F1 – MDS: Accuracy = Quality = Reimbursement

1. F1 – MDS: Accuracy = Quality = Reimbursement Sandy Fitzler, RN Senior Director of Clinical Services American Health Care Association Joy Morrow, RN, PhD Senior Clinical Consultant Hansen, Hunter, & Co., PC

2. MDS 3.0 Introduction • The final info is NOT out • 3.0 has been validated in the field. 2.0 was not • 3.0 is an interview assessment • Yes/No questions not good • Choices better

3. 3.0 Validation – 5 yr Pilot. 2.0 revisions needed • To make MDS more clinically relevant • Improve ease 7 efficiency of tool • Integrate selected standard scales • Elicit res voice thru interview questions

4. Changes to MDS Will Continue to Achieve • Federal payment mandates • Quality initiatives

5. Resident Interview • Emphasizes Res quality of life • Facilitates Res centered care • Improves accuracy • Is feasible • Improves efficiency

6. Assessor Talks To • Resident • Family • Staff across all shifts • (And reviews the record)

7. Simple Resident Interview • Using standardized items • For cognitive assessment • Mood • Preferences • Pain • Can be the SOLE source information

8. 3.0 and pain assessment • 3.0 is an improvement • Self reported pain has been proven to be very valid

9. Cognitive Assessment • You can use old format if res is unable to be interviewed • This was RARELY a problem during the pilot and the old format was used very little • Delirium detection much better in 3.0 • New tool for cognition

10. If Res Cannot Do Interview • In these rare cases, move on to observational items

11. Mood/Depression • Under detection with 2.0 • New standard for identifying depression • Some nurses in pilot thought the questions too personal; most thought they were appropriate

12. Many 2.0 old “labels” were pejorative & not valid • 3.0 wording is much better • “Resists care” – Not good • Behavior that “interferes with care” – much better

13. Customary routine & activities • 2.0 not valid using historic preferences • 3.0 asks what is important NOW

14. Interview/Information Details • Using info reported by other staff is fine • If resident cannot be interviewed • Interview items are improved • They are more accurate • Again, self reported pain is really the 5th vital sign

15. Pressure Ulcers • Reverse staging is eliminated • M6 – colors of slough/eschar not clear – more work is being done – not completed for 3.0 yet • “DTIs” not included. Instruction manual may incl. info on this but too new for inclusion per CMS

16. Other 3.0 improvements • Catheters are no longer continent • Toileting trials are documented • ADL’s have single response • There are goals for care • Swallowing info is better • Restraints for bed & chair separate

17. Improvements (cont.) • Hearing aide part is good • Observation part for pain is better even if res cannot relate themselves

18. Hearing Deficits vs. Cognitive Deficits • Historically not handled well • New focus on hearing • Evidence that there is less cognitive deficit & more hearing deficit • USE OF AMPLIFIER VERY IMPORTANT

19. Pilot Performed by Nurses • Nurses liked 3.0! • Validity better • More accurate • Better clinical standards • (some items dropped based on nurses input)

20. Time to do 3.0 • Reported as reduced by 45 % • New nurse doing 3.0: 62 mins • New nurse doing 2.0: 112 mins • (these were full assessments)

21. Look Backs • 5 days on most clinical issues • Some issues, like therapy, stayed at 7 days • Look back study continues

22. Some Things Not Decided • RUGs & payment • Raps • QIs for 3.0 will be finalized 2011

23. Specific Times • Cognitive Patterns – conduct interview on day before, day of, or day after ARD • Mood Section – same as above • Sec M – skin; record date of assessment

24. Section G - ADLs • It appears that these questions and answers will more easily allow CMS/Fiscal Intermediaries to correlate Sec G info w/Sec T and decide if therapy is reasonable & necessary

25. 3.0 Can Be Accomplished By Nurse • Social service & dietary wanted more pilots with their staff • Not going to happen • Cognitive Assessment test can be administered by nurse, or other trained staff • Mood questions might be better asked by nurse

26. 3.0 Works!! • Under reporting was not an issue in pilot • Over reporting is not issue as nurse is not developing a medical diagnosis

27. Remember 3.0 Is Currently a Draft • It is similar to what will be the final • Some items will change • Some missing items will be added • Using it as a “style” introduction is fine • It is NOT the final product

28. Discussion Of Some MDS Sections

29. Discussion Of Parts of Crosswalk

30. MDS 3.0 and RAPs Will There Be An Update?

31. Introduction • February 08 – CMS tells AHCA that MDS 3.0 contract does not include updating the RAPs • CMS not sure if update will occur

32. CMS RAP Concerns • No funds to update RAPs or to provide updates on a regular basis to ensure information is current • Even if funding is available, not sure if updating a process that is poorly utilized is a wise investment

33. Issues with RAPsAHRQ Survey Results • In the fall of 2004, AHRQ pulled together a RAP workgroup, conducted a survey on RAP utilization and released a report • Survey encompassed 1,835 AANAC, MDS Coordinators and 56 VA respondents

34. AHRQ Findings • 76% found RAPs are somewhat, rarely or never helpful • RAP completion does not involve the interdisciplinary team as they are often completed separately by multiple individuals (30%) or by individuals who do not participate in care (26%) like MDS Coordinators having no clinical responsibility

35. AHRQ Findings Continued • 31% saw RAPs as too time consuming • 27% stated RAPs are done for paper compliance • Physicians often uninvolved in the RAP and do not consider the care plan when making resident treatment decisions • CNA work is not reflected in care plans

36. AHCA Next Steps • Conducted a non-scientific survey to assess if the AHRQ findings remain constant • Surveyed AHCA members, state associations, multi-corporations and others • Use 2 survey tool • Recommendations to keep or not keep RAPs also received via email

37. AHCA Survey Findings • Use feedback only received from surveys • The majority of survey and non survey respondents indicated they do not want to keep RAPs as they currently exist.

41. AHCA Recommendations to CMS • Do not update RAP Utilization Guidelines & RAP Summary • Go “back to the basics” for care planning & use interdisciplinary team • Consider retaining & revising Trigger Legend & renaming it “Triggers for Analysis and Planning (TAP)”

42. AHCA Recommendations to CMS - Continued • To help clinicians make decisions about care planning & to support clinical approaches use evidence-based clinical practice resources found on www.nhqualitycampaign.org, www.medqic.org, AMDA CPGs and other recognized resources

43. Justification for AHCA Recommendations • Title 42, Part 483.20, Section K – “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.”

44. Justification for AHCA Recommendations - Cont • Section K (2) (ii) – the comprehensive care plan is “prepared by the interdisciplinary team that includes attending physician, a registered nurse with responsibilities for the resident, and other appropriate staff and 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.”

45. Justification for AHCA Recommendations - Cont • Section K (2) (iii) – calls for periodic review and revision of care plans by a team of qualified persons after each assessment • Note – the law does not reference RAPs but use of the interdisciplinary team

46. RAPs in Regulation • CMS identifies the RAP as the recommended nursing home care planning tool in the RAI • F279 – Interpretive Guidance mentions RAP summary and triggers

47. RAPs in Regulation - Cont • RAI MDS 2.0 User’s Manual – OBRA 87 requires the Secretary of HHS to specify a minimum data set of care elements for use in conducting comprehensive assessments. It further requires the Secretary to designate one or more resident assessment instruments based on the minimum data set • CMS uses this to justify RAPs

48. Justification for Change • AHCA believes that adding, changing or eliminating RAPs require no change in law • The MDS already meets the OBRA requirement for the Secretary to specify a tool for comprehensive assessment • The RAP is Not an assessment tool but an analytical tool

49. RAPs • Survey results showed that RAPs confuse clinicians in purpose, use & sequencing • Clinicians are not sure if RAPs are a continuation of the resident assessment or an analytic step in nursing process • Some of the confusion stems from inconsistent use of RAP descriptors in the RAI Manual

50. RAP Descriptors in RAI • Manual states RAPs follow nursing process – assessment, planning, implementation & evaluation. • ANA nursing process – assessment, diagnosis, outcomes/planning, implementation & evaluation