Nursing Diagnosis And Care Plan

welcome to the centers for medicare & medicaid services post-acute care provider training series. my name is dave nolley and i will be moderating today's training session on mds 3.0 policy updates. before we begin talking about the actual updates we will be covering today, we would like for you to know a little bit about why this training series is so important and how it will assist in improving health and health care in our country. quality health care has always been a concern, not only in the united states, but throughout the world. we are happy to let you know that the united states is a

global leader in health care. our academic institutions, healthcare professionals, and service providers are internationally known and admired all over the world. cms's role in this large health care arena expands beyond the traditional role of administering medicare, medicaid, and the children's health insurance program, also known as chip. cms has been tasked to be the leader in providing high quality care and better health at lower costs through improvement to health care for all americans. we at cms strive for excellence in all that we do to continue to be a global leader in health care to provide better health care and improved health for our

beneficiaries. so, what is cms's purpose? cms's mission states, “as an effective steward of public funds, cms is committed to strengthening and modernizing the nation's health care system to provide access to high quality care and improved health at lower cost.” what is cms’s picture of the future? our vision of future success here at cms is to have a high quality health care system that ensures better care, access to coverage, and improved health. we mentioned lower costs. being an effective steward of public funds commits us to providing better care to our beneficiaries at lower costs.

to fulfill our mission and achieve our vision of a high quality health care system, cms has chosen four strategic goals that we must achieve. the first goal is better care and lower costs. our beneficiaries receive high quality, coordinated, effective, efficient care. as a result, health care costs are reduced. the second goal is prevention and population health. all americans are healthier and their care is less costly because of improved health status resulting from use of preventive benefits and necessary health services. the third goal is expanded health care coverage. all americans have access to affordable health insurance options that protect them from financial hardship

and ensure quality health care coverage. and finally, the fourth goal is enterprise excellence. we will have achieved enterprise excellence when cms' high quality, diverse workforce develops, supports, and utilizes innovative strategies, tools, and processes, and collaborates effectively with its partners and agents to reach its goals. it is very important that we at cms help our providers and stakeholders in any way we can to assist in achieving these goals and attaining our vision. we do this by providing up-to-date, accurate information, through training such as this, to those who are critical in compiling and submitting information on all

of the requirements that must be fulfilled by the providers as participants in the medicare, medicaid, and chip programs. now that you have learned a little bit about cms and its mission, vision, and goals, let's turn to our training topics. today's training is the first post-acute care web-based training that cms is providing for 2013. our topic today is mds provider updates, which will include information on discharge assessments and dashes and how to code these items in the mds 3.0. first, let's find out a little more information on what the mds is and why we use it. to do this, i would like to introduce our two panelists

today, cheryl wiseman and rabia khan. welcome ladies. both cheryl and rabia work at cms in the quality measurement and health assessment group of cms' center for clinical standards and quality. cheryl and rabia will answer questions on what the mds is and other frequently asked questions. so, we’re going to start with cheryl. cheryl, what is the minimum data set (mds)? dave, the mds 3.0 assessment instrument is the tool to collect individualized information about each resident, and the user manual provides coding instruction. the primary purpose of the mds 3.0 is to provide a basis for an

individualized, person-centered care plan for the resident. rabia, what then is the resident assessment instrument (rai)? the rai consists of three basic components: the minimum data set (mds) 3.0; the care area assessment (caa) process, and the utilization guidelines which are found in the long-term care facility resident assessment instrument user's manual, version 3.0, often referred to as the rai user's manual. the latest version of mds, version 3.0, was launched october 1, 2010. updates are posted on cms's website annually or semi-annually. it must be completed for any resident residing in a medicare- and/or medicaid- certified facility.

that is very helpful. thank you! rabia, can you tell me a little more about the resident assessment instrument? certainly, dave. the resident assessment instrument, or rai, including the mds 3.0, is designed to promote high quality nursing home care and is mandated for use in assessing people who receive post-acute, short-term, and long-term care through medicare- or medicaid-certified nursing homes. the mds 3.0 helps staff gather information on resident's strengths and needs as well as preferences. this in turn helps evaluate goal achievement and care plans, which guide each resident's unique path to achieving or maintaining his or her highest practical

level of well being. are medicare- and medicaid-certified nursing homes required to use the rai, rabia? yes, the rai meets the intent of the omnibus budget reconciliation act of 1987, which is referred to as obra ’87. it is also known as the federal nursing home reform act. these regulations require nursing homes that are medicare certified, medicaid certified or both, to conduct initial and periodic assessments for all their residents. the resident assessment instrument (rai) process is the basis for the accurate assessment of each nursing home resident

rabia, can you give a brief history on how we got to this point? development of the rai began in 1988, and became effective october 1990. the mds 2.0 was released in 1995, and mds 3.0 became effective october 1, 2010. cms has undertaken the development of the new instrument to capture more clinically relevant information that will be used to assess nursing home residents health and functional status and to assist in the planning of care. cheryl, why did cms come out with mds 3.0? mds 3.0 was released as a new tool and developed with certain underlying goals in mind. these goals include resident voice, clinical relevancy, and efficiency.

what is meant exactly by “resident voice?” dave, resident-centeredness is at the heart of many changes in the mds 3.0. the mds 3.0 reflects the resident's voice: resident interviews have been incorporated into the assessment of cognitive function, mood, personal preferences, pain and goal setting. getting this information directly from the resident supports the goal of having the resident participate in the assessment and ensures that their needs, goals, and priorities are heard and incorporated into their plan of care. when the resident is unable to participate in the assessment process, family or significant others can provide valuable

information about the resident's needs, goals and priorities. you also mentioned clinical relevancy? yes, with regards to clinical relevancy, the mds 3.0 is based on clinically useful and validated assessment techniques. mds 3.0 items were developed to be consistent with the current state of the science, clinical guidelines, and recommendations, and continue to be reviewed and revised each year. okay, can you explain efficiency to us, cheryl? i certainly can. the mds 3.0 was developed to be an efficient tool in identifying resident needs and enhancing individualized care planning. care area

assessment, which we refer to as caa information is used to develop, review, and revise the resident's plans of care that will be used to provide services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. mds information and the caa process provide the foundation upon which the care plan is formulated. the care plan becomes each resident's unique path toward achieving or maintaining his or her highest practical level of well-being. you’ve told us about the mds, but how does cms use data collected through the mds? although the rai's first and primary use continues to be driving care planning,

there are several other uses for the data that is collected including: determination of payment for nursing homes for all residents whose stay is being paid for by medicare part a and, in many states, for residents whose stay is being paid for by medicaid, serving as the basis for publicly reported quality measures which are available to assist prospective residents and their families in their selection of a nursing home. data collection also provides insights to surveyors regarding potential areas of concern to be further investigated during survey and serves as the basis for quality reporting to the facility staff on areas that may need improvement.

thank you cheryl for all your helpful answers to these questions. we hope that this short discussion period has given our viewers a better understanding of mds and why training on this subject is so very important. now let's move on to the training topics we are offering today. as mentioned, we’re covering two topics today. our first training topic will focus on our relatively new discharge assessments, and our second topic will explain how to properly code with dashes. let's begin our training with information on coding of discharge assessments. the purpose of this training is to educate you on how to accurately code the mds

3.0 and submit resident information in addition to identifying the importance of why you need to code accurately. at the end of this policy update, you will be able to properly code discharge assessments and recognize the appropriate use of dashes on the mds 3.0. we will provide information on how to address situations when a dash has been used inappropriately. also, you will be able to describe the importance of timely and accurate discharge assessments and identify steps you should take to ensure compliance with discharge assessment requirements. our training will begin with coding discharge assessments. why is it so important to complete discharge assessments? first and foremost,

the discharge assessment captures the resident's health and functional status upon exiting the facility and closes them out of the facility in the mds national database. an accurate discharge assessment ensures that the resident's status is accurately reflected for quality measurement and other reporting purposes and can be used by a receiving facility in order to ensure continuity of care. discharge assessments include discharge tracking information. discharge assessments are required. our training today will focus on accurately coding discharge assessments, which ensures accurate patient information upon exit. in summary, in promoting cms's strategic goals of better care and expanded

health care coverage, these discharge assessments are very important. capturing the resident's status assists in developing and assessing quality measures, assists in care planning and care transitions across settings, and helps the provider, the resident, and cms work together as a team. when mds 3.0 was released in october 2010, a discharge assessment was added to the assessment process. federally required tracking records and assessments include the entry tracking record, the discharge assessments, and the death in facility tracking record. these include the completion of a select number of mds items in order to track residents when they enter or leave a facility.

the discharge assessments include items for quality monitoring. they do not include completion of the caa (which stands for care area assessment) process and care planning. the discharge date on the mds 3.0 must be the same date as the assessment reference date (or ard), of the discharge assessment. it is the discharge date that drives when an assessment must be completed. the completion of the assessment is required no longer than 14 days after the discharge date and then must be submitted no more than 14 days after completion. there are two types of discharge assessments. one is discharge return

anticipated, and the other is discharge return not anticipated. discharge assessment return anticipated must be completed when the resident is discharged from the facility and the resident is expected to return to the facility within 30 days. for a resident discharged to a hospital or other setting (such as a respite resident) who comes in and out of the facility on a relatively frequent basis and reentry can be expected, the resident status is "discharged return anticipated" unless it is known on discharge that he or she will not return within 30 days. this status requires an entry tracking record each time the resident returns to the facility and a discharge assessment each

time the resident is discharged. discharge assessment return not anticipated must be completed when the resident is discharged from the facility and the resident is not expected to return to the facility within 30 days. for instance, if a resident was discharged to home or to an assisted living facility, this would be the correct type of discharge to complete. in the event that the discharged resident returned, the facility would begin the assessment process over again with an admission assessment after completing an entry tracking record signifying that the resident is an “admission.” a key point to remember when determining the type of discharge assessment needed is that nursing home

bed hold status and opening and closing of the medical record have no effect on these requirements. what is an unplanned discharge and how does it affect coding of discharge assessments? discharges are also described as planned or unplanned. so what is the difference? an unplanned discharge includes, for example: acute-care transfer of the resident to a hospital or an emergency department in order to either stabilize a condition or determine if an acute-care admission is required based on emergency department evaluation. keep in mind that once the resident is

admitted or is in the observation stay greater than 24 hours that a discharge assessment is required. an unplanned discharge also includes a resident unexpectedly leaving the facility against medical advice or a resident unexpectedly deciding to go home or to another setting. for instance, if a resident decides to complete treatment in an alternate setting and leaves the facility, this would be considered an unplanned discharge. for unplanned discharges, the facility should complete the discharge assessment to the best of its abilities. the use of the dash is appropriate when the staff are unable to determine the response to an item, including the interview

items. keep in mind that in a stand-alone discharge assessment, there will be no interview items however if combined with another assessment type, there may be. in some cases, the facility may have already completed some items of the assessment and should record those responses or may be in the process of completing an assessment. the facility may combine the discharge assessment with another assessment(s) when requirements for all assessments are met. planned discharge assessments should be scheduled proactively and completed in the same manner as any other assessment. while less interview items are required in the discharge assessment, those that are required must be considered a

priority. it is expected that the need to use a dash on a planned discharge would be infrequent and rarely encountered. discharge assessments have many reporting uses, including the quality measures and reports such as the mds 3.0 roster, discharges and missing obra assessment reports. without a discharge assessment, it is not possible to determine the exact length of time that a resident is in the facility (known as stay) and therefore the resident's stay and episode length are not appropriately calculated. this can result in a resident being considered long-stay when they should be short-stay or vice versa. this is one of the reasons why it is very

important that we complete a discharge assessment every time a resident exits the facility. many times, the discharge assessment is potentially used as the target assessment for quality measures. if the assessment is missing or not completed as fully as possible, the status of the resident is potentially not accurately reflected and the actual resident outcomes may not be accurate for their intended use such as care planning and quality measures. in addition to the quality measures being publicly reported, they are also used for survey purposes as part of the traditional survey process. because all of the quality measures and some of the quality of care and life indicators are comprised on

mds data, inaccurate or missing discharge assessments have an impact on the potential focus of survey for a given facility. to further emphasize the importance of discharge assessments in relation to quality measures, it is important to understand the terms "stay" and "episode" and see how these are used to determine short and long stay. so what is a stay? a stay is essentially contiguous days in the facility. for example, if a patient is hospitalized it would end the leave of absence. this would not require a discharge nor would it end the stay. a resident who has a leave of absence for therapeutic purposes would not require a discharge assessment to be

completed. the start of a stay is either upon admission or re-entry. the end of a stay is the earliest of either: any discharge, or a death in the facility, or the end of the target period. now, what is an episode? an episode would be all of the stays of the resident added together. an episode starts with an admission entry and not a re-entry. an episode ends with the end of the target period (or calendar quarter), a death in the facility, or if the resident was discharged return anticipated and did not return within 30 days, or the patient was discharged return not anticipated. it is critical to ensure the resident's time in the facility is accurately

represented; otherwise, when a discharge assessment is missing, it is difficult to define the length of stay and episodes of care for each resident. to assess a resident's health and functional status, it is important to conduct an interview prior to discharge. documenting the resident's voice and how they perceive their status are key aspects in not only completing the mds 3.0 but in ensuring person-centered care is provided. the interviews in the mds 3.0 and the inclusion of the resident in the care area assessment process helps to ensure that their needs, wishes and goals are the driving forces in care planning. at the end of this training presentation, there is a list of helpful resources,

some of which will assist you in conducting a discharge interview. let's look at a scenario related to discharge assessments. a resident who was planning to return to their assisted living facility next week but decided instead to leave today to go home to stay with her daughter. is this a planned or unplanned discharge? the answer is that this is an unplanned discharge. an unplanned discharge includes a resident unexpectedly deciding to go home or to another setting but the facility should determine if the resident's unplanned discharge does not allow you to complete an interview during the discharge process. the gateway questions would be coded as “no” and the staff assessments

would be completed. thanks, rabia. now that we have learned about coding discharge assessments, let us turn to the topic of using dashes in coding on the mds. because the may 2013 manual updates bring some important changes as to when a dash is allowed to be used, let's begin with defining what a dash means on the mds 3.0 and when it can and when it cannot be used. almost all mds 3.0 items allow a dash value to be entered and submitted. you can use a dash in the end date of the most recent medicare stay, or any of the items documenting the end date of therapy. this signifies that the date has not yet occurred. the few

items that do not allow dash values include some items in sections a, v, x, and i. by referring to the mds 3.0 data submission specifications on the cms web site, you can determine whether a specific mds 3.0 item allows a dash. excessive use of dashes in any assessment item, including on the discharge assessments, also affects the accuracy of the quality measures reported on nursing home compare and the 5-star nursing home quality rating system. using a dash may reduce the size of the facility's quality measure resident sample and result in an inaccurate representation of the facility's actual resident population. important clinical information regarding resident condition may be missing, and

missing data will distort the quality measures. this will impede the facility's ability to be able to demonstrate quality improvement and to accurately determine appropriate care for its residents. effective with the may 2013 mds 3.0 manual release, the dash will be removed as a valid value for gender, a0800. last fall, cms posted version 1.12.0 of the mds 3.0 data submission specifications informing providers of this upcoming change. because the dash will no longer be a valid value to be used for gender (a0800) as of this date, the assessor must choose either a value of “1” indicating male or a value of “2” indicating female. this change means that beginning on the

implementation date, a dash will not be allowed on any record regardless of its target date. the dash response used after these data specifications are implemented will result in the record being rejected. effective with the may 2013 mds 3.0 manual release, under no circumstance can a dash be used to code section a0800 (gender). so how should this be answered? the gender listed on the mds 3.0 should match the gender listed in the social security system, which is that stated on the medicare card. there are many items for which entering a dash will cause a fatal error if the dash is not consistent with other information entered.

there are, however, a few items that never allow a dash. many of these items are those identifying items in sections a and x; but those items not allowing a dash are not limited to these sections and the data specifications are the definitive source on when a dash is allowed. it's time for a question to consider: what gender should be documented on the mds 3.0 if the individual's gender identity does not match the gender in the social security system? it is important to remember that a person's gender identity or their private sense and subjective experience of gender may differ from the gender reflected in the social security system however, what should be

documented on the mds 3.0 is that which is identified by the social security system. within 24 hours of the successful submission of a file, the mds 3.0 submission system processes the file and automatically produces a final validation report detailing the errors, if any, that were encountered in the submitted records. this final validation report is available to you in the casper reporting application. processing errors range in severity from ones that render the file unable to be processed, to ones that prevent a specific record from being processed, to others that are simply warnings or informational. many conditions exist that prevent a record from being a successful submission. the final

validation report outlines the errors, whether fatal or simply a warning, that were encountered in the submitted records. there is an individual error message identifier associated with each error or warning on the report. the individual warning and error message identifiers and tips and actions to use to address the warnings and errors are available in the mds 3.0 provider user's guide which is available on the qies technical support website, known as the qtso website, at www.qtso.com. it is important to highlight that the mds 3.0 provider user's guide is a separate and distinct resource from the long-term care facility resident assessment instrument user's manual, version 3.0

(commonly referred to as the rai user's manual) and is available on the qtso web site. at the end of today's program, we have provided a listing of several references, including the provider's user's guide. thank you, cheryl. we have covered several topics today in our training. first we let you know a little bit about cms' mission, vision, and strategic goals. we then had a panel discussion covering the history of the mds and rai tools. we also focused on two important topics, discharge assessments and the use of dashes in coding. a powerpoint slide presentation highlighting information covered in this training video can be accessed through the cms.gov website,

nursing home quality initiative page under the mds 3.0 training download section. this information will better enable you to understand the process and help you code properly. in conclusion, as you have seen throughout this training, proper coding is important for discharge assessments and the proper coding of dashes is important for all assessments. proper coding will ensure valid quality measures and quality care both in the nursing home facility and through the resident's care transitions. it will also help your facility evaluate the quality of its programs and care planning more effectively. we would like to thank our

presenters, cheryl and rabia, and you, for your time and attention and hope this training has been helpful to you. if you have any additional questions regarding this training, please see our last slide of references that provides more information on these topics and others. if you still have a question whose answer has not been provided with these resources, please feel free to contact your state rai coordinator. as previously indicated, there is a list of state rai coordinators in appendix b of the rai user's manual. thank you for your time and attention to these important updates. we hope that you find them helpful and informative. we look forward to sharing with you

additional updates as they become available.