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MDS 3.0 and the DON

March 1, 2010
by Rena R. Shephard, MHA, RN, RAC-MT, C-NE
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The words “MDS 3.0” undoubtedly trigger a number of disparate thoughts in a director of nursing's (DON's) mind. This is going to be a year of change for nursing homes, and much of it will be centered on implementation of this new version of the Minimum Data Set, scheduled for October 1, 2010. Since it is the foundation for care planning, Medicare Part A reimbursement, quality monitoring, and survey activities, the facility team's mastery of the MDS 3.0 will be a key to success-and a significant challenge.

At a glance…

Implementation of the MDS 3.0 offers the perfect opportunity to improve the quality of care in a facility by improving the quality of assessment and care planning for the 20 care areas involved. The DON must assume the leadership role.

The DON's leadership will be critical. There is a lot that is new with this MDS. In fact, so much is new that it should be approached as a brand-new assessment tool as opposed to looking at it as simply an update to the MDS 2.0. There will be much for the team to learn, a lot of analysis for the administrative team to conduct to understand the reimbursement implications, and some re-evaluation of facility systems to take place. In that context, “opportunity” might not be the first term a DON associates with MDS 3.0, but, nonetheless, the opportunities presented by MDS 3.0 implementation can be very exciting. They are opportunities that can lead to significant improvements in the quality of care and quality of life for the residents.

Culture change

The MDS 3.0 provides a direct and important connection to culture change. Through the scripted interviews that are integral to the assessments of cognition, mood, activity and routine preferences, and pain, the staff can learn about the resident's own feelings, needs, concerns, and priorities, and they can learn it from the resident's own words.

The testing of the MDS 3.0 in volunteer nursing homes in eight states showed that about 85% of residents were able to complete the interviews, including cognitively impaired residents. The message is that even the most cognitively impaired residents retain the ability to communicate about issues that are important to them. Thus, this MDS 3.0 interview process presents a huge opportunity to improve each resident's quality of life by learning about and then honoring what is important to the resident. But these interviews represent a significant change in MDS process in most facilities, and it will require dedicated leadership from the DON to transform the MDS from a paper compliance into a critical tool for resident-centered, resident-directed care. The Long-Term Care Facility Resident Assessment Instrument User's Manual contains detailed instructions for each interview in Chapter 3 as well as very helpful information about interviewing skills to elicit the resident voice in Appendix D. But without strong leadership and clear goals, it is likely that many folks will simply transfer the processes they use with the MDS 2.0 to the 3.0-and for many facilities that will be a significant missed opportunity.

There are some steps DONs can take to get this ball rolling:

  • Familiarize yourself with the scripted interviews, the instructions in the manual, and the information in Appendix D, and work with the staff responsible for the interviews to help them hone their interview skills. Try a couple of interviews with residents yourself.

  • Ensure easy availability of a private location for the interviews to take place. Most residents live in semi-private rooms, which don't offer much privacy as far as conversation is concerned. So it's going to be important to figure out how to make this happen for each and every interview.

  • Help the staff to understand the importance of ensuring that the resident can hear as well as possible. This might be as simple for some residents as ensuring that the ambient noise is minimal or that their hearing aids are in good working order. But for some residents with hearing loss who do not have hearing aids, the availability of a hearing amplification device can be the determining factor in making the interview meaningful.

  • Once the information is collected from the resident, work with the staff to ensure that it translates into care planning and care delivery specific to the resident's stated preferences, needs, desires, and values. If your facility is not already on board with culture change, this will undoubtedly require redesign and revision of many resident care systems to change the focus from facility schedules, routines, and preferences to honoring each resident's preferences and needs. This, too, will require strong leadership.

The MDS 3.0 offers a new opportunity when it comes to the quality of assessments, too. The MDS process isn't changing. The MDS 3.0, like its predecessor, is a screening tool. It will alert the team that a resident may have problems in any of 20 different care areas, such as delirium, mood, pain, etc. When any of those care areas are flagged, or triggered, based on selection of a particular answer option on the assessment, that means that a further, more in-depth assessment of the care area must be conducted. This is to determine the nature of the problem, the root causes, and contributing factors so that a resident-specific care plan can be developed. This will assist the resident in overcoming the problem as much as possible to attain or maintain his or her highest practicable level of well-being. This process has been mandated ever since the MDS was first implemented via the Omnibus Budget Reconciliation Act of 1987, but it often hasn't been carried out appropriately nor has its connection to quality been well understood.