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It's time for a look-back period

August 16, 2011
by root
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Three MDS experts reflect on 3.0′s impact and weigh in on areas for improvement

Everyone needs a good sounding board. For many nurses, that forum is oftentimes a listserv. In commemoration of last year's big MDS package, Long-Term Living invited three erudite MDS professionals to engage in a civil email powwow on all things 3.0-the good, the bad and the “baptism by fire” that was October 2010.

First, the participants:

Sheri Kennedy, RN, BA, MSEd, RAC-MT, is president and CEO of Knowledge Solutions. An AANAC Master Teacher and author with more than 40 years' experience in healthcare, Kennedy was a Gold Standard Nurse on the Centers for Medicare & Medicaid Services' (CMS) RAND project team, conducting reliability and validity testing on the MDS 3.0 prior to its implementation.

Carol Maher, RN-BC, RAC-CT, is a member of the AANAC Board of Directors with more than 15 years' experience on the MDS. Maher was a member of the AHRQ Technical Expert Panel and RTI's Technical Expert Panel for MDS 3.0, as well as a Gold Standard Nurse providing training to the California facilities participating in the RAND validation project.

Dawn Diyer, LVN, RAC-CT, is a certified nurse assessment coordinator with 20 years' experience in long-term care, completing MDS assessments for more than 10 years. Diyer participated in the national MDS 3.0 validation study.

What would you change about the MDS 3.0?

Carol Maher: If I could alter one aspect, it would be to shorten or eliminate the discharge assessments. Since resident interviews must be done within the 7-day look-back window, MDS coordinators had to find new ways of scheduling assessments. It is no longer easy to change Assessment Reference Dates (ARDs) and no one on the team can drop the ball.

This could be managed with the assessments previously required. However, the addition of the discharge assessments requires so much additional work that it seems to be the straw that breaks the camel's back. Doing large assessments for residents who no longer require a care plan or care seems unnecessary. For example, a resident admitted to the SNF and discharged within a few hours now requires an entry tracking form and a 27-page discharge assessment. Residents who come and go on respite stays need entry tracking forms each time they are admitted and a discharge assessment each time they are discharged.

Sheri Kennedy: I had difficulty focusing on just one thing to change. Then I realized that the common thread between every item I considered was time. The time issues originated with the MDS 3.0 national study where the Gold Standard Nurses and staff who participated were able to complete the assessment in significantly less time than what was required to complete the MDS 2.0. Unfortunately, the tool underwent numerous additions and revisions, resulting in a final product that took longer to complete than the version we studied. And it was the timeline from the original study that was touted as one of MDS 3.0′s advantages. So right out of the gate “the boss” expected completion of the MDS 3.0 to take less time. Thus began the setup to fail.

The Care Area Assessment (CAA) process was slightly changed and for many it was the first time they realized how the decision-making phase of the Resident Assessment Instrument (RAI) process was supposed to work. This resulted in a significant increase in workload for MDS nurses who had not previously been working the Resident Assessment Protocols (RAPs).

Finally, although I love the SNF Open Door Forum (ODF) Calls, they have been a source of conflict and confusion. Questions and answers during these calls need to be incorporated in an RAI User's Manual update, or some other official document. Since not everyone is aware of what is being said, MDS 3.0 data is becoming less reliable.

Now back to the original question: What I would like to change is the time required to complete a reliable and valid MDS 3.0. Some suggestions: pare down the discharge assessment to essential items only; clarify in detail the End of Therapy (EOT) OMRA timing issues in the manual; and allow the interviews to be completed after the ARD in conjunction with all other data collection to limit the number of times the staff needs to interrupt the resident's routine.

Maher: The EOT OMRAs are to be required when a resident misses therapy for three consecutive days regardless of reason (all tied into how many days the facility is capable of providing therapy per week). As Sheri mentioned, this has been instructed on the ODF calls with instructions requiring new therapy evaluations in order to begin collecting therapy minutes again. This was never added to the RAI manual, however, even though there has been a manual update. This means facilities that are proactive and listening to the ODF calls are getting less reimbursement when completing the EOTs as instructed than the facilities not following or knowing the new rules. And the fiscal intermediaries seem unaware of the instructions given on these calls as well.

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