In October 2010, the minimum data set (MDS) 3.0 changed the way in which nursing home residents’ needs were assessed. It created new psychosocial requirements, including direct resident interviews for cognition, mood, customary routine and preferences, pain, and return to the community.
It also requires nursing home interdisciplinary staff to use standardized tools, including the Brief Interview for Mental Status (BIMS) and the Confusion Assessment Method (CAM) in Section C, the Patient Health Questionnaire (PHQ) 9 in Section D, a new Preference Assessment Tool (PAT) in Section F, and a Numeric Rating Scale (0-10) or a Verbal Descriptor Scale pain assessment tool in Section H.
In Section Q, residents are asked about their desire to return to the community. If the answer is yes, there are procedures to follow with local contact agencies and support through Money Follows the Person or local contact agencies.
This article is a follow-up to a Provider October 2010 focus group article that found MDS 3.0 psychosocial training was needed because social workers and interdisciplinary staff were not prepared for the new requirements.
There were concerns about inconsistent levels of social work staff, qualifications, and caseloads. Given these results, a second set of focus groups was conducted in 2011 with social workers and nurses to learn how the implementation was going from the perspective of staff in the field.
This article presents the results from these group sessions, which aimed to understand the impact of MDS 3.0 implementation on psychosocial assessment and care planning in nursing homes.
Focus Group Findings
The second set of focus groups was conducted in two phases, each held with nursing home nurses and with both licensed and unlicensed social workers/social work designees. Twenty-four participants represented a range of for-profit and not-for-profit facilities, small and large facilities, and rural and urban areas.
During the teleconference, they responded to questions sent in advance regarding the positive and negative impacts of MDS 3.0 on both residents and staff, as well as on the care area assessments (CAAs).
The results of the focus groups revealed consistency in responses to questions and concerns identified from nurses and social workers. MDS 3.0 positive findings included the insightful nature of resident interviews, which often resulted in new information for staff, and the identification of suicidal residents with the PHQ 9.
Importantly, interdisciplinary roles were found to be better defined as different team members are now required to fill out different sections of the MDS 3.0.
A stronger role for social work has now been created in terms of acting as interdisciplinary facilitator and leader. The most common MDS 3.0 role configuration involved social workers completing cognition, mood, and return-to-community items; nurses completing the pain and delirium items; and the activities therapist completing preferences.
Redundancy, Time Management
The focus group participants identified the requirement to repeat multiple clinical interviews for the five-, 14-, 30-, 60-, and 90-day Medicare assessments; discharge assessments; and OBRA (Omibus Budget Reconciliation Act) assessments as their most significant concerns about MDS version 3.0.
The redundant interviews were reported to be frustrating for residents and resulted in reduced quality time staff can spend with residents. The negative impact on overall quality of care as the result of more time being spent on documentation, repeated interviews, and CAAs was noted to be most concerning to both disciplines.
The participants also noted the importance of interdisciplinary work, while also acknowledging a lack of formal training in how to function as a team. Those who believed their teams functioned well prior to MDS 3.0 expressed less role conflict and ambiguity.
Several participants emphasized that the greater demands of the new system placed more stress on the teams and therefore more conflict.
Ideally, staff members need to be trained to work as a unit, where members feel comfortable expressing themselves and decision making is shared. There needs to be role clarity where staff understand what is expected of them by the organization as it relates to MDS 3.0 completion, care plan development, and implementation.
This is a problematic area in facilities, where staff have no training in teamwork and the training and credentials of staff vary.
Interdisciplinary teamwork with appropriate understanding of each other’s roles is the gold standard; teams that do not have this seem to struggle more with the MDS 3.0.
Both social workers and nurses were concerned because there was limited CAA training, especially around psychosocial issues.
CAA Processes ‘Hard To Follow’
All focus group staff reported using CAAs developed by the Centers for Medicare & Medicaid Services (CMS), and none were using their own evidence method, as described in the “MDS 3.0 Manual” (Appendix C–84). Yet, they had major concerns: CAAs were described as “not easy to follow” and not providing step-by-step evidence-based approaches that would be suitable for staff with varying educational backgrounds, such as those from a social service designee with a high school education versus masters-trained social workers or nurses.
In addition, multiple CAAs are triggered and keep staff so busy with documentation that there is less time for continued assessment, interventions, and interdisciplinary coordination of care. Documentation requirements must be understood in terms of the number of CAAs and total caseload.
Finally, completion of Section Q creates problems because of inconsistencies across states regarding procedures, expectations, referral response times, and lack of clarity as to how this section should be completed.
Engaging residents in the interview process is a positive step toward a person-centered approach, the focus groups agreed. If the MDS 3.0 is to be an effective tool, there need to be consistent standards of training done for an interdisciplinary group of qualified practitioners, participants concluded.
This study confirmed the 2010 focus group findings that “clinical training beyond MDS 3.0 coding is required and should be offered by national nursing facility organizations and their affiliates.”
The types of training needed include: team cohesion, using and interpreting scores on standardized scales, and testing issues.
In addition, staff need more guidance on developing procedures for addressing differences in self-reporting versus clinical observations and guidelines for developing treatment responses, the focus group observed.
Residents’ voices are critical to person-centered care; however, the frequency of the interviews needs to be addressed as it creates frustration for elders and staff.
These focus groups provided critical feedback for improving both processes and practice.
Go to: www.providermagazine.com for a case study example of how the MDS 3.0 has impacted a resident.
Robert P. Connolly, LCSW-C, a consultant and retired from the Centers for Medicare & Medicaid Services, is based in Ellicott City, Md., Deirdre Downes, LCSW, is director of social work for Jewish Home Lifecare, New York, N.Y., and Jake Reuter, LSW, is director of the North Dakota Money Follows the Person program, Bismarck, N.D.