​In early January, the Centers for Medicare & Medicaid Services (CMS) released the draft Minimum Data Set (MDS) item sets (v1.18.0), which provided insight into the plethora of changes coming Oct. 1, 2020. These changes include demographic information, health literacy, pain interference, nutritional approaches, and medications, just to name a few.

With nearly 60 items being added to the MDS this fall, it is important for the interdisciplinary team (IDT) to understand the rationale behind the additions, who the changes will affect, and how workflows may need to be adjusted.

Why is CMS adding so many items to the MDS?

The answer to the question is simple—the IMPACT Act of 2014 (Improving Medicare Post-Acute Care Transformation) required the addition of data elements to the assessment instruments that are used in each of the post-acute care settings.

For skilled nursing facilities (SNFs), this prompted changes to the MDS. This legislation requires that CMS develop and implement quality measures from the quality measure domains and Standardized Patient Assessment Data Elements (SPADEs). 

In addition, SNFs must report SNF Quality Rating Program (QRP) measure data and SPADEs to meet the set thresholds. If the SNF fails to report 100 percent of the required data on at least 80 percent of the assessments, the provider will be penalized with a 2 percent reduction in the Medicare annual payment update (APU) for that program year.

To begin collecting SPADEs data, the fiscal year (FY) 2020 SNF Prospective Payment System (PPS) Final Rule finalized the addition of 59.5 items to the MDS item set, taking effect Oct. 1.
Big changes are in store for the workflow of the nurse assessment coordinator (NAC), the IDT, and leadership. 

When major MDS changes occur, it is not just the NAC who needs to know—the IDT and leadership team must also be tuned in. But keep in mind, facilities still need more information to understand and effectively plan for these new items. When CMS releases the updated RAI (Resident Assessment Instrument) User’s Manual, its coding instructions will clarify requirements so that SNFs can begin implementing these new items.

Although the yet-to-come manual will be the final piece to the puzzle, SNFs can still get started by looking at what’s to come and preparing for what is currently known. Here are a few of the big changes to expect this October.

A1005 Ethnicity, A1010 Race

MDS items A1005 and A1010 on the draft item set have greatly expanded ethnicity and race options. This information may be collected by social services, the admitting nurse, or another delegate. 

Often, the software autopopulates demographic information on the MDS when this information is entered elsewhere in the electronic health record. Leadership may need to work with software vendors to ensure these additional ethnicity and race options are made available.

A1250 Transportation, A1270 Transportation (Discharge)

MDS item A1250 collects information on transportation at the start of a Medicare stay, and A1270 collects these data at the time of discharge. CMS clarified in the FY 2020 SNF PPS Final Rule that they “believe that use of this data element will provide sufficient information about transportation barriers to medical and nonmedical care for SNF residents and patients to facilitate appropriate discharge planning and care coordination across PAC [post-acute care] settings.”The SNF team will need to determine not only how this information will be gathered and documented, but also who will be responsible for coding this information on the MDS.

B1300 Health Literacy, B1320 Health Literacy (Discharge)

In the FY 2020 SNF PPS Final Rule, the Department of Health and Human Services defined health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions.”

CMS further clarified that, “Poor health literacy is linked to lower levels of knowledge about health, worse health outcomes, and the receipt of fewer preventative services but higher medical costs and rates of emergency department use.”

Starting this fall, health literacy will be assessed on the 5-day assessment and on the Medicare PPS Discharge Assessment by asking, “How often do you need to have someone help you when you read instructions, pamphlets, or other written material from your doctor or pharmacy?”

BIMS interview and the Confusion Assessment Method (CAM) on discharge

Another addition to the October 2020 MDS item set will be the introduction of, at the time of discharge, cognition assessment using the Brief Interview for Mental Status (BIMS) and for signs and symptoms of delirium using the CAM assessment.

The discharge BIMS instructions on the draft item set state, “Complete only if (A0310F = 10 or 11 AND A0310G = 1) or (A0310H = 1).” This indicates that the BIMS will only be assessed at the time of an Omnibus Budget Reconciliation Act (OBRA)-planned discharge, return anticipated or return not anticipated, and any time the PPS Part A discharge assessment is completed.

However, the instructions for the CAM assessment on discharge is for any time an OBRA discharge, assessment, return anticipated or return not anticipated, is completed (planned or unplanned) and any time the PPS Part A discharge assessment is completed.

PHQ-2-9© changes how and when the Resident Mood Interview is conducted

The draft item set changes the PHQ-9© to the PHQ-2-9©. On the new item set, the assessor will ask the questions regarding “little interest or pleasure in doing things” and “feeling down, depressed, or hopeless.”
The remainder of the questions are only asked if the resident reported having either of these symptoms at least seven of the past 14 days. If not, the interview is ended. This interview is repeated at the time of an OBRA-planned discharge, return anticipated or return not anticipated, and any time the PPS Part A discharge assessment is completed.

D0700 Social Isolation, D0720 Social Isolation (Discharge)

In the FY 2020 SNF PPS Final Rule, CMS also emphasized how social isolation impacts health outcomes and increases mortality risks. Understanding a resident’s risks will improve care planning and care coordination for residents with an actual or perceived lack of contact with other people.

The new MDS item D0700 asks the question, “How often do you feel lonely or isolated from those around you?” Item D0720 asks the same question at the time of a planned discharge from the SNF. The importance of this question is not only in the identification of the social isolation, but in how the SNF team provides activities and interventions to increase the resident’s engagement.

Closing Thoughts

Yes, there are many changes coming, but SNF teams can be better prepared by examining the new item sets to gain knowledge and then using that information to implement changes to workloads and workflows. There is a lot of new information coming, and SNFs must be prepared to collect and submit these data—or risk facing a 2 percent decrease to their Medicare APU.

Many trainings will be made available soon: CMS is offering a series of trainings starting this spring (see How to Begin Prepping for October 1 MDS Changes, which includes a timeline of training opportunities from CMS), and AANAC will continue to offer support to NACs via articles, podcasts, webinars, and tools. Start getting ready now for an easier full implementation later.
Jessie McGIllJessie McGill, RN, RAC-MT, RAC-MTA, is a curriculum development specialist for the American Association of Post-Acute Care Nursing. Previously, she worked as the director of clinical reimbursement for a large long term care organization overseeing 17 clinical reimbursement consultants across 21 states. Her experience includes time as a restorative nurse, MDS coordinator, regional clinical reimbursement specialist, clinical reimbursement trainer, and director of clinical reimbursement. She can be reached at jmcgill@aapacn.org.