Transition to MDS 3.0

Long-term care providers continue in a holding pattern awaiting the anticipated transition from MDS 2.0 to MDS 3.0. While exact specifications of MDS 3.0 are not yet known, one fact is certain-the change will be significant, and its effect will be facility-wide. Based on detailed analysis of the most recent draft, significant changes are expected in the methodology for data collection, coding, and reporting. Consequently, now is the time to begin the process of educating staff regarding the timeline for implementation, the overall change in assessment philosophy, and laying the groundwork for a smooth transition to MDS 3.0.

Transition timeline

In March of 2009, The Centers for Medicare & Medicaid Services (CMS) delayed implementation of MDS 3.0 until October 2010. This fortuitous delay grants providers a one-year lead time from the release of final documentation until the revised implementation date of October 2010. Assuming the draft is indicative of the final publication, providers will benefit from advanced preparations. To that end, it’s important to review the most recently published timeline and remain informed of future modifications. As of today, key dates include:

• October 2009: Publication of MDS 3.0 Resident Assessment Manual

• January 2010: National Quality Forum (NQF) call for Quality Measures

• February/March 2010: Train the Trainer Educational Forums

• September 2010: NQF Endorsement of Quality Measures

• October 1, 2010: Initiate Implementations (National data collection; SNF PPS-based on MDS 3.0 data; and national data collection of QM/QI using MDS 3.0 data)

• April 2011: Begin analysis of MDS 3.0 quality measure data

• July 2011: Complete analysis of MDS 3.0 quality measure data

• October 2011: Begin public reporting using MDS 3.0

(For a complete list of transition dates, visit CMS online at https://www.cms.hhs.gov/NursingHomeQualityInits/Downloads/MDS302010ImplementationTimeline.pdf.)

Change in philosophy

The main objective of MDS 3.0 is to make the resident assessment process more clinically relevant and reliable. To accomplish this, increased emphasis is placed on the residents themselves by expanding the use of resident interviews. While resident interviews have always been a component of MDS 2.0, they have been loosely prescribed with staff often extracting necessary information from the chart, not the resident directly. Studies have shown, however, that asking residents directly about their condition and their preferences conveys respect for the individual and is fundamental to both higher quality of care and higher quality of life.

Based on detailed review of the draft documentation, MDS 3.0 will likely require resident interviews in determination of:

• Mental status

• Mood

• Preferences for daily routine

• Pain

• Long-term goals

In each category, the interview process uses standard questionnaires with a methodology for coding responses and ultimately calculating a quantitative score using industry standard scales. The interview process will rely on structured questions with a range of potential answers from which the resident can make a selection. All residents, regardless of cognitive ability, will be assumed capable of participating until determined otherwise. Interestingly, in the pilot study, 90% of residents were able to complete the mental status interview; 86% completed the mood section, and 84% completed the section regarding preferences for daily routine. Should residents be deemed unable to participate, the staff will substitute observations for the interview process.

While the exact specifications of MDS 3.0 remain unknown, the inclusion of resident interviews is certain and will require providers to overcome challenges. Such challenges may include locating a private place to conduct interviews, identifying a process to schedule interviews around resident activities/therapies, addressing potential cultural issues in discussing depression and anxiety, and eliminating potential language/comprehension barriers as a result of impairments that may require new accommodations. At a minimum, it’s important for providers to equip staff with the skills necessary to confidently conduct resident interviews.

Fortunately, MDS 3.0 is a major step forward in redirecting attention away from forms and paperwork back to the resident as an individual. Nurses, in particular, offered favorable reviews in response to the pilot study. Many nurses expressed satisfaction with the dialogue that flowed from the resident-focused approach and credited the interview process with gaining information that would otherwise have gone undetected.

As far as reimbursement, MDS 3.0 with 66 RUG groupings will impact reimbursement in a profound way. In addition to new group definitions and additional groups, the proposed rule for fiscal year 2011 indicates that look-back periods for IV medications and IV fluids will not go into the hospital. Providers were never good at coding IV medications/fluids from the hospital prior to the RUG 53 grouper, when there became a financial incentive to do so. Going forward we can predict that the percent of Medicare assessments qualifying into the Top RUGs will decrease significantly.

Prepare groundwork

MDS 3.0 will affect change across all disciplines and, accordingly, will necessitate an interdisciplinary transition team including the administrator, director of nursing, MDS coordinator, therapy, social services, nursing/certified nursing assistants (CNAs), dietary, as well as the business office. A good starting point in laying the proper groundwork is an assessment of current internal systems and the various roles played in the process. Then, each team member can take his or her respective piece of the assessment and review it for expected change, educational, and/or process needs.

For example, if the nursing and CNA team are collaborating on activities of daily living (ADL) assessments, they can examine the documentation and data collection process (flow sheets or electronic data entry) currently used and anticipate the changes. Furthermore, the lead nurse and CNA can use the preparation process to provide refreshers in ADL coding.

After the facility-wide assessment process, team leaders can develop written action plans to document and communicate the transition plan to the entire transition team. Once again, an opportunity exists for providers to seize the day and tear down discipline silos built around MDS assessments and rebuild with an interdisciplinary team approach.

Because MDS data is the basis for many operational systems-clinical, financial, and regulatory-all operational and clinical systems need to be evaluated to determine the extent of MDS data interaction. Most importantly, the MDS process will not function without an upgraded software system. Thus, it’s essential to contact software vendors and ask important questions such as:

• Will they upgrade from 2.0 to 3.0? (If not, get shopping for a new vendor.)

• If yes, do they expect changes to the look/feel of software?

• Will software training be necessary?

• Will system interfaces require any modifications?

• Will the upgrade offer any system enhancements?

Quality of care, quality of life

The transition from MDS 2.0 to MDS 3.0 will support the industry-wide goal of offering the best possible quality of care and quality of life for long-term care residents. By focusing increased attention on the resident, the staff will likely perceive more value in the MDS process and discover new opportunities to improve resident care. The strategies a facility uses to implement these changes will affect its financial, survey, and quality care outcomes. Accordingly, take advantage of this holding pattern and get a head start on the transition.

Cheryl Field, RN, MSN, CRRN, is a Senior HealthCare Specialist; and Jennifer Gross, RN, BSN, BA, RAC-CT is a HealthCare Specialist at PointRight Inc., Lexington, Massachusetts. PointRight is a company committed to improving the quality of care in long-term and post-acute settings by providing information-based clinical management tools and services to providers, payers, regulators, suppliers and consumers.

For more information, please call (781) 457-5900 or visit https://www.pointright.com. To send your comments to the editor, e-mail mhrehocik@iadvanceseniorcare.com.

Sidebar

At a glance…

October 2010 might seem a long way off, but it’s not too early to begin preparing for the arrival of MDS 3.0. Laying the groundwork by educating staff and reviewing equipment needs now will help pave the way for a smooth transition.

Sidebar

Timeline for Implementation of MDS 3.0

• October 2009: Publication of MDS 3.0 Resident Assessment Manual

• January 2010: National Quality Forum (NQF) call for Quality Measures

• February/March 2010: Train the Trainer Educational Forums

• September 2010: NQF Endorsement of Quality Measures

• October 1, 2010: Initiate Implementations (National data collection; SNF PPS-based on MDS 3.0 data; and national data collection of QM/QI using MDS 3.0 data)

• April 2011: Begin analysis of MDS 3.0 quality measure data

• July 2011: Complete analysis of MDS 3.0 quality measure data

• October 2011: Begin public reporting using MDS 3.0

(For a complete list of transition dates, visit https://www.cms.hhs.gov/Nursing HomeQualityInits/Downloads/MDS302010ImplementationTimeline.pdf.)

Long-Term Living 2009 September;58(9):34-36