Voices and choices

Several years ago, while attending a meeting of a local woman’s club, the oldest in the group, who was nearly 85 years old, said something very interesting: “When I visit with you girls, I forget I am so much older… until I look in the mirror. I still see with the same eyes of my youth. And in my mind’s eye, I am still 30.” A few years later she succumbed to dementia. When she no longer remembered who we were, she still envisioned herself as that vibrant and educated 30-year-old woman with her own unique thoughts and opinions. Getting old and sick may have caused her to forget many things, but she didn’t forget who

she was.

The Institute of Medicine issued a report in 2001 proposing recommended performance expectations for the 21st century healthcare system. The report called for fundamental changes in healthcare delivery and advised a stronger focus on patient-centered care, with the stipulation of providing long-term care residents a stronger voice in that care. Considering the demographic implications of the aging population, with some estimates anticipating the number of older adults in the United States nearly doubling between 2005 and 2030, this recommendation is not only appropriate, but also baffling. Why wasn’t it recommended earlier? Providing some level of choice in how we are all treated in any environment should be a basic tenet to civilization. Expecting to have a voice in healthcare is crucial.

The Centers for Medicare & Medicaid Services (CMS) has responded to the recommendations in their recently launched MDS 3.0. The updated reporting system requires a direct resident interview with “all residents able to be understood at least some of the time.” This requirement replaces staff observations regarding customary routines and activities. Families may serve as the proxy if the resident cannot participate in the interview.

The American Association of Nurse Assessment Coordination (AANAC) listserv has been lit up with complaints from providers regarding the patient interview provision since the October 1, 2010 launch of MDS 3.0. Dr. Debra Saliba, MD, MPH, director of the UCLA Borun Center for Gerontological Research at the Jewish Home for the Aging, reported at the fall 2010 AANAC conference in Baltimore that she has heard a variety of concerns regarding the interview of residents. Her examples included: “I can’t do this. I can’t go in and ask these questions.” “This isn’t in my scope of practice.” “What if they cry?” “You haven’t been to my nursing home. My residents are too impaired to answer.” Prior to launching the new MDS 3.0, a national test of 4,500 residents was completed. The test measured safety and resident voice items, which included accuracy (reliability and validity), staff satisfaction and perceived utility, time to complete, and feasibility (ability to complete). The interviews assess cognition, mood, preferences for customary routines and activities, and pain.

The American Association of Nurse Assessment Coordination (AANAC) is a nonprofit professional association representing nurse executives working in the long-term care profession. AANAC is operated by nurses for nurses and is dedicated to providing members with the resources, tools, and support they need in their specialized role of leaders and managers in long-term care. For more information, visit www.aanac.org or call (800) 768-1880.

Dr. Saliba reported that the nurses completing the MDS 3.0 testing rated it vastly improved over MDS 2.0. Eighty-five percent of respondents rated MDS 3.0 as likely to help identify unrecognized problems. Eighty-nine percent rated MDS 3.0 as providing a more accurate report of resident characteristics than MDS 2.0, and 84% reported that MDS 3.0 interview items improved their knowledge of residents. The average time reported for completing all interviews was 17 minutes.

Once the testing was completed, a follow-up evaluation was performed to test the results of the new MDS process. Staff responses to the interview process drastically transformed: “This new MDS reminds me of why I became a nurse.” “You know, it’s the most amazing thing. Residents really don’t mind being asked and you really learn a lot.” “I thought it would take a lot of time and that you were crazy. I was wrong: It saved me time.” “Even if their memory isn’t great, they were able to answer.” “We didn’t know how much he was suffering.”

The resident interview also replaces staff observations for residents who can report pain symptoms. According to Dr. Saliba, the pain interview questions provide a fuller picture of pain from the resident perspective and are more likely to lead to increased pain detection. Additionally, utilizing improved scales and inference items gives a more clinically meaningful picture and allows healthcare providers to better recognize the commonly used pain scales. It is the expectation that providers will improve pain management skills, resulting in a better quality of life for residents.

Additionally, utilizing improved scales and inference items gives a more clinically meaningful picture and allows healthcare providers to better recognize the commonly used pain scales. It is the expectation that providers will improve pain management skills, resulting in a better quality of life for residents.

The Coalition of Geriatric Nursing Organizations has put together a list of nursing competencies that focus on supporting nursing home culture change. It is the goal of the coalition to support the importance of “person-directed” care practices while advocating a team approach in long-term care that includes not only the caregivers but also the families and residents. These competencies can be found at www.pioneernetwork.net/Providers/ForNurses.

AANAC has had some wonderful anecdotal stories from members that illustrate how the addition of the resident/family interview has allowed care providers to improve their services. One member wrote about a resident named Sam, who had been a somewhat successful artist and his creativity often came through in the stories he told. Sam suffered several strokes and struggled with severe hemiplegia along with a diagnosis of moderate receptive aphasia. Although usually very pleasant, he was described as unreliable and suffering from dementia.

Sam called for help multiple times every night and never seemed well rested. When the care provider arrived he usually needed nothing. Instead he would ask about the men with guns outside his window. He was clearly very frightened. Sam’s room is on the second floor and even after we took him to the window, he persisted in his belief that there were men with guns outside his window. It was not until we formally interviewed his wife that she was able to clarify the situation. Sam had been a bomber pilot in World War II and was shot down on an island in the South Pacific. He spent several years as a Japanese prisoner of war and had endured some horrific experiences. She reported that he had always experienced hallucinations at night during their marriage and he could be oriented only by turning on the overhead light for a few minutes. Now the staff knows how to re-orient him when he is hallucinating and he is sleeping through most of the night. The outcome of this is a much more rested gentleman who feels stronger, is more reliable in his communication, and expresses more contentment in his life.

Requiring a resident interview will compel MDS coordinators to interact more directly with residents. It is important to help staff members acquire the necessary interview skills to adequately obtain valid and reliable data. Consider accessing the Video on Interviewing Vulnerable Elders (VIVE), which can be viewed at www.iadvanceseniorcare.com/VIVE and provides support in teaching the needed skills. Staff members may not find some of the questions clear or realistic. There is a vital need for feedback on that information. AANAC invites all who have either concerns or solutions regarding the interview process to provide a response on the listserv, which will allow AANAC to offer timely and direct feedback to CMS on how to improve the interview section.

This new requirement, which is so obvious in theory but sometimes so difficult in action, is designed to help long-term care providers improve the quality of the services they deliver. Each resident is an individual with an abundance of life experience that forms the tapestry of who they are and what they need. LTL

Ingrid Johnson Serio, RN, BSN, MPP, is the Director of Content Management for AANAC. She can be reached at

iserio@aanac.org. Long-Term Living 2011 January;60(1):20-23