Changes​ made by the Centers for Medicare & Medicaid Services (CMS) for the Minimum Data Set (MDS) 3.0 system effective Oct. 1, 2011, will add more assessments for skilled nursing facilities and make some significant alterations to group therapy provisions and other measures, according to experts in the field.
The bottom line is that providers must keep track of the changes and meet the requirements or suffer incorrect, inadequate, or misdirected payments and possible CMS scrutiny or even investigation. 
The evolution of MDS 3.0 and related systems is an ongoing process for the nursing home profession, and what happens next is as important to know now as it was when CMS shifted the paradigm from MDS 2.0 to the present calculation in October 2010, experts say.

Adjusting Anew

By now skilled nursing operators realize the changes CMS made to MDS for fiscal year 2012, which have been the subject of CMS outreach efforts and training for some months, as well as trade association educational programming. Even days before the Oct. 1 trigger date, CMS was making clarifications to help providers navigate the changes.

To help explain the issues swirling around assessments, Kindred Healthcare’s Darlene Thompson and Tami Johnson recently made a presentation to the American Health Care Association (AHCA) and its members, titled, “CMS Changes Related to MDS Completion and SNF Medicare Billing,” which reviewed the most important changes contained in the CMS prospective payment system (PPS) final rule.

Their theme was simple: Providers have successfully dealt with the changes that came when MDS 3.0 started in 2010, along with the Resource Utilization Group (RUG) IV transition, and so the latest CMS adjustments will be overcome as well.

“Our industry is resilient and has a demonstrated track record for adapting to change,” Thompson and Johnson said.

Their outline reviewed the key points of the rule, including the fact that CMS adjusted the case mix index and associated rates, which grabbed national headlines with the sharp “correction” in payments to skilled nursing facilities by a negative 12.6 percent. The adjustments, which were met with sharp criticism by AHCA and the entire long term care community, targeted the nursing component of the rehab RUGs. 

CMS also applied a positive 2.7 percent market adjustment, but reduced that by 1 percent as mandated by provisions in the Affordable Care Act health care reform law. Overall, the Medicare reimbursement reduction is 11.1 percent.

Changes Take Toll

“The biggest thing CMS has done is set up a system where the patient is evaluated essentially every seven days, which has the potential to increase assessments 10 to 25 percent,” says Johnson, Kindred’s director of care management.

“This represents the second time in two years we’ve had an increase in the number of assessments,” she says.

Johnson is referring to the fact that when CMS switched from MDS 2.0 to 3.0 last year, there was a 30 percent jump in the number of assessments. Now, with the changes in place for 2012, there is a potential for an increase of more than 40 percent over two years.

This rise in the number and depth of assessments has a real impact at the facility level, with more time being spent by various staff members to fill out electronic versions of MDS forms instead of doing other productive tasks in caring for residents, Johnson says.

Paperwork On Paperwork

The people inside a facility most affected by the paperwork battle are logically the MDS coordinator, or multiple coordinators in the case of larger buildings, social workers, nutritionists, rehab therapists, and activities directors. At its larger buildings, there can be as many as four MDS coordinators, Kindred said.

“It takes away time from nurses to be at the bedside or teaching,” says Thompson, Kindred’s vice president for clinical information systems and training.
The reason for the higher volume of assessments is the result of CMS wanting nursing facilities to prove their rehab services are indeed needed at the higher rates seen in recent years. The skilled nursing sector understands that rehab is a larger and larger chunk of its business, but the government has not caught on, Thompson says.

“CMS, in their words, believes they are paying for rehab services that are not being delivered. In some of our conversations [with CMS], they still have the perception that we are running nursing facilities like they were run 10 to 20 years ago,” she says.

In fact, in the modern nursing care world, Louisville, Ky.-based Kindred discharges 50 percent of its residents, reflecting the sea change in the industry for shorter stays and more rehab.

Asked why there is this disconnect with CMS on what actually goes on in today’s nursing homes, Johnson says it is a lack of expertise in the new long term care world that is resulting in the misdirected policies.

“They have people with long term care experience; however, they have experience from 15 to 20 years ago and haven’t been in the field recently enough,” Johnson says.

If you added all the time spent at Kindred’s 225-plus skilled nursing facilities, it would amount to 37,000 hours every month on filling out MDS forms, she says. “And it is extremely technical work. In an average month, one Medicare patient with us for 30 days will have had three assessments,” Johnson says.

Benefits Seen In New System 

MDS 3.0 is not a negative experience except for the paperwork, Johnson notes. The improvement from MDS 2.0 is significant, with the direct resident input helping to drive a more successful care plan. “It’s just the constant repetition of information,” she says.

Thompson expands on that sentiment, saying the CMS effort to create a more resident-centered care plan is a good idea. She sees any further changes to MDS 3.0 to make it more efficient happening over an extended period of time. 

“It has to be more of a day by day reaction to taking care of the patient,” she says for her hopes of a future, less burdensome, assessment process.

Certainly, the negative part of the revisions for 2012 was the steep Medicare reimbursement reduction, says Lori Opfer, executive director of Covenant Care-owned Edgewood Manor Nursing Center in Port Clinton, Ohio.

Her 99-bed skilled nursing facility is stepping up its efforts to market its services and fill as many beds as possible to make up for lost reimbursement from Medicare, she says.

As for the work it takes to meet the requirements of MDS 3.0, Opfer says her staff is handling it well. 
“We’ve been able to meet requirements, thanks to a lot of corporate training. It is going extremely well,” she says.

The shift last year from MDS 2.0 to 3.0 saw the inclusion of patient input into the assessment process, a change that Opfer feels is worthwhile. To collect assessments in the more patient-centered 3.0 program takes a lot more time.

“There is a lot more paperwork, but we have the staff totally dedicated to MDS to make it work. There also is a lot more time for social services to get involved with the assessment, but it is up to the MDS coordinator to be totally involved, of course,” she says.

The biggest changes she sees for 2012 are in therapy classification and scheduling, but right ahead of the Oct. 1 deadline she echoed the sentiments of a lot of providers when it comes to MDS.
“We are prepared for it,” Opfer says.

MDS And Care Planning 

If there is one person who knows about the MDS system and its development in the Resident Assessment Instrument (RAI) it is Steve Levenson, multifacility medical director for Genesis HealthCare, Kennett Square, Pa. This summer marked his 30th year in the long term care sector, most of which saw him logging extensive time helping to develop regulations and guidelines included in the “RAI Manual,” in which the MDS resides.

He calls the changes made by CMS for 2012 “not radical” in nature and limited in scope. Levenson has worked out a training program for providers showing how to use the data from the MDS/RAI for providing better care planning.

“I talk about what to do with the information,” he says. “How do you determine a system, and how do you identify if it’s a problem.” This is where the MDS/RAI can be used for evidence-based medicine, to be used as a tool for caring for residents and eliminating some of the faulty assumptions about what ails residents.

Depressed? Or is it Something Else?

If a resident is unhappy, does that mean the individual is depressed? “If depressed, do they need a treatment?” Levenson asks as part of his example. There is no evidence that for mild and moderate forms of depression that antidepressants help, he says. The evidence actually shows antidepressants are only better than placebo for severe or very severe depression.

Still, antidepressants are used for almost half of residents in nursing facilities for even minimal symptoms. Levenson wants the assessment process to be part of a new way of making adjustments to a resident’s care based on reality, not assumption.

Levenson advocates for correcting these flaws by using MDS assessments and RAI to cut down on guesswork, look for the causes of resident symptoms, and put historic details of the patient into the care plan. 

“History is all-important to causation. You gather facts in bits and pieces,” he says. He likens the process to that of common everyday occurrences and how people go about figuring out the causes of problems. If your roof leaks, he says, you examine what is making it leak. Is it the wind? Is it the rain or something else?

Besides depression, other common topics that call out for better use of evidence-based care are hydration, hypothyroidism, dementia, delirium, pneumonia, pain management, bowel obstruction, and risk of aspiration, among others, he says.

It’s A Tool

The MDS is a tool, Levenson says, but to be used effectively in individualizing a care plan, it must first be mastered. “You can walk into a Home Depot, but that doesn’t make you a builder. This is a tool that needs to be understood. It’s not just a check-off option,” he says.

Providers need to be careful of making mistakes in administering the MDS process, he says. It is not good if staff are not trusted to help with the assessments, if the process is all turned over to an MDS coordinator. He also says facilities should seek out causes for symptoms and have a care process as a result of the data set being built for each resident.

Levenson conducts seminars across the country on the assessment process and focuses on what to do with all the information CMS and the states want gathered. “The focus of the talk is what does it all mean, how do you decide toward a care planning process,” he says. 

RAI Has Its Uses, Limits 

The gist of the discussion is on the uses and limits of the RAI. It is a meaningful and helpful process when used correctly for intended purposes, but can be a problem if used without proper understanding or used outside of its intended design, he notes.

Levenson says RAI use cannot serve in every situation, like with a resident suffering from complex and multiple symptoms. Additional information beyond MDS is needed for care, Levenson says.
MDS covers three key dimensions: physical, like a person’s weight, skin condition, medical condition, and vision; functional, ADLs and behavior; and psychosocial, like preferences, beliefs, goals, interests, and family interactions. The 3.0 version of MDS has greatly improved the details of a resident’s personal preferences and choices and has better screening tools. It also gives a foundation for clueing in on possible issues and concerns that may require more review.

The remainder of the RAI allows care area assessments (CAAs) and utilization guidelines to start the process of thinking about areas for possible investigation, whether findings represent a problem or risk requiring further intervention, causes and risk factors related to a triggered care area, and formulating a care plan.

Levenson says the CAAs are indentified by responses to items on the MDS and reflect conditions, symptoms, and other areas that could need review and investigation. 

“If certain responses on the MDS occur, then CAA is triggered because an item may be associated with the possible presence of a condition, concern, risk, or problem. 

“Further assessment is needed to determine the significance because MDS findings alone cannot guide effective clinical problem solving and decision making,” Levenson says.

Examples of MDS as a screening tool are for tuberculosis, depression, and fall risk.

Steps To Evidence-based Care Include History

To get beyond MDS and to individualized patient-centered care, Levenson lays out a case for long term care facilities to take a history of residents. 

Delving into residents’ histories will allow staff to discover symptoms; get accurate descriptions; secure a chronology of events; and determine how an illness, impairment, or psychosocial concern has changed their lives.

“MDS data are often at the level of a chief complaint [headache, vomiting, coughs when eating] or isolated finding, missing important detail,” he says.

“It is important to avoid premature interpretation such as failing to record seemingly irrelevant symptoms or events, and it may be problematic to assume the conclusion and fail to seek additional information.”

Using the basics of the famed researcher Richard DeGowin, it is important for providers to insist that residents describe their symptoms in their own words, not using medical jargon. 

If several conditions are suggested from this process, notice how there may be some symptoms missing from the direct descriptions offered by the resident, making it clearer to diagnose what is wrong.

Levenson says some common widespread advice is to believe whatever the resident tells a nurse and accept the resident’s word on pain. But, this does not mean a resident’s answers cannot be questioned for accuracy and to act just on what the resident says.

The Opportunity Of MDS 

MDS 3.0 is a great chance to rethink what an assessment means and implies, Levenson says. It is also a chance to rethink other areas of the care process, like the use and limitations of the tools in MDS 3.0 and how RAI fits in the context of the entire clinical problem-solving and decision-making process.

The steps to use RAI components are critical to develop individualized care planning and follow-on care, Levenson says. 

This sentiment for patient-centered care through the RAI/MDS system coincides with the CMS shift to promoting evidence-based care and the agency’s requirements that providers give more explanation on how they provide care and why they should be reimbursed for such services.

The mantra for providers and their staff is to be able to change with the times and look for opportunities to continue to improve quality for the nation’s frail and elderly. ​
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