1 Transition to MDS 3.0 By: Haideh Najafi, RN, BSN, MSED, EDS And Tedi Beckett, RN, MSN September 14, 2010

2 Objectives  Describe the goal of the MDS 3.0.  Compare MDS 2.0 and 3.0.  Describe section Q.

3 Important!  MDS 3.0 will replace MDS 2.0 on October 1, 2010.

4 Areas of Changes  RAPs CAAs  RUG-III RUG-IV  OSCAR CASPER  Swing beds submission of QM data

5 MDS 3.0  The MDS is a core set of screening, clinical, and functional status elements, including common definitions and coding categories, which forms the foundation of comprehensive assessment for all residents.

6 Purpose of the MDS 3.0  The primary purpose of the MDS is to identify resident care problems.  It is used for reimbursement.  It is used to monitor the quality of care in the nation’s nursing homes and develop QI (Quality Indicator) and QM (Quality Measures) reports.

7 Goal of the MDS 3.0  Introduce advances in assessment measures.  Increase the clinical relevance of items.  Improve the accuracy and validity of the MDS tool.  Increase user satisfaction.  Increase the resident’s voice by introducing more resident interview items.

8 Goal of the MDS 3.0 (continued)  Increase the reliability, efficiency, and usefulness of the MDS.  Use standard protocols used in other settings.  Improve clinical assessment.

9 Resident interview sections Section C: Cognitive Patterns. Section D: Mood. Section F: Preferences for Customary Routine and Activities. Section J: Health Conditions. Section Q: Participation in Assessment and Goal Setting.

10 MDS 3.0: The Instrument SectionTitle AIdentification Information BHearing/speech/vision CCognitive Patterns DMood EBehavior FActivity preferences GFunctional Status

11 MDS 3.0: The Instrument (continued) HBladder/Bowel IActive Diagnoses JHealth Conditions KSwallowing/Nutritional Status LOral/Dental Status MSkin Condition NMedications

12 MDS 3.0: The Instrument (continued) OSpecial Treatment/Procedures/Programs PRestraints QParticipation in Assessment/Goal Setting VCare Area Assessment (CAA) Summary XCorrection Request ZAssessment Administration

13 Resident Assessment Instrument (RAI) RAI MDSCAA (RAPs) Utilization guidelines

14 RAI (continued)  The three basic components of the RAI are: a) MDS 3.0. b) Care Area Assessment (CAA) process. c) Utilization guidelines.

15 Care Area Assessment (CAA)  The CAA assists the assessor to interpret the information recorded on the MDS 3.0.  The CAA provides guidance on how to focus on key issues identified by the MDS 3.0.  The CAA directs facility staff to evaluate triggered care areas.

16 Comparison of MDS 2.0 & 3.0 MDS 2.0MDS 3.0 RAPCAA There were 18 trigger areas on the RAPs in MDS 2.0 of the RAI. There are 20 care area triggers (CATs) for the CAAs in MDS 3.0, which includes the addition of Pain and Return to community.

17 USE of the QM and QI in MDS 3.0 The quality indicators (QIs) and quality measures (QMs) assist: 1) Nursing home providers with quality improvement activities and efforts. 2) State surveyors to identify potential care problems in a nursing home.

18 USE of the QM & QI (continued) 3) Nursing home consumers in understanding the quality of care provided by the nursing home. 4) CMS with long term quality monitoring and program planning.

19 Important!  During an interim period after MDS 3.0 is implemented, the QI/QM reports will not be available to facilities or surveyors. This interim period may last up to one year (or longer).

20 Section Q: Participation in assessment and goal setting

21 Intent of Section Q  The items in this section are intended to record the participation and expectations of the resident, family members, or significant other(s) in the assessment and to understand the resident’s overall goals.

22 Section Q  In January 2008, CMS asked 12 volunteer states to provide input on the development and implementation of policies, procedures, and tools used in transitioning individuals from institutional to community living setting, including changes to Section Q of the MDS 3.0.

23 Section Q (continued)  Changes in the MDS 3.0 Section Q are part of broader, systematic efforts by CMS to support an individual’s right to choose the services and settings in which they receive those services. This right became law under the American with Disabilities Act (1990) and were clarified with further interpretation by the U.S. Supreme Court in the Olmstead vs. L.C. decision in 1999.

24 Section Q (continued)  Based on the Americans with Disabilities Act (ADA), residents needing long-term care services have a right to receive services in the least restrictive and most integrated setting.

25 Section Q (continued)  The MDS 3.0 Section Q should not be confused with the Money Follows the Person (MFP) grant program.

26 Section Q (continued) MFPMDS 3.0 Section Q The MFP program is narrowly targeted to Medicaid clients, specifically to those Medicaid clients who have been residing in institutions (nursing facilities and ICF-MRs) for six months or longer. The MDS 3.0 process covers everyone in a nursing facility, Medicaid and non-Medicaid clients alike, and covers them from admission onward.

27 Section Q and Discharge Planning  Section Q has been broadened beyond the traditional definition of discharge planning for sub-acute residents to encompass long stay residents, including the elderly, disabled, intellectually challenged, and younger nursing home residents.

28 Section Q (continued)  Section Q now asks the resident directly (instead of nursing facility staff), “Do you want to talk to someone about the possibility of returning to the community?”  Section Q also asks if there is a discharge plan in place and if a referral has been made to the local contact agency (LCA).

29 Section Q (continued)  A “Yes” response will trigger follow-up care planning. The facility will contact the designated local contact agency (LCA) about the resident’s request within 10 business days of a “Yes” response being given.

30 Section Q (continued)  The facility will inform the resident that answering “Yes” to the question signals the resident’s request for more information and will initiate a contact by someone with more information about support available for living in the community.  The facility will inform the resident that he or she can change his/her decision (whether or not he/she wants to speak with someone) at any time.

31 Section Q (continued)  Answering “yes” does not commit the resident to leave the nursing home at a specific time; nor does it ensure that the resident will be able to move back to the community.  Answering “No” is also not a permanent commitment.

32 Section Q (continued)  The resident must be actively and meaningfully participating in this assessment process.  If the resident is not able to actively and meaningfully participate in this assessment process, then the family or significant other(s) can participate.  “Significant other does not include nursing home staff.”

33 Section Q (continued)  If the resident is not able to actively and meaningfully participate in this section of the assessment process, and there was no family or significant other(s), then the legally authorized representative can participate in this assessment.

34 Comparison of Section Q of the MDS 2.0 & 3.0 MDS 2.0MDS 3.0 Discharge potential item asked the assessor if the resident expressed a preference to return to the community Return to the community referral item asks the individual (resident) if he or she is interested in speaking with someone about the possibility of returning to the community

35 Comparison of Section Q of the MDS 2.0 & 3.0 (continued) MDS 2.0MDS 3.0 The assessor’s findings were recorded in the data base and no follow-up action was required. If the resident responds “Yes,” then the facility must initiate care planning and refer the resident to a state- designated local contact agency (LCA).

36 Comparison of Section Q of the MDS 2.0 & 3.0 (continued) MDS 2.0MDS 3.0 Determined if the resident has a support person who is positive toward discharge. A more extensive series of questions for assessment and investigation for care planning is asked. Asked only upon admission and annually Asked at admission, annually, quarterly, and on significant change assessments

37 Section Q (continued)  Section Q is resident-driven rather than what the nursing home staff judge to be in the best interest of the resident.  The focus is on the resident’s options, not whether or not the staff considers the resident to be a good candidate for return to the community.  Section Q avoids trying to guess what the resident might identify as a goal regarding returning to the community.

38 Section Q (continued)  Do not infer based on a specific advance directive, such as a “do not resuscitate” (DNR) order.  The resident should be provided options, as well as access to information that allows him/her to make the decision and to be supported in directing his or her care planning.

39 Section Q (continued)  Do not assume that any particular resident is unable to be discharged to the community.  Even if the staff believes that it is unlikely for the resident to return to the community based on available social supports and past nursing home residence, this section should be coded based on the resident’s expressed goals.

40 Section Q and the Discharge Plan  The care plan for the resident who will be discharged should include: The name and contact information of a primary care provider chosen by the resident, family, significant other, guardian, or legally authorized representative.

41 Section Q and the Discharge Plan (continued) The arrangements for the durable medical equipment (if needed). The formal and informal supports that will be available. The persons and provider(s) in the community who will meet the resident’s needs.

42 Section Q and the Discharge Plan (continued) The place the resident is going to be living. In addition to home health and other medical services, discharge planning may include expanded resources such as assistance with locating housing, employment, and social engagement opportunities.

43 Focus of the Section Q  Asking the resident and family about whether they want to talk to someone about a return to the community gives the resident voice and respects his or her wishes.  This step does not guarantee discharge but provides an opportunity for the resident to interact with local contact agency (LCA) experts.

44 Discharge Instructions  Discharge instruction at a minimum should include: The individual’s preferences and needs for care and supports. A follow-up appointment with the designated primary care provider in the community and other specialists (as appropriate). Medication education.

45 Discharge Instructions (continued) Prevention/disease management education Focusing especially on warning symptoms regarding when to call the doctor. Who to call in case of an emergency or if symptoms of decline occur.  Use return demonstration methods to ensure that the resident understands all the factors associated with his or her discharge.

46 Discharge Instructions (continued) Involve community mental health resources (as appropriate) to ensure that the resident has support and active coping skills that will help him or her to readjust to community living.

47 Important !  The nursing home staff must not make an interdisciplinary determination that discharge is not feasible without consulting the resident, if the resident can be interviewed.

48 Important !  Each nursing home needs to develop relationships with their LCAs to work with them to contact the resident and their family concerning the potential return to the community.

49 Section Q and the Discharge Plan  For additional guidance, see CMS, Planning for Your Discharge: A checklist for patients and caregivers preparing to leave a hospital, nursing home, or other health care setting, available at:  pdf/11376.pdf

50 State of Michigan Local Contact Agency (LCA)  The MI Choice Waiver Agencies

51 State of Michigan Contact Person  The state of Michigan’s designated point of contact for the MDS 3.0 section Q: Telephone #:

52  MDS update: tyInits/25_NHQIMDS30.asp. tyInits/25_NHQIMDS30.asp  National Government Services (NGS): & hot line number: or

53  State MDS Automation Coordinators: hot line number:  State RAI/MDS Coordinator: hot line number:

54  Questions?

55 Acronyms Americans with Disabilities Act (ADA) Care Area Assessment (CAA) Certification and Survey Provider Enhanced Reporting (CASPER) Care Area Triggers (CATs) Center for Medicare and Medicaid Services (CMS)

56 Acronyms Do Not Resuscitate (DNR) Local Contact Agency (LCA) Money Follows the Person (MFP) Minimum Data Set (MDS) National Government Services (NGS)

57 Acronyms Online Survey Certification and Reporting (OSCAR) Quality Indicator (QI) Quality Measure (QM) Resident Assessment Instrument (RAI) Resident Assessment Protocol (RAP) Resource Utilization Group (RUG)