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e have received quite a few questions from new practitioners in the long-term care arena who do not quite understand what the Minimum Data Set (MDS) is all about. So this column will be a refresher on the MDS—what it is, what it does, and why it is important.
       The MDS was originally developed as an assessment tool. It was created in response to a study conducted by the Institute of Medicine in 1985, which revealed a need for more thorough and systematized assessments in long-term care. In 1989, the Omnibus Budget Reconciliation Act, which included the MDS, was passed into law. All long-term care facilities receiving federal funds were required to complete the timed assessments. Completion of the form began in 1991 and continues today. There have been 3 revisions to the form. At present, we are using the MDS 2.0, and the MDS 3.0 is scheduled for release in 2007.
       The MDS has more than 300 possible entries on a 10-page form. It is divided into 24 separate parts, covering cognition, behavior, activities of daily living (ADL) performance, and other areas. As you may imagine, all entries are defined in great detail. The Resident Assessment Instrument (RAI) manual contains all the definitions for entries contained in the MDS. It also explains how and when to set the Assessment Reference Date (ARD), what constitutes a significant change in condition, and timing for routine assessments. It is the MDS bible, and anyone completing the MDS must have the most recent edition of the RAI. The more recent in-depth revision of the manual was released in December 2002. Revisions continue on an ongoing basis. A copy of this manual, along with revisions and updates, can be obtained at http://www.cms.gov.
       There have been and continue to be many testing sites to refine the MDS. Revision will continue to be an ongoing process as the definition of care changes to coincide with new care techniques and developments.
       Since its inception, the MDS has had more job duties added to its description. Currently, it is used to assess the resident and direct care through the standardized development of a care plan and to gather information for quality improvement. This statistical analysis of MDS information is called Quality Indicators (QIs). Currently, there are 24 QIs that are accessible to state surveyors and each long-term care facility that has submitted data. While a facility could share its Qls with other facilities, other facilities and the public in general do not have access to the QIs. This information is a way for the facility to compare itself to other long-term care facilities.
       Proper use of the QIs should enable a facility to spot problems and take corrective action through its in-house quality improvement program. It also acts as a watchdog for the state surveyors, because they can easily spot a problem before they even enter a facility. Through sentinel events, such as fecal impaction, which are not supposed to happen but do on occasion, some QIs are identified as being more important than others. If you have even one resident who has the characteristics to land in these particular QIs, it is necessary to thoroughly investigate the care being given in that area and initiate corrective action immediately. State surveyors will investigate those areas during annual surveys.
       Another job the MDS performs is to bill for the care given. This is a complex and difficult area to comprehend. Through analysis of tasks performed by direct care and medical staff, a score is assigned to the resident. This score places the resident in a group (Resource Utilization Group) that is classified by how much of the direct care staff resources the resident uses. Reimbursement depends on how much staff time the resident requires. The federal government uses a 34-group classification system, or “grouper,” to set the rate for Medicare reimbursement. Some states, presently about 24, also use systems similar to this to help set reimbursement rates for Medicaid.
       Another use of the MDS is to generate Quality Measures (QMs), which are different than QIs. QMs are for the general public to use when deciding where to place a loved one in long-term care. There are currently 14 QMs, and a new report was released in November. The QMs are available to anyone who is interested at http://www.medicare.gov/. From this site, follow the “Compare Nursing Homes in Your Area” link. You may also check the QMs for another facility, since QMs are part of the public domain.
Several universities and government agencies continue to analyze MDS data. This research may help to improve long-term care. As time passes, more functions are being discovered for this wealth of data.
       The actual MDS consists of the 10-page form, plus more in-depth assessment pointers. Together, they make up the RAI. With the pointers, or “triggers” as they are often called, one goes to the Resident Assessment Protocols (RAPs). These protocols consist of standardized guidance to perform an in-depth evaluation and assessment of specific areas of concern. There are 18 areas that have been identified as concerns central to the care of the resident. These areas cover delirium, cognition, communication, vision, mood and behavior, psychosocial issues, ADL performance, urinary incontinence, activities, falls, nutrition and dehydration, feeding tubes, gum and teeth assessment, pressure ulcers, psychotropics, and restraints.
       This in-depth assessment with the MDS is completed at prescribed times but always by the 14th day of admission or 14 days from the ARD for a yearly assessment or significant change in condition. Then, every 90 days, an abbreviated version is completed. These abbreviated versions are called quarterlies. They are only 4 1/2 pages, containing half of the questions.
       Completing the MDS in a timely fashion is a critical factor in assuring useful data. A very discrete time period is examined. This is accomplished by setting an end date, or ARD. This mechanism enables all disciplines to look at the resident during the same time period, which is usually, but not always, 7 days before the ARD.
       Typically, elderly residents take multiple medications, which are recorded. Most notably, the MDS asks if the medications fall into the category of psychotropics or diuretics and requires a care plan to examine behaviors and side effects related to the medications.
       Toward the end of the tool are sections to complete on various treatments, including intravenous therapies, oxygen, or treatments administered in the hospital (such as use of a ventilator or a transfusion) in the past 14 days. Also included in this section is whether the resident needs cueing or has received behavioral or psychiatric interventions. If the rehabilitation department has seen the resident, it records in this section the number of days and minutes the resident has been seen. Details, such as the number of days of physician’s visits and physician’s orders, are also recorded here.
       The updated MDS 2.0 User’s Manual states, “Although not required, completion of the RAI is best accomplished by an interdisciplinary team that includes facility staff with varied clinical backgrounds. Such a team brings their combined experience and knowledge together for a better understanding of the strengths, needs, and preferences of each resident to ensure the best possible quality of care and outcomes of life.” Thus, the tool is best completed by several staff members from nursing, social services, dietary, and activities. Even the pharmacist, nurse practitioner, physician, and rehabilitation services are encouraged to participate. It also asks for the discharge plans of the resident. Lastly, the form asks if the resident, family, or significant other participated in the completion of the form. Most do, because background information is obtained from all sources to complete the form.
       Assessments are completed for all new residents by Day 14 after admission. By Day 14, the in-depth questions, or RAPs, are also completed. The person completing the RAPs decides whether to proceed with the care plan. From there, the care plan is developed. For example, say a resident had a Foley catheter inserted in the hospital and had it removed in the hospital as well. If the nurse coding the section on urinary continence counts 14 days back, and the catheter was in place, this would be marked. It would trigger the RAP “Urinary Incontinence/Foley Catheter.” If one would need to monitor voiding and perhaps intervene if problems arise, a care plan would be warranted. However, if there are no catheter or voiding problems, a care plan for this area is most likely unnecessary.
       Finally, the care plan is developed to encompass the care of the resident. However, it is not exclusive of the questions, and other care plans may be developed regarding the care of the resident.
       Anyone who has completed a portion of the MDS knows the difficulty in finishing the paperwork in a timely manner. The government has a “no tolerance” policy and has a federal tag number to cite the facility if the work is not completed as prescribed. The MDS coordinator is responsible for ensuring that the assigned sections are completed on time and that the care plans are in order. This is a tall order, so a good team must work together to make sure it all happens as planned.
       It is good to network periodically with other nurses who have experience in the MDS. When it comes time for a vacation, it is best to complete the MDS early, within the 80- to 90-day acceptable window if possible, or have a back-up who knows the ins and outs of the job cover for you. With regard to many other questions (Who completes what section? What is the previous history of assignments? What should you do about “gray” areas, or items about which one is not sure? Most people rely on mentors or consultants for help. The state MDS office is a wealth of information, and it is a good idea to introduce yourself by phone to establish a relationship. All state MDS offices and phone numbers are listed in the MDS User’s Manual, which is the one book that will answer those difficult, detailed questions.
       Another function of the MDS coordinator is to transmit the information to the state MDS office. First, the information is put into a computer file and transferred electronically to the state computer, in a matter of seconds. One must also transmit information about a resident if he or she is discharged and/or readmitted. All information must be sent to the state office within 31 days of the occurrence. Just as chart documentation is important, so are the MDS and all related forms. Remember, this is a federally mandated tool to be used. It is also important to keep the past 15 months’ worth of MDS records handy for reference.
       Remember, the process gets easier with experience. The MDS was not developed to create more work (although it may seem that way at times) but to direct the best care for the resident. We have decided to start off each calendar year with an overview to help new people who are working hard to accurately complete the MDS. So send us your specific questions, and we will be happy to answer them. Happy MDS-ing!

       If you have a question for Mabel, you can e-mail us at MabelMDS@aol.com.