRequest Form:CorrectionSection

MDS-RCA Training: Corrections

Purpose of this form:To request correction of errors in anassessment or tracking form that hasalready been accepted into the database.

• To modify a record in the database• To inactivate a record in the database

It is important that the information in theState database be correct.

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Correction Request Form

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MDS-RCA Training: Corrections

To INACTIVATE a record in the State database

1. Complete this correction request form2. Create an electronic record of the form3. Place a hard copy of the documents in the

Clinical record4. Electronically submit this request.

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Correction Request Form

MDS-RCA Training: Submission

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The link to the SMS website can befound on the Muskie School of Public

Service, Minimum Data Set (MDS)Technical Information website:

http://muskie.usm.maine.edu/mds/

Click on the link and the SMS log-in screen will appear.Type in your username and password and hit the Log Inbutton to enter the site.

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MDS-RCA Training: Documentation Requirements

Documentation Requirements

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Clinically Complex

MDS-RCA Training: Documentation Requirements (Clinically Complex)

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MDS-RCA Training: Documentation Requirements (Clinically Complex)

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Impaired Cognition and Problem Behavior

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Physical Impairment

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MDS-RCA Training: Quality Indicators

What are Quality Indicators??

• Identify flags• Identify exemplary care• Identify potential care problems• Identify residents for review• Provide general information• Identify education needs• Based solely from responses on the

MDS-RCA

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Quality Indicator Reports

The “PNMIResidential CareFacility QualityIndicator” report isprepared & mailedto each facility every6 months.

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MDS-RCA Training: Quality Indicators

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MDS-RCA Training: Quality Indicators

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Quality Indicators

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The QI Report

Allows each facility review the results and compare yourfacility’s percentage to the state average.

What could cause your facility to be higher or lower thanother facilities?

Verify that the resident’s condition was accuratelyassessed at the time the MDS-RCA was completed

Identify if facility changes are needed

MDS-RCA Training: Quality Indicators

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MDS-RCA Training: Wrap up

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MDS-RCA Training: Wrap Up

Reminders:

Quarterly Res Care Forum Calls in March,June, September, and December-

Call the MDS help desk to register.

ASK questions!

ASK more questions!

Attend training as needed

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Contact Information• MDS Help Desk: 624-4019

[email protected]

• Lois Bourque RN: [email protected]

• Darlene Scott-Rairdon RN: [email protected]

• Maxima Corriveau RN: [email protected]

• Heidi Coombe RN: [email protected]

• Sue Pinette RN: [email protected]

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