By: JOANNE KALDY
MDS 3.0 on Pressure Ulcers
Nearly 5 months after the Minimum Data Set (MDS) 3.0 went into effect, some nursing facilities are still struggling to implement the new tool. But many have embraced the tool's many new features and are using them to ensure high-quality, person-centered care. In particular, the new approach to resident interviews, still regarded warily by some nursing home staff, is turning out to be enlightening and rewarding, according to several professionals now accustomed to using them.
Kathy Skaggs, RN, (left) and MDS Coordinator Kim Chacon (center) explain MDS 3.0 assessment to patient Bettie Warren at a Piñon-managed nursing home.
Darlene Thompson, RN, CRRN, vice president of clinical information systems/training for the nursing center division of Kindred Healthcare, Louisville, Ky., summed up the attitude many caregivers have toward the new MDS: “I really like the addition of the resident interviews. They are a challenge to obtain, but I like the fact that residents are more involved in the assessment process.”
There is much more about the MDS 3.0 that practitioners and others like, too. “I haven't really heard anything negative about the new MDS,” said Karyn Leible, RN, MD, CMD, chief clinical officer at Piñon Management in Lakewood, Colo., and a speaker at two sessions about MDS 3.0 at Long Term Care Medicine – 2011 in Tampa next month. “As I'm going through the charts, I get a much better picture of residents because of the resident interviews. They definitely provide better data, and I find that nursing staff is more tuned into clinical areas such as pain management because of the interviews,” she noted.
As a result, she said, pressure ulcer management has improved. “We're picking up more deep-tissue injuries than before.”
“The assessments take less time – although 45% less than CMD predicted – and we are getting good information from them,” said Sarah Collings, RN, director for medicine and clinical informatics at Brookdale Senior Living in Nashville, Tenn.
“We get to spend time with residents, and they get to talk about how they are doing. It's great for them, and we are learning more about how they feel and what they need,” explained Ms. Collings.
“The amazing thing about the interviews is that staff will say, 'Wow, I've known the resident for years, and I didn't know this about him.'” said Kathy Skaggs, RN, a quality improvement specialist at Piñon Management. “Every time they learn something new. It's a wonderful experience.”
As a researcher, Dr. Leible said, “I am getting much better information and richer data about pressure ulcers, pain, and other issues. This data will translate into quality improvement models.”
Robert Gibson, PhD, JD, senior clinical psychologist and social work supervisor at Edgemoor Hospital in Santee, Calif., applauded the changes from the old MDS Section E (“Mood and Behavior”).
“It was very poorly structured, and we had a lot of people triggering for mood symptoms when the symptoms were really related to dementia,” he said. “It was not very useful. The 'Patient Health Questionnaire (PHQ)–9' included in 3.0 is helpful for targeting depression.”
Some Challenges Remain
“One of our issues involves installation problems with 3.0 software,” said Dr. Gibson. “We found that we couldn't input or access certain information as part of MDS. That has been a significant issue,” although it might have been specific to his facility, he said. Information technology staff worked closely with vendors and were able to fix the problem, he added.
“The main challenge we've seen is getting used to coordinating the interviews and data collection,” said Dr. Leible. “The other issue is just adjusting to the new tool and taking the time to implement it.” She noted that some billing problems arose last fall, when Congress put the Resource Utilization Group–Version Four (RUG-IV) on hold for a year.
Ms. Collings added, “Transitioning into the new RUG-IV and [prospective payment] changes for billing purposes was really challenging. The initial uncertainty about RUG-IV made payment unsure. We were transmitting in October but not getting validation reports back. It was a rocky month pretty much industrywide, from what I've heard.”
Congress rescinded the hold on RUG-IV in a bill that President Obama signed during the last days of December (see
While most people interviewed for this report lauded the MDS 3.0 resident interviews as an important contribution to quality, person-centered care, the task can be challenging with certain populations, said Dr. Gibson. “We have people with personality disorders who just flat-out refuse to answer questions,” he said. “We also have a fair number of residents with impaired, but still understandable, speech and/or significant cognitive impairment, and conducting interviews with them can be a real challenge.”
Corraling residents to conduct interviews is another challenge, Dr. Gibson said. Many of the facility's residents are younger than age 60 but suffer from brain injuries and diseases such as amyotrophic lateral sclerosis and Huntington's.
“During the day, they may be at physical therapy or at a doctor's appointment, they may be off campus or at an activity, or they may be sleeping or in a bad mood,” explained Dr. Gibson. “Tracking them down has taken longer in many cases than conducting the actual interview.” At the same time, he noted, some patients get irritated or frustrated with the repetitive interviews. “We have some patients who get annoyed because it's the same questions over and over again.”
There are some issues with the Brief Interview of Mental Status (BIMS), designed to detect cognitive impairment. Dr. Gibson noted, “The BIMS doesn't seem to be very sensitive to cognitive impairment. We have residents who are cognitively impaired but can repeat things. Even some of our very demented residents can tell you what the month and year is. A surprising number of people who we know are severely demented score as cognitively intact, and we have to account for this in the notes.”
Ms. Thompson said, “The BIMS assessments are most helpful when you don't know about a resident's cognition. They're not really that useful for short-stay residents who are alert and oriented or with residents who can't answer at all.” However, she added, the BIMS did not create a burden for her staff, who were using a similar tool already. “When MDS 3.0 came out, we looked at what assessments we were using and decided to switch to comparable tools in the MDS to avoid creating more work for staff,” she explained.
Many practitioners suggest that the Centers for Medicare & Medicaid Services should revisit the new system's requirements for discharge assessments. “People are really struggling with those last discharge assessments as they go out the door,” Ms. Collings said. Ms. Thompson said that she likes the information she gets from these assessments but added that that they are “a lot of work.”
“Our short stays have gone up tremendously, so with each assessment involving 38 pages of data, it's a lot of time and effort,” Ms. Thompson explained. “It would have been useful if we could skip the sections that we don't have questions on and just print the necessary pages; but the document doesn't allow us to skip pages, even though our software is intelligent enough to know what can be skipped.” As a result, the team at Kindred Healthcare invested in high-speed, double-sided printers.
“If people are gone for 24 hours, we are supposed to assess them before they leave,” said Dr. Gibson, “which is difficult because they might be too ill or otherwise occupied. It would be useful if we had more latitude about whether there is a need for reassessment, particularly if we expect them to return without significant change.”
Ms. Thompson applauded the new section Q on discharge and returning the resident to the community, but said she has concerns about how realistic it is. “We want to [ensure] good transitions, but this requires more work and documentation, especially on the part of the social services department, which does not always have enough staff to handle this.” She added that many communities don't have the appropriate resources to support a discharged resident.
“CMS certainly has been responsive and said that they are on a learning curve as well with this tool,” said Ms. Collings. “I feel that they are acting as a partner in this, and we really appreciate that. Ms. Thompson also gave the CMS kudos for its training and responsiveness. “The agency did a good job of answering questions, adding vignettes, and putting information online,” she said.
Preparation, Planning, Progress
Facilities that have successfully implemented MDS 3.0 stress that they prepared in advance for the new tool's arrival.
Dr. Leible explained, “We had numerous training sessions about the resident interviews where people role played.” In addition to training videos provided by the CMS, Piñon used one developed by Ms. Skaggs, the facility's quality-improvement specialist.
“Several patients agreed to help our nurses practice their interviewing skills,” said Ms. Skaggs. “After the first couple of interviews, our team felt really comfortable and would sail through them. … Because of this training, they were ready to roll on Oct. 1; and we were all pleasantly surprised at how smoothly it went.”
Ms. Thompson urged facilities to start with the “Long Term Care Facility Resident Assessment Instrument User's Manual” and go through it section by section. “Make use of the training materials the agency has developed. Remember that not just nurses are involved in assessments, so bring social services, recreation, and other players to the table for training,” she said.
Problems that facilities had with MDS 2.0 won't necessarily go away with 3.0, Ms. Thompson said. For example, “with 3.0, you only have 14 days to do the transmission. If you barely had enough time to do the transmission in 31 days [with MDS 2.0], you won't make 14.”
Ms. Collings suggested continuing attention to the MDS changes after initial training.
“We make sure this is a team process,” she said. “We sit down every morning and talk about the assessments: 'Where is the team?' 'Are we on track?' We try to keep everyone focused as a team about what is going on with the residents. … When residents tell us something about themselves during an interview, we want to make sure we do something constructive with that information.”
As a medical director, Dr. Leible has been updating facility policies and procedures to correspond to MDS 3.0's approach to issues such as pain management and restraint use, she said. For example, she took language directly from the revised MDS about what constitutes emergency use of restraints. She also is bringing in information from AMDA clinical practice guidelines, which are referenced in the MDS as a clinical resource.
Although MDS 3.0 isn't perfect and users have some concerns and questions, most remain optimistic. “Taken as a whole, MDS 3.0 is daunting,” Ms. Thompson said. “The wisest approach is to take it section by section and make sure everyone understands what they need to know.
Senior contributing writer Joanne Kaldy is a freelance writer in Harrisburg, Pa., and a communications consultant for AMDA and other organizations.
Sessions Aim To Clarify MDS 3.0
The MDS 3.0 went into effect on Oct. 1, and physicians and other team members are likely to have many questions as facilities implement this tool and adjust to the changes it entails. AMDA will continue to work to educate physicians and other team leaders about how to use MDS 3.0 effectively. Several sessions at AMDA Long Term Care Medicine – 2011, March 24-27 in Tampa, Fla., will focus on the new MDS. These include the following:
▸ MDS 3.0's Care Assessment Area and the AMDA Care Process - Why You Need to Care! (Thursday, March 24, 8:30-11:30 a.m.)
▸ MDS 3.0 Boot Camp for Cognitive, Delirium, and Depression Screening (Friday, March 25, 11:00 a.m.-noon)
▸ Hot Topics in Pressure Ulcers for Long Term Care: A Step-by-Step Review of the Revised Skin Condition Section of MDS 3.0 (Friday, March 25, 1:30-3:00 p.m.)
▸ MDS 3.0 in 2010 … Uh Oh … A Whole New Set of Quality Measures in 2012: Develop a Plan Now to Ensure Your Facility Quality Data Reflects Your Commitment to High Quality Care (Friday, March 25, 3:30-5:00 p.m.)
▸ MDS 3.0 and Clinical Tools (Saturday, 8:00-10:30 a.m. – part of General Session II)
▸ MDS 3.0: Physician Responsibility and Accountability in the Care Process (Saturday, March 26, 11:00 a.m.-12:30 p.m.)
Check out descriptions of these and other sessions at Long-Term Care Medicine - 2011.
MDS 3.0 on Pressure Ulcers
Jeffrey Levine, MD, CMD, will be speaking about “Hot Topics in Pressure Ulcers for Long Term Care: A Step-by-Step Review of the Revised Skin Condition Section of MDS 3.0” at Long Term Care Medicine – 2011 (Friday, March 25, 1:30-3:00 p.m.).
He will be sharing the session with nationally recognized wound-care expert Elizabeth Ayello, RN, PhD. Dr. Levine talked to Caring for the Ages:
“The new section M is 2 pages long and excruciating in detail. I could take hours just to introduce it,” said Dr. Levine. “Much of the section is brand new, and people are still trying to understand it. There is a great deal of confusion about issues of staging and classification of wounds.”
Significant in the new tool is a prohibition against reverse staging. “Previously, the MDS required reverse staging, so facilities and staff are having difficulty accepting this change,” he said. However, this change is just one revision in the MDS designed to better meet patients' needs and provide for better assessments and standards of care gleaned from clinical practice guidelines that didn't exist 20 years ago.
“This revised tool raises the bar for wound assessment skills, but it is taxing on facilities because it will require retraining and increased manpower,” Dr. Levine said.
Section M records whether a pressure ulcer developed in the nursing facility or other setting (such as the hospital). However, Dr. Levine noted that the Long-Term Care Facility Resident Assessment Instrument User's Manual makes this determination a bit more complex than meets the eye.
If a resident is admitted with a pressure ulcer and that wound worsens in the nursing home, it is no longer coded as hospital acquired. Nonetheless, MDS 3.0 presents an opportunity to improve transitions of care regarding pressure ulcers, said Dr. Levine.
He explained that many facilities will have to upgrade their wound care services, including identifying an in-house person qualified to oversee this care.
As all aspects of clinical care benefit from interdisciplinary teamwork, the new MDS form “screams for physician collaboration on skin care,” said Dr. Levine. “You have to get physicians in line with the issues addressed in the document. This is a great place for the medical director to step in and provide guidance.”
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