an introduction to the mds minimum data set assessment instrument for medical directors l.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
An introduction to the MDS (Minimum Data Set) Assessment Instrument for Medical Directors PowerPoint Presentation
Download Presentation
An introduction to the MDS (Minimum Data Set) Assessment Instrument for Medical Directors

Loading in 2 Seconds...

play fullscreen
1 / 53

An introduction to the MDS (Minimum Data Set) Assessment Instrument for Medical Directors - PowerPoint PPT Presentation


  • 261 Views
  • Uploaded on

An introduction to the MDS (Minimum Data Set) Assessment Instrument for Medical Directors. George Heckman MD MSc FRCPC Assistant Professor of Medicine McMaster University Schlegel Research Chair in Geriatric Medicine, University of Waterloo. Disclosures.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'An introduction to the MDS (Minimum Data Set) Assessment Instrument for Medical Directors' - oshin


Download Now An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
an introduction to the mds minimum data set assessment instrument for medical directors

An introduction to the MDS (Minimum Data Set) Assessment Instrument for Medical Directors

George Heckman MD MSc FRCPC

Assistant Professor of Medicine

McMaster University

Schlegel Research Chair in Geriatric Medicine, University of Waterloo

disclosures
Disclosures
  • Consultant and speaker fees from Janssen-Ortho, Novartis, and Pfizer
  • Research support: Heart and Stroke Foundation of Ontario, CHANGE Foundation, Canadian Institutes of Health Research, Novartis
  • Primary panelist: Canadian Cardiovascular Society Consensus Conference on Heart Failure
objectives
Objectives
  • Terminology : MDS? RAI?
  • Why is this important to know?
  • To familiarize clinicians with the content, reliability and validity of the RAI-MDS
  • To understand the role of Clinical Assessment Protocols (CAPs) in resident assessment
  • To understand the role of CAPs in following resident progress
rai mds 2 0
RAI MDS 2.0

What is it?

Where does it come from?

policy directive
Policy directive
  • January 7 2009: MOH-LTC announces roll-out of MDS-RAI to all Ontario LTC homes
  • 217 early adopters
    • Ironed out the bugs
  • 12 month implementation / training program with facility RAI coordinators
  • Expected completion Summer 2010
rai mds hawes et al age ageing 1997
RAI / MDSHawes et al Age Ageing 1997
    • Developed in response to 1987 US Omnibus Budget Reconciliation Act addressing quality of nursing home care and need for standardized assessment
    • Targets frail seniors, disabled adults in LTC homes
  • MDS: Minimum Data Set
  • RAI: Resident Assessment Instrument
    • includes the MDS
what is in the rai mds 2 0 www interrai org
What is in the RAI-MDS 2.0?www.interRAI.org

Intake/ initial history

Cognition

Communication / senses

Mood / behaviour

Psychosocial well-being

Functional status

Elimination

MDS: includes approximately 300 items:

  • Diagnoses
  • Medications
  • Health conditions
  • Oral / nutritional
  • Skin
  • Activities
  • Treatments / procedures
  • Care directives
  • Health outcomes scales
rai 2 0 scales
RAI 2.0 scales
  • Cognitive Performance Scale
  • Depression Rating Scale
  • Index of Social Engagement
  • ADL Self-Performance Hierarchy Scale
  • CHESS Scale: health instability
  • Pain scale
clinical assessment protocols
Clinical Assessment Protocols
  • CAPs
  • Best-practice guidelines designed to assist assessor
    • Identify and interpret key clinical issues
    • Develop a plan of management
  • Developed by expert panel with validation from focus groups and research
  • More on CAPs later
software
Software
  • Software vendors licensed by InterRAI
  • Automated entry
  • Print out patient / resident summaries
    • Demographics
    • Medications
    • Diagnoses
    • CAPs +/- scales
interrai
interRAI
  • International, not-for-profit network of 60+ researchers and health/social service professionals
  • Design instruments for comprehensive assessment of care needs
  • Multinational collaborative research to develop, implement and evaluate instruments and their related applications
interrai countries
interRAI Countries

Europe

Iceland, Norway, Sweden, Denmark, Finland, Netherlands, France, Germany, Switzerland, UK, Italy, Spain, Czech Republic, Poland, Estonia, Belgium, Lithuania, Portugal, Austria, Portugal

North AmericaCanada

US

Mexico

Pacific Rim

Japan, China, Taiwan,

Hong Kong, South Korea,

Australia, New Zealand

Central/

South AmericaBelize,

Cuba, Brazil,

Chile, Peru

Middle East/South AsiaIsrael, India

the interrai family of instruments
The interRAI Family of Instruments
  • Home Care (HC)
  • Contact Assessment (CA) Screener
  • Acute Care (AC)
  • Emergency Department (ED) Screener
  • Mental Health (MH)
    • Inpatient
    • Community
    • Emergency Screener
    • Forensic Supplement
  • Community Health Assessment (CHA)

Common “core” items, as well as specialized ones

  • Complex Continuing Care & Long Term Care Facilities (LTCF & 2.0)
  • Palliative Care (PC)
  • Post-Acute Care-Rehabilitation (PAC)
  • Intellectual Disability (ID)
  • Assisted Living (AL)
implementation testing of interrai instruments
Implementation & Testing of interRAIInstruments

RAI 2.0

RAI-HC

RAI-MH

interRAI CMH

interRAI ESP

interRAI PC

interRAI ID

interRAI ED/AC

interRAI CA

interRAI CHA

interRAI AL

interRAI LTCF

DB

Solid symbols – mandated or recommended by govt; Hollow symbols – research/evaluation underway

can you rely on the data
Can you rely on the data?

reliability and validity

reliability
Reliability
  • Reliability: is this data reproducible, with a measurement error small enough compared to true value?
    • test-retest
    • inter-observer: particularly important for RAI

Streiner & Norman, Health Measurement Scales: A practical guide to their development and use

validity
Validity
  • Validity: does the information actually reflect what it was intended to reflect?
    • Face validity: what do “experts” think?
    • Content validity: is everything important measured?
    • Criterion validity:
      • Does the data correlate as expected with other assessments (concurrent validity)?
      • Does the data predict the expected outcomes (predictive validity)?
how is this data collected
How is this data collected?
  • Trained clinicians conduct the RAI-HC assessments
  • Accuracy of information recorded through
    • discussions with MDs
    • family and caregivers interviews
    • review of medical records if necessary
  • Exercise clinical judgment as to most appropriate answer based on guidelines in manual
  • Is this reliable??
international reliability study hirdes et al bmc health services research 2008
International reliability studyHirdes et al BMC Health Services Research 2008
  • 12 countries
  • Trained individuals completed dual assessments on 783 individuals
    • RAI-LTCF 8 countries 31% of assessments
    • RAI-HC 6 28%
    • RAI-PAC 5 16%
    • RAI-PC 4 13%
    • RAI-MH 1 11%
  • Canada 147 individuals assessed
  • 2 blinded assessments within 72 hours
patient characteristics ltc
Patient characteristics - LTC
  • Age
    • 65 to 84 years 50.9%
    • 85 years+ 45.6%
  • 72.3% women
  • Selected characteristics
    • 83.4% impaired decision-making ability
    • 17.3% any aggressive behaviour
    • 65.8% hygiene problems
    • 57.7% walking problems
    • 21.8% feeding problems
weighted kappa
Weighted Kappa
  • Measure of degree of agreement
    • <0.40 poor
    • 0.41-0.60 moderate
    • 0.61-0.80 substantial
    • >0.81 excellent

Landis & Koch, Biometrics 1977

rai ltcf inter observer reliability weighted kappa
RAI-LTCF Inter-observer reliabilityWeighted Kappa
  • Gender 0.96 (!! ;-))
  • ADL 0.87
  • Pressure ulcer stage 0.85
  • Standing ability 0.83
  • Continence 0.90
  • Cognition 0.77
  • Falls/fractures 0.86
  • Pain 0.63
  • Advance directives 0.63
reliability of rai ltcf
Reliability of RAI-LTCF
  • Overall reliability of individual items substantial to excellent
  • Core / common items more reliable than specialized items
    • Not unexpected: in development longer
  • Reliability across languages, countries
  • Bottom line: The data is trustworthy
is the rai mds data valid
Is the RAI-MDS data valid?
  • Face validity
  • Content validity
  • Concurrent validity: do the scales correlate with more established tools?
  • Predictive validity: do the scales predict expected outcomes?
chess scale hirdes et al jags 2003
CHESS ScaleHirdes et al JAGS 2003
  • Changes in Health, End-stage disease, Signs and Symptoms
  • Reliable
  • Predicts 3-year mortality in LTC, physician activity, medical procedures, i.e. health instability
  • Items include:
    • Symptoms/signs: shortness of breath, edema, weight loss, leaving food uneaten, vomiting, dehydration
    • End-stage disease
    • Decline in cognition
    • Decline in ADLs
does rai 2 0 predict mortality better than the nyha class predictive validity
Heart Failure is characterized by instability

CHESS measures instability

Figure from Goodlin JACC 2009

Does RAI 2.0 predict mortality better than the NYHA class?(predictive validity)
the study tjam et al abstract ccs 2006
The StudyTjam et al, abstract CCS 2006
  • Secondary analysis of HF educational intervention for LTC
  • 149 residents with HF, 68% over age 85 years, 79% female
  • Multiple comorbidities
  • 6 month mortality: 22.1%
results
Results
  • Logistic regression
    • C-statistic: measures Goodness of Fit of model
    • 1.0 is perfect fit
  • NYHA: C-statistic = 0.686
    • Pretty good
  • MDS/RAI: CHESS plus “requires help walking in room: C-statistic = 0.838
    • Better!
  • Speaks to predictive validity
depression rating scale burrows et al age ageing 2000
Depression Rating ScaleBurrows et al Age Ageing 2000
  • The scale
    • Negative statements
    • Persistent anger
    • Expression of unrealistic fears
    • Repetitive health complaints
    • Repetitive anxious complaints
    • Sad, pained, worried expression
    • Tearfulness
  • Scoring items
    • 0 if not present
    • 1 if present at least once in last 30 days or up to 5 days /week
    • 2 if 6-7 days a week
validation study burrows et al age ageing 2000
Validation studyBurrows et al Age Ageing 2000
  • 108 LTC residents from 2 homes
    • Semi-structured interview
    • Trained assessors
  • Correlation:
    • 0.69 with Cornell Scale for depression
    • 0.70 Hamilton Depression Rating Scale
  • Compared to DSM-IV geriatric psychiatry assessment
    • Sensitivity 91%
    • Specificity 69%
drs as a predictor of depression martin et al age ageing 2008
DRS as a predictor of depressionMartin et al Age Ageing 2008
  • 7818 patients admitted to Ontario CCC beds and for > 3 months
    • 65 years and over, average age 81 years
  • Not depressed on admission, not on antidepressants, not severely cognitively impaired
  • At f/u, 7.5% new diagnosis of depression
  • Odds ratios for new depression: DRS range of
    • 1-2 1.45 (1.16-1.80)
    • 3-5 2.08 (1.63-2.67)
    • 6+ 2.07 (1.47-2.92)
comments
Comments
  • Examples of validity
    • CHESS: predictive validity
    • DRS: concurrent validity, predictive validity
  • A few other studies dispute this for the DRS
    • 1 did not adhere to RAI/MDS administration methodology (Hendrix et al, JAMDA 03)
    • 1 did not report on whether methodology followed (Anderson et al, Age Ageing 2003)
  • Tools should be used appropriately and correctly
clinical applications
Clinical applications

Clinical assessment protocols to

Screen

Follow outcomes

slide36
CAPs
  • Clinical Assessment Protocols: provide guidance on care for particular clinical problems and identify those
    • at risk of decline
    • who may improve
  • “Triggered” by MDS items, scales
    • On average, LTC residents trigger 4 CAPs

interRAI Clinical Assessment Protocols (CAPs) – For use with interRAI’s Community and Long-Term Care Assessment Instruments, March 2008 (Ottawa: CIHI, 2008)

slide37
CAPs
  • ADLs
  • Restraint use
  • Delirium
  • Communication
  • Cognitive impairment
  • Mood
  • Behaviour
  • Falls
  • Cardiopulmonary conditions
  • Activities
  • Social relationships
  • Pain
  • Pressure ulcers
  • Nutrition
  • Feeding tube
  • Dehydration
  • Medication use
  • Elimination
  • Prevention
activities of daily living cap
Activities of Daily Living CAP
  • Goal: Maintain or possibly improve function
  • Triggers:
    • Recent clinical event from which functional recovery possible
      • Need some, not total, ADL help; not imminently dying
      • Cognitive reserve present
      • 2+ of chronic disease flare, delirium, changing cognition, pneumonia, fall / hip fracture, receiving PT, recent hospitalization, fluctuating ADLs / care needs
    • Functional decline potentially preventable
      • As above, with at most 1 risk factor
why bother
Why bother?
  • 20% trigger when functional recovery possible
    • 1/3 improve
    • 1/3 decline
  • 60% trigger to prevent functional decline
    • 1/3 improve
    • 1/3 decline
cap elements
CAP elements
  • Target nursing and MD
    • Rule out concurrent medical problem
    • Review medications
    • Consider depression
    • Consider orthostatic hypotension
    • Consider pain
  • May trigger other CAPs
    • Delirium, falls, pain, malnutrition
  • Consider physiotherapy (formal, family)
cardiorespiratory cap
Cardiorespiratory CAP
  • Triggered if any MDS item present
    • Chest pain
    • Shortness of breath
    • Irregular pulse
    • Dizzy
  • Additional trigger
    • Systolic BP > 200, < 100
    • RR > 20
    • 50 < HR < 100
    • O2 sat < 94%
  • Triggered by 15% LTC resident
cardiorespiratory cap guidelines
Cardiorespiratory CAP Guidelines
  • Provides guidelines on RN, RPN interventions but promotes MD assessment
    • Consider undertreated chronic disease (e.g. HF)
    • Acute exacerbation of chronic disease
    • Acute problem: pneumonia, PE
comments on caps
Comments on CAPs
  • For complex patients, identifies priority problems
  • Focus on patients in whom intervention may maintain / restore / improve health
  • Provide best-practice guidelines
  • Intend as an aid to, and not as a substitute for, clinical judgement
  • Can also be used to monitor resident progress
following progress
Following Progress

Another use for CAPs

example behaviour cap
Example: Behaviour CAP
  • Triggered if daily
    • Wandering
    • Verbal abuse of others
    • Physical abuse of others
    • Socially inappropriate or disruptive behaviour
    • Inappropriate public sexual behaviour or public disrobing
    • Resistive to care
  • Triggered in 10% of LTC residents
  • Present but less than daily in 8%
behaviour cap
Behaviour CAP
  • 3 trigger levels
    • Daily problem: 1/3 may improve over 90 days
    • Less than daily problem
    • No problem
  • Care plan provides extensive documentation and advice on behavioural management and when to consider medications
  • Opportunity to monitor progress q 3 months
example pain cap
Example: Pain CAP
  • Validated against pain scale Visual Analogue Scale
    • 0 no pain
    • 1 less than daily pain
    • 2 daily pain but not severe
    • 3 severe daily pain
  • 3 trigger levels
    • High priority 3 (5%; 45% may improve; 15% pain-free)
    • Medium priority 1-2 (12%; 35% may improve; 15% pain-free)
    • Low priority 0
pain cap
Pain CAP
  • Provides guidelines on
    • Further assessment, physical exam, diagnostic testing
    • Concurrent / aggravating comorbidities
    • Functional implications
  • Treatment options review
    • Pharmacological
    • Non-pharmacological
  • Progress can be monitored over time
broader considerations
Broader Considerations

The bigger picture

interrai suite hirdes age aging 2006 35 329
interRAI suiteHirdes Age Aging 2006;35:329
  • Integrated set of information systems
    • Common core elements
  • Across sectors within a health care system
    • E.g. Acute care, Home care, Long-Term care
    • LHIN to LHIN
  • Across borders
    • Interprovincial
    • International
other applications to come
Other applications to come
  • Quality assurance indicators
  • Case-mix tools: more accurately / appropriately target resources
  • Research: CIHI is Canadian repository
  • Important component of integrated health information system
closing thoughts
Closing thoughts
  • Coming to a LTC home near you!
  • Data is reliable and valid
  • Information provided allows clinicians to identify and track priority concerns for residents
  • CAPs available to provide guidance to clinicians
closing thoughts53
Closing Thoughts
  • Sit down with your facility’s RAI advisor and play around with the software
  • www.interRAI.org
  • Thank you!