How the RAI Manual changes encourage collaboration

As payment across healthcare and in skilled nursing facilities (SNFs) shifts from a volume- to value-based system, a lot is changing. Despite the challenges, these changes also usher in opportunity. In particular, three changes are prompting facilities to demonstrate high-quality care more clearly: the new Quality Measures for pressure ulcers and falls with major injuries, the new item set for functional status and the new discharge assessment. As a result, the new requirements are also challenging team members in SNFs to work more closely together than before, both internally and with upstream and downstream providers.

The MDS Coordinator and therapy

The new item set, section GG, which is required by the new Quality Measure “Application of Percent of Long-Term Care Hospital Patients With an Admission and Discharge Functional Assessment and a Care Plan That Addresses Function” (NQF #2631), has posed the biggest challenges for SNFs.

According to Mark McDavid, OTR/L, RAC-CT, of Seagrove Rehab Partners, “The MDS coordinator and therapy department in most facilities have been collaborating and communicating regularly for some time, whether with a daily meeting or email. Section GG has increased the level of collaboration and communication.” Section GG requires more face time. McDavid has observed that in many facilities, in the first three days upon admission of a Part A resident, the therapy department completes therapy evaluations while nursing completes admission assessments and section GG observations and assessments. At approximately day four, they jointly establish the usual performance and a discharge goal. In some larger facilities, teams have created a new meeting just for section GG. “The volume of your facility’s Part A population drives how much of an impact section GG will have in increasing the need for collaboration,” McDavid says.

McDavid makes it clear that “we should not delay the start of therapy because of data collection.” If facilities do that, “it is a disservice to their residents.” If therapy begins on day one, two, or three (which typically happens), any data collected after the start of therapy is post-intervention data and is no longer valid. Staff members need to be on the same page about when therapy intervention starts and when collection for the section GG admission assessment ends.

The MDS Coordinator and social services

Maureen McCarthy, RN, BS, RAC-MT, CQP-MT, president of Celtic Consulting, agrees that therapy and MDS coordinators have been working together successfully for years in most facilities. “And now they are just collaborating about a new subject, section GG.” She finds the increased collaboration between social services and MDS coordinators most notable. “Social services typically sends out the notice of Medicare non-coverage 48 hours before discharge, which can be appealed. Because of section GG, the MDS coordinator now needs to know when that notice is going out to be sure that he or she is charting and coding the correct days for the discharge assessment.”

Prior to section GG and its inclusion of the discharge assessment, “MDS coordinators didn’t need to know as much about discharge planning, just the day of. Now they do.” She stresses how important it is that the MDS coordinator code for the correct discharge day. If the Medicare non-coverage is successfully appealed for any reason and the MDS coordinator is not aware, the ARD for the discharge assessment period will change and the data collection period will also change. Therefore, the MDS coordinator may not have the right data collected to complete the discharge assessment for the revised ARD date.  “It’s crucial that 100 percent of MDSs include 80 percent of the data so as to not be penalized per the Quality Reporting Program,” McCarthy stresses.

The MDS Coordinator and the admission nurse

Even though section M isn’t new, the new pressure ulcer Quality Measure (“Percent of Patients or Residents With Pressure Ulcers That Are New or Worsened,” NQF #0678) as part of the Quality Reporting Program requires that admission nurses do a thorough body audit so that any reddened spots can be treated immediately, McCarthy explains. The admission nurse must successfully communicate any items of note to the nursing staff and include these in the care plan. In turn, MDS coordinators now need to communicate with the admission nurse to ensure that pressure ulcers are accurately coded as present on admission or not. The October update to the RAI User’s Manual indicates on page M-7 that when a “resident who has a pressure ulcer that was ‘present on admission’ (not acquired in the facility) is hospitalized and returns with that pressure ulcer at the same numerical stage, the pressure ulcer is still coded as ‘present on admission’ because it was originally acquired outside the facility and has not changed in stage.” This was great news for facility staff who had inflated Quality Measures in those situations, though the pressure ulcer had not occurred under their care.

For the new Quality Measure for falls with major injury (“Application of Percent of Residents Experiencing One or More Falls With Major Injury (Long Stay),” NQF #0674), admission nurses must also do a more thorough job of assessing fall risk as residents are admitted and communicating this to nursing staff, McCarthy says. Completing a thorough assessment of the history of falls obtained from the resident and family at the time of admission is also key for accurate MDS coding and care planning.

According to page J-26 of the RAI User’s Manual, “A previous fall, especially a recent fall, recurrent falls, and falls with significant injury are the most important predictors of risk for future falls and injurious falls,” adds Jessie McGill, RN, RAC-CT, curriculum development specialist at AANAC. The need for collaboration went to a new high in October when CMS added the following instructions to page J-32 of the RAI manual: “Review any follow-up medical information received pertaining to the fall, even if this information is received after the ARD (e.g., emergency room x-ray, MRI, CT scan results), and ensure that this information is used to code the assessment.”

The MDS Coordinator and the wound nurse

Continued collaboration with the wound nurse or nurse responsible for assessing the wound is also key, McGill says. The new pressure ulcer Quality Measure utilizes documentation from the PPS assessments completed during a Medicare resident’s skilled stay, including the PPS Part A Discharge or OBRA assessment. The resident’s Medicare stay is included in the numerator of the Quality Measure if the number of unhealed pressure ulcers for either stage 2, 3 or 4 (M0300B1, C1, or D1) is greater than the number of pressure ulcers that were documented as present on admission (M0300B2, C2, or D2). Collaborating discharge planning with the wound nurse will ensure the wound has been assessed during the look-back period of the PPS Part A Discharge assessment. If any of the areas in M0300B, C or D are dashed, this will count against the SNF in the QRP measure for completing at least 80 percent of collectable data.

SNFs and home health

McCarthy has also seen increased collaboration between SNFs and home health, because the SNFs are ultimately responsible for the success of the discharge to the community. In the SNFs for which she consults, she helps to create informal preferred provider networks. The SNFs then follow up with home health to determine how discharged residents are performing and receive feedback about individual residents. “This wasn’t happening before,” McCarthy says.

Aiding in the collaboration between SNFs and home health agencies is the potential overlap of measures for each setting, McGill adds. While SNFs are measured on the 30-day Post-Discharge Readmission Measure and Discharge to Community, home health agencies are measured on Rehospitalization During the First 30 days of Home Health and Emergency Department Use Without Hospitalization. For example, if a resident spends 15 days in the SNF, then is discharged with home health and is rehospitalized after 10 days at home, both the SNF and home health measures are impacted. Collaboration of care between the SNF and the home health agency is vital to improving the continuum of care and patient outcomes.

SNFs and hospitals

McCarthy also has observed increased collaboration with hospitals upstream, specifically in learning about diagnoses. “Admission nurses are expected to collect diagnosis information, which will inform risk adjustments. With ICD-10 codes that require more specification, sometimes this means following up with the nurse discharging with the hospital,” she says. On the same note, SNF nursing staff must ensure collaboration with hospitals to collect accurate and comprehensive details for section J, falls with major injury, even after the ARD.


Effective communication and collaboration is essential to success on any team. In long-term care, improving patient outcomes depends on it—both internal, among SNF team members, and external, with providers that send residents to and receive residents from the SNF. In the wake of new payment initiatives across post-acute care settings, it is imperative that SNFs provide the highest value of care. It also is imperative that SNF team members collaborate and understand that no facility can succeed as an island unto itself. Instead, the recent changes require that staff and providers across settings proactively get on the same team because they share in the same goal: patient and resident success.

Judi Kulus, MSN, MAT, RN, NHA, DNS-CT, RAC-MT, is Vice President of Curriculum Development for the American Association of Nurse Assessment Coordination (AANAC).

Topics: Articles , Facility management , Finance , MDS/RAI , Medicare/Medicaid , Rehabilitation