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Much to be done before MDS, RUG 2010 changes

January 1, 2010
by Rena R. Shephard, MHA, RN, RAC-MT, C-NE
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At a glance…

Technology now holds promise for compliance with some of the new CMS interpretive guidance (effective June 12, 2009), for several of the quality of life requirements and ultimately contributes additional means for good care.

Version 2.0 of the Minimum Data Set (MDS), the assessment tool used to determine payment for Medicare Part A, will be obsolete on October 1, 2010; MDS 3.0 will be “in.” The next generation of the Resource Utilization Group (RUG) system that uses the MDS information to categorize residents into payment groups based on acuity also kicks in on that day.

MDS 2.0 to MDS 3.0 and RUG-III to RUG-IV sound like they might be upgrades to existing systems. No problem, you might think-find out what's changed, incorporate the changes into existing systems and processes, and go from there. But from all indications, that would be a mistake. While the underlying concepts of the MDS and the RUG systems are very familiar, the changes are so extensive that it would be wise to approach them almost as if they were brand new.

How a facility approaches implementation of these important and powerful requirements can be the difference between success down the road and problems with reimbursement, surveys, and quality reporting. Administrative team members who were around when the MDS originally was implemented circa 1990, probably understand in retrospect that a lot was learned about how not to implement change: It wasn't taken seriously, it wasn't given priority from an organizational perspective, and the result too often was survey deficiencies, Medicare denials, missed reimbursement opportunities, and poor quality indicator scores. Some of this continues today. Here's an opportunity to get it right.

It starts with effective leadership. An effective and dynamic leader develops a vision for what must be accomplished and shares that vision in a clear and positive manner that leaves no question about the goal-and the worthiness of the goal-that everyone will work toward together. A great leader entices others to follow. As leaders, administrative team members have the central role in this vision.

Start preparing now

A critical first step is to make a plan for implementation well in advance of the October 2010 start date. Involve the entire facility team, and, as a leader, be the facilitator throughout the process-leave no doubt that this project has the full support of the facility's administrative team.

Provide formal training. Ensure that all staff members who will participate in the MDS assessment and in SNF PPS receive formal training from recognized experts. As the leader, be sure to remove obstacles that might prevent them from receiving the training and support they will need. Also, ensure they have the most up-to-date MDS 3.0 RAI User's Manual at all times. Affiliation with the American Association of Nurse Assessment Coordinators (AANAC) can be instrumental in meeting these needs.

Create team specialists. Solicit volunteers among the staff to become the experts on the various items, one person/one item (or section). Each of these specialists would provide additional mentoring and support to other team members with regard to the item specialty and would act as a resource person on that item on a continuing basis.

Find out about your software vendor's transition plan. Each vendor will develop its own process and timeline for software development and testing. It is critical that your facility be aware of your vendor's plan well in advance and that a joint plan for integration of the new software into your facility, including plenty of time for staff training, be developed.

Recognize that the MDS is a complex process. When the original MDS was implemented, in many ways, the complexities of the process were not recognized and accounted for at that time, and to this day, the ripple effect of consequences continues in inaccurate assessment data that may be attributed to inadequate training, lack of priority from administrative team members, and a job description for MDS nurses that in many ways cannot be accomplished.

Understand the MDS 3.0 yourself. Make sure you have a clear understanding of the processes of the MDS 3.0-how it works and how it can be used to improve quality of care, quality of life, and outcomes for your residents-how it can be the foundational tool for culture change for your facility. Understanding the MDS 3.0 yourself is important also so you can assist the interdisciplinary team by removing obstacles to success, providing needed resources, and monitoring to identify training needs and to recognize successes.

Administrative team members in many organizations have never really understood their key role in the MDS 2.0 in this context. To this day they may have significant problems with MDS accuracy and effectiveness as a care planning tool, despite the critical role this instrument plays in the survey process, reimbursement, and quality monitoring. Unless you will be completing some portion of the MDS 3.0, that doesn't mean that you have to know how to fill out every item on the MDS. But it does mean that you must know enough about it to ensure that the team responsible for completion of the form gets it right.