June 1, 2011 |

Resident interviews demystified

The scripted interviews that are integral to the MDS 3.0 are a rich source of information about each nursing home resident that often may not be available through any other resource. After all, when you’re the patient, where does your healthcare provider go for details about you-about your pain, your preferences, your mood, your cognition? Do they just make assumptions based on their observations? Or do they go to your family? To your friends? To your coworkers? Not likely, since you are the best source for that information.

Even though collection of this very resident-specific information is critical to providing high-quality care and a good quality of life for residents, the indications are that these interviews are often not being attempted even when they should be. One reason seems to be a bias that nursing home residents generally are incapable of answering the interview questions, even though the national MDS 3.0 testing found that about 85% of nursing home residents were able to complete the interviews.

TO INTERVIEW OR NOT

The decision to interview a resident must be made based on whether the resident is able to make him- or herself understood. According to the RAI User’s Manual, the only reason an interview would not be attempted is if it is revealed through assessment that the resident is rarely or never understood. This determination must be based on observation of the resident and not based on the coding of item B0700, Makes Self Understood. This connection to this item was removed at some point prior to implementation of MDS 3.0. To begin with, the timing isn’t right to rely on B0700 for this as it isn’t completed until after the Assessment Reference Date (ARD)-the end of the observation period-because the resident must be observed for the entire look-back period, which ceases at the end of the ARD. On the other hand, interviews must be conducted on or before the ARD.

Rena R. Shephard, MHA, RN, RAC-MT, C-NE

To be specific, the instructions are to complete the Mood and Pain interviews preferably on the day of or the day before the ARD. The reason is that for each of these interviews, the resident is asked to think back over a certain time period: the last two weeks for the Mood interview and the last five days for the Pain interview. Conducting these interviews as close to the end of the observation period as possible places those time periods well into the observation period of the assessment as a whole. By contrast, the Cognition and Preferences interviews are single point-in-time interviews within an assessment that do not ask the resident to look back in time. They can therefore be conducted at any time during the seven-day look-back period.

When it comes to attempting the interview or not, that decision must be based on the resident’s ability to make him- or herself understood in general during the look-back period through the date the interview is attempted (no later than the ARD). So, even though B0700 is not factored into the decision to attempt the interview or not, chart documentation from the look-back period should support the decision and it is unlikely to be in conflict with B0700.

These interviews are extremely important to resident quality of care and quality of life. In fact, each of the screening items on the MDS that precede the interviews asks if the assessment should be attempted. The MDS expressly states, “Attempt to conduct interview with all residents.” Thus, it is imperative not to write off the interviews if the resident is not understood on just one or two days. If the resident’s cognition fluctuates, his or her status should be monitored each day in the look-back period, and the interviews should be attempted when it seems that he or she can be understood.

Once the interview is attempted, if the interviewer finds that the resident is not able to complete the interview (the criteria for stopping are written into the instructions for each interview), he or she can desist and conduct the staff assessment instead.

EMERGENT DISCHARGES

When a resident is discharged unexpectedly on an emergent basis, there is no expectation that the interviews will be conducted for the Discharge assessment. In that case, each screening question that asks whether the interview should be conducted should be answered based on whether the resident is rarely or never understood, as the instructions direct. If the resident is understood at least some of the time and the interview was not conducted prior to the emergent discharge, the interview items should be answered with dashes (-). The staff assessment should be skipped. If the screening question reveals that the resident is rarely or never understood, then the interview questions would be skipped and the staff assessment items would be dash-filled. If any of the information required for the assessment was collected before discharge, it should be entered on the Discharge assessment.

QUALITY MONITORING

The MDS 3.0 scripted interviews are so important to the well-being of nursing home residents that quality monitoring processes should be developed to ensure they are being conducted with every resident capable. Some suggestions to monitor interview quality follow.

If the resident’s cognition fluctuates, his or her status should be monitored each day in the look-back period, and the interviews should be attempted when it seems that he or she can be understood.

Chart audit: Check the coding of the interview screening items against overall documentation in the medical record for the look-back period for residents who were not interviewed to verify that they are in agreement regarding whether the resident makes him- or herself understood.
Talk to residents: A facility staff member who is not involved with the MDS should talk with and observe residents who are documented as rarely or never understood to verify the accuracy of the coding.
Care planning: Check the care plan against the interviews and resulting Care Area Assessments to ensure that there is a direct connection between the assessment findings and the care-planned goals and interventions.
Care delivery: Verify that the plan of care documented on the care plan is being delivered to the resident.
Training: Require specific training for staff members who conduct the interviews to verify that they received training in interview skills for this population. Training materials may include the Video on Interviewing Vulnerable Elders from CMS (www.iadvanceseniorcare.com/VIVE) and Appendix D of the RAI User’s Manual. Also verify via training records that training has occurred.

Rena R. Shephard, MHA, RN, RAC-MT, C-NE, is President of RRS Healthcare Consulting Services and Executive Editor for the American Association of Nurse Assessment Coordination (AANAC). Shephard is a member of the MDS 3.0 development team, a presenter for the CMS MDS 3.0 Train-the-Trainer events, and a consultant to CMS and to several QIOs. She can be reached at (858) 592-6799. 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. Long-Term Living 2011 June;60(6):18-19