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hat is the single most important instrument in the extended care facility that can impact resident care, care planning, financial success or failure, legal defense, survey outcomes, quality assurance, and communication between facility staff in the extended care facilities? The most important process that can positively impact all of the above and more is the minimum data set (MDS)!
       In 1990, HCFA unveiled the MDS to nursing facilities in Washington, DC. I attended this session in order to teach the MDS/RAPs process at the state level. In conjunction with the South Carolina Department of Health and Human Services and the South Carolina state certification agency, I participated in training for the MDS process. When the MDS 2.0 version surfaced in 1995, I conducted the state training through state associations.
       In the past 12 years, I have presented many on-site and off-site training sessions involving the MDS, Resident Assessment Protocols (RAPs), and care planning for individual, state, and national associations. The theme of the presentation (and sometimes the title) was "How to Have a Love Affair With the MDS." I feel rewarded by the feedback given by the participants of these training sessions. The participants arrive eager to be updated and hear success stories that have positively impacted resident's quality of life as a result of the MDS process. They leave the session feeling "intimate" with the MDS process.

Using the MDS to Improve Care Outcomes
       Often, I explain how I became intimate with the MDS process. I had a personal experience that convinced me that the MDS and RAPs were much more than government regulation and/or paper compliance. In 1990, my mother was hospitalized, had surgery, and was diagnosed with wide-spread metastasized cancer. After being in the hospital for six days, my mother became acutely confused, although she had been alert and oriented before and after her surgery. I was called and was told that the cancer may have invaded my mother's brain. Although this was a possibility, I wanted to be sure that first an assessment was conducted to assure she received appropriate care while investigating possible causes of her delirium. I had been with my mother earlier that morning and she had not exhibited any signs of confusion--this confusion was sudden in onset. On my way to the hospital, I started my own assessment process. I realized that many of my mother's symptoms were addressed on the MDS and triggered the Delirium RAP. I began the structured investigative process offered by the Delirium RAP. I went through the RAP guidelines and began to assess and identify possible causes for the acute confusion. Simply following the Delirium RAP guidelines, I noted 1) my mother had diagnoses and conditions that could be causing the delirium; 2) my mother had several additional medications added since hospitalization, one being cimetidine, that could possibly be causing her acute confusion; 3) my mother had been told she had three to four months to live and could be experiencing sad and/or anxious moods, which could have contributed to her confusion; and 4) she had been moved between several locations in the hospital, which could have also added to her confusion.
       When I arrived at the hospital, I was approached by the medical staff and was told that several tests had been ordered (i.e., scans, etc.) to determine if the cancer had spread to the brain. Of course, being the "daughter who was a nurse," I refused the tests and asked that the items I had identified through the RAP assessment be first considered and ruled out while care planning to provide safety measures and reality orientation until my mother's normal level of mental status returned. Of course, the medical staff was shocked and established that I was the "daughter who was a nurse" in denial. However, when some specific drugs were discontinued, reality orientation provided, and infection/depression syndrome ruled out, my mother returned to her previous mental status and never suffered confusion again before she died six months later.
       There are thousands of untold stories like this that demonstrate how the holistic, structured approach provided by the MDS/RAPs process can add quality to life and care of the resident through appropriate assessment and care planning. The MDS was not intended to take the place of every assessment (i.e., physical assessment, diagnostic tests, etc.), but it is an excellent functional assessment that often identifies common needs of the extended care resident. More importantly, if the comprehensive assessment (MDS and RAPs) process is utilized, the staff will begin to systematically consider alternative solutions and resident-specific items to develop an individualized comprehensive care plan. My story emphasizes the most valuable benefit of the MDS and RAPs--to provide quality care for the resident. However, facilities must not forget to include any other available information, such as the physician orders, discharge summaries, etc., in consideration of development and implementation of the care plan. Accuracy and understanding of the MDS process is essential for successful assessment and care outcomes.

Using the MDS to Improve the Financial Health of Your Facility
       Payment is based on case mix categories defined by MDS responses for Medicare. In many states and some managed care companies, the MDS is used to establish payment rates. To achieve the best financial outcome for the facility, the MDS team must learn to work smart. They must understand the MDS process and be willing to work together to make adjustments as needed--including setting appropriate assessment reference dates and completion dates within the PPS guidelines. Most importantly, they must understand how to code the MDS accurately.
       Since the onset of PPS, my company, New Day Professional Services, has been asked if we could "guarantee a certain percent increase in the facility's revenue" if we were retained to monitor the MDS assessments. As I explain to these facilities, our mission is to guarantee accuracy, which usually results in a higher return for the facility and always ensures the best care for the resident. To monitor the accuracy of the MDS process, an on-site visit is needed to communicate with the staff and resident and to complete a record review. Often, we find that the staff are not accurately coding items on the MDS or are not choosing the best assessment reference date to capture the maximum level of services provided to the resident. Both of these common pitfalls have the same unfortunate outcome--lower financial return for the facility. Accuracy and understanding of the MDS process is essential for the financial success of the facility.

Using the MDS to Legally Defend the Facility
       The MDS and RAPs are part of the legal medical record that is reflective of the functional status of the resident through his or her stay in an extended care facility. When I serve as a legal nurse consultant, I focus on the admission MDS and subsequent MDS assessments. The MDS can show improvement, no change, or decline of the resident's functional status. The MDS can also reflect when the facility has identified significant changes in the resident and completed additional assessments to assure they are assessing the resident comprehensively and updating the plan of care as needed. Accuracy and understanding of the MDS process is essential for the legal defense of the facility.

Using the MDS to Assure Positive Survey Outcomes
       Since the mandate to transmit the MDS to government agencies, the survey process has been impacted. The survey team reviews the facility's quality indicator reports off site and plans focused survey issues based on these results. New Day Professional Services consultants have noted that many of the problems for facilities during a survey often stem from inaccurate MDS assessments. When a resident's needs, strengths, and preferences are not identified through the MDS and RAP process, inaccurate care plans are produced, and ineffective care is provided.
       The facility's quality assurance process can be positively impacted by the MDS. In addition to reviewing the quality indicators on a regular basis, specific MDS items can be selected for a proactive, focused review. For example, all residents with symptoms of pain can be reviewed to ascertain appropriate assessment and care planning for treatment of pain. As it is with all the other previously mentioned areas, accuracy and understanding of the MDS process is essential for survey outcome success.

How to Assure Accuracy and Understanding of the MDS Process in Your Facility
       The first step in assuring accuracy and understanding of the MDS process in your facility is to provide in-depth training to the entire nursing staff and interdisciplinary team. Each member must understand the fundamentals of the MDS process and how their input contributes to the accuracy of the process. If the staff member is responsible for completing any portion of the MDS, understanding of the MDS "Item-by-Item" definition and access to the MDS 2.0 manual is imperative. After the initial training, the facility should devise an ongoing plan to stay abreast of changes in the MDS process. Regrettably, keeping up to date with changes is frequently overlooked as an educational need.
       In 1995, the MDS assessment tool was made uniform for every state and expanded to cover some additional care items that should always be considered in assessment, such as pain. At that time, the MDS manual was updated to reflect the changes and to provide instructional information for the MDS 2.0. Since that time, there has not been a manual published for MDS. The Centers for Medicare and Medicaid Services (CMS--formerly known as HCFA) is planning to release an updated manual later this summer. There have been many clarifications and additional uses of the MDS since 1995, such as using it as the foundation for PPS and identification of nursing home quality indicators (QIs). There are proposed plans to use MDS data for quality measures in long-term care facilities this Fall.
       Since none of the PPS or QI information is available in the 1995 MDS manual, facilities are burdened with the responsibility of keeping up through regulatory transmittals and routinely checking the CMS websites for clarification on MDS, PPS, and QI items. Because of the burden on facilities to keep up with the various websites and the effort to assimilate and communicate the information, many facilities learn about the updates through payment denials, survey deficiencies, or word of mouth from peers. New Day Professional Services recently produced a Frequently Asked Questions (FAQs) Long Term Care Resource Manual that includes all the FAQs posted on the CMS websites since 1995 for MDS, PPS, QIs, surveyor protocols, and HIPAA. Annual quarterly updates are available for less than $20.00 a month. The questions are conveniently categorized by topic and arranged by the date they were published. Facilities that have purchased this manual have found it to be an invaluable resource for the MDS team and one of the best returns on investment for their facilities. To find out more about this resource and ordering information, check the New Day website at www.newdayprofessionals.com.
       Regardless of how the facility chooses to accomplish this challenge, accuracy and understanding of the MDS process is essential for ongoing quality care outcomes, financial success, legal scrutiny, survey success, and quality assurance success of the facility.