Nursing Nandas

hi, good evening. my name is tracy montag. i was one of the gold standard nurses for the state of pennsylvania. there were two of us. terry reiser and i, and she'll introduce herself to you. i wanted to give you a little of my background so that you knew who was actually doing the pilot study so that you have an idea where we came from. so that's what we're going to do, talk to you about that. i started in long-term care back in 1990 and was actually an mds nurse back then. and so i worked through with the first mds and the mds 1.2 and worked

through for the 2.0 and so when the opportunity came up to participate in a pilot project for the 3.0, i jumped on it because i thought i have all this experience and i would be somebody that could do that because i felt for the pilot study they really needed to have people participate in the study and to be part of it who already knew the mds and who had been doing assessment after assessment after assessment. i got involved in the project because at the time i worked -- i worked as a corporate nurse at the time, but i also served as the

president of a state nurse assessment coordinators association, panac. we have a state association in pennsylvania and i had served as the president. and part of the president's role, i was an advisor on the quality insights of pennsylvania the state qio organization. so when they threw in their hat to throw in pennsylvania to be a state to participate in this study, they had asked me then to participate because i was on the advisory board and they knew that i had the mds experience and had done thousands of them and felt

that i would be somebody who had the experience to be able to do the study. one of the things that we really want to convey to you is that -- and i'm sure deb will contest to this if you talk to her about it -- although don't be talking about me. is that i was really one of the people who in sitting in your seat right now that when we went to learn about what we were going to have to do to test this item, to test this mds 3.0, i was really one of the people who said, "this can't be done. we can't do the interviews. it's

not going to be a good piece." i don't think i was really negative about it, at least i hope not. but really in my mind i felt that you know i'm going to try this and work this out but i just can't possibly see how this is going to work. it's going to take too much time. it's going to be too involved and it's just not going to work. and i really started out with that attitude. but once i got into it and once we learned the interview pieces, learned the questions, it just went very smoothly, very quickly, and the best part about it is with my

experience with it, and i'm probably going to take what they are going to say to you is that with this instrument, we went into facilities. we had ten facilities that we had to set up to do the pilot study in. they were facilities that terry and i had never been in before. we didn't know their charts. we didn't know where they kept their documentation or how their documentation systems were set up. we certainly didn't know the residents or anything about them. we worked with the mds coordinator. part of what we were charged with doing was going in for comprehensive

assessments only, going into the building and doing the 3.0 within 48 hours of the assessment reference date of the 2.0. what that did for the facility nurses, it charged them with having to have the 2.0 done before we walked in the door. so, it was very stressful for them, too. so, they had to have the mds done, comprehensive assessment and then we came in right after that and followed them. but my point is, and i'm sort of going on here, is that not knowing the systems, not knowing the facility, not knowing the resident or anything about the resident, when we were done with the mds 3.0, i knew

exactly what to do to take care of that person. and it wasn't about their medical issues. it was about them. and it was about their wants, their needs, their preferences. and that's the best piece about this document, and that's what you will find out when you go out and start putting this into practice, that you're going to know them and be able to formulate a plan of care aside from the medical diagnosis piece that we all know and can all do and they're drugs and all that, but really know about the resident. that's really the best piece about this

document. and i'm pat harrison. i'm from the state of georgia. and i actually worked as a surveyor in the state of georgia for 12 years, various places and positions in the office. actually trained surveyors for a couple of years also. actually how i got into this was i hadn't worked with the state for eight years or so. i was working with the facilities as a consultant doing mock surveys and helping them with their regulatory issues. but one day i was talking to a good friend in the georgia healthcare association. i

didn't ask her if i could tell you her name. but she was telling me about this project, and the evaluation was coming to georgia. and suggested that i call our qio. and i did call our qio and here i am. it was really, i thought, just a very wonderful project. i really enjoyed doing the 3.0 even though it was really crazy to get all of the scheduling in for the 3.0 as tracy talked about, i enjoyed interviewing the residents and talking to the residents. and as tracy said, once you finished the interview and finished the 3.0 you had a pretty clear picture of that resident. actually i think you have a better

picture than what's in the record so to speak. also one good thing that i got out of it was that i got to interview one of my nursing fundamental instructors from 31 years ago. that was really, really neat. it was really a surprise to find out her name was on the list the day i was in the facility. so that was a real treat. i'll tell you one thing if you wonder about interviewing difficult residents. well, i got thrown out of a room one time. i had been told that the resident may or may not talk to you. sometimes she'll talk to people. sometimes she won't. i said okay, fine. so i go and

sit, you know, go in there, sit down and start talking to her and thought we was doing pretty well. started asking my questions and she was answering my questions. i thought, "well, see, i have no problem, no problem whatsoever." lo and behold a few questions later she said, she looked at me and she said, "you got a big butt." i'm going well, yeah, i guess i do. but, you know, i know i need to exercise and diet, but you know, i just can't do that right now.

so we talked a little bit more and i asked more questions. then a few questions later, she asked me to leave. she didn't want to answer any more questions and told me to leave her room. so, you know, it happens. but i did, i think, get information about that resident that really is very beneficial in planning her care, which i thought was essential. so that was just a unique experience for me, getting thrown out of a resident's room. we actually interviewed residents between the ages of 50 and 102. which was really interesting. so we had a wide range and gamut of ages.

and some of the 90 something and 102-year-olds were just absolutely delightful, just delightful. one of them was a braves fan, and we used the hearing apparatus on her because she was hard of hearing and her comment to us was, "oh, i can watch the braves now, and i can hear what they're saying." so it was just a really, really remarkable. so thank you. hi, i'm sherry kennedy. and i'm not sure how i got in this project. one day someone called me and asked me if i was interested and i went, "yeah, sure." the mds had been my life since 1991. i

started out my long-term care career as an mds nurse in a facility in dallas, texas. i did the mds. we didn't know back then that it was the mds 1 or 1.2. we just thought that was the mds. and then being in texas, we were a demonstration state. and so we did do the mds plus and from there we went to the mds 2.0. so i think i've seen them all. and the idea of being involved in the 3.0 is very exciting. my life, my long-term care career has been the mds, whether it was the mds coordinator or whether it was my corporate life, where i helped facilities

across the country or since 2000 i've had my own business where i've been doing seminars and consulting that revolve around the mds involvement in aanac with the mds. some of you may have seen my name on some of the materials in the past. anyway, so the mds is my life; the project was incredible. as we sat there in training, as they did for you this week, we actually had the dentist come up and talk to us, and he said something about, "and then you're going to put on -- you'll find gloves in the resident's rooms." and i'm like, "gloves, what are we going

to need gloves for? " and at that point i had already received so much training that i knew there was no getting out of it. and so i was going to have to do whatever they told me i had to do. when we did our return demonstrations -- and i'm going to let terry tell you what turned me around on that one. but let me tell you, it was not a problem going into a resident's room and doing an oral exam. it was not a problem going into a resident's room and doing or asking any of the things [not anything that was]

required on the 3.0. this may sound strange and i've not said this to anyone anywhere else, but it was almost like i was a doctor. it was like, i'm this healthcare professional, and if i'm asking these questions and wanting to do these things, then they were obliging and didn't question it. and so it was really well received by the residents. the other thing that they trained on that i kind of gulped over was when they said that we were going to have to ask the question about harming themselves or they might be, they need to be dead. and i'm like, when i

asked them what? these are strangers; these are people we've never met before. that's a pretty intimate question. when i was in the facility, i had a resident that i asked that question of. and he said, "yes, i would." he said, "my family would be better off without me, and it would be just as well if i wasn't here anymore." i finished the assessment with him and went out and reported to it the nurse as we had been instructed to do. and she said, "oh, no, not mr. jones. i said, "yeah, mr. jones." she said, "now, the mr. jones i'm thinking of, he's in room 101." i said, "this man was in

room 101." she said, "he always wears a red baseball cap." i said, "he had on a red baseball cap." "really! mr. jones! he's always out here with a jokes for the nurses ever morning. he's got a new joke. and he's always the first one to volunteer to help push somebody into the dining room." she says, "wow, thank you for finding out. we had no idea. never would have guessed on him. last person we would have thought of." and so it's seeing the results that made some of the things that i had been most apprehensive about much easier, much easier to do. i've

heard from some of the others, as tracy and pat have talked, they've talked about resident care and the data that we got from the 3.0 and how much that helped in developing the care plan, helped in determining resident care issues. i actually had a facility nurse who asked if she could continue doing the 3.0 after the project ended. and i had to say, "no, you're still required to do the 2.0." and she said, "oh, no, no. i'll still do the 2.0, but i also want to do a 3.0. she says, "i get much better information to work my raps and develop my care plan."

so that's the best testimonial i can give you for the type of material and the type of answers, the type of data that you'll get from the 3.0. there were tears. i've never cried -- well, i cried with one. usually it was just the resident that cried. but one touched me to the point that we actually sat there and cried together. the residents told me nobody has asked me what do i think, what do i care about. they all just come in and tell me what they're going to do. and this is the first time anyone has sit down and asked me my opinion, and i can't tell you how much

they appreciated it. one resident, we all worked in teams. and i had one resident, marcy, marcy lockwood was my team member. we were the two gold standard nurses for texas. she came back to the room one day, and she said, "i just got done with smith. and his wife had to go out to the car, but she wants to be in there when you go in, because she saw him respond to things that she hadn't seen any response from him in over two years." i said, "marcy, was he able to repeat any of the three items,

sock, blue or bed? " she said, "yeah, he did." i said, "let's go in. i got an idea." so we went in and i found out that his wife's name was margaret. and i looked at him and i said, "mr. smith, say margaret. he said margaret. so marcy and i hurried back out of the room. when his wife came back in i went up to him and i said mr. smith say margaret. and he said margaret. tears ran down her face. she hadn't heard her name from his lips in over two years. so not part of the assessment

but just a simple gift that we were able to give. one other thing that i wanted to talk about is the fact that we kept asking for noninterviewable residents. and they kept saying, "oh, ms. brown, she's noninterviewable." we used the hearing device. we found out she was interviewable. we asked for someone else who was noninterviewable. we used the cards with the answers. we got answers. she was interviewable. we asked for someone else who was noninterviewable. she sat there and said yes, yes, yes. we're looking at each other going does she really

mean yes or is she just saying yes? and then she said no. and so we went back over and we repeated the questions. and again we got yes, yes, yes. no. she was answering our questions. we bonded with these residents. we knew more about the residents than the facility they were living in knew about them by the time we left after doing one assessment. you're up. testing. my name is terry reiser and i've been in long-term care for a long time, since actually 1981. i started as a floor

nurse, as many of you, i'm sure, and then once the mds came about, i jumped in on that and have been doing it ever since. i currently work and manage an arnac temp agency in the state of pennsylvania. tracy's other half of the pennsylvania gold standard nurse. and i've been doing this for such a long time, it seems like second nature for me doing the mds and doing education and training and consulting and making sure that my arnacs are doing what they're supposed to be doing and that we are looking at the

resident as a whole. and going back to 1990, when the mds started and cms was looking at the reason for us doing the mds was to assess the resident to make it a standardized reproducible form. and the reason they put that out is because the quality of care needed to improve. and we needed to look at the resident as a whole, and to look at them as a person. and that's how it started. and then i think it kind of, down the road, kind of got lost in the reimbursement system. and when i heard about the mds 3.0 coming into play and the way

that i heard about that is i was working for the quality improvement organization for the state of pennsylvania. and when i was working for them, that's how we heard about the mds 3.0 coming out and that they would need -- if pennsylvania was elected to be one of those states to participate, that they would need two gold standard nurses. i of course jumped at my boss and said me, me, let it be me, because i've had lots and lots of experience. i love doing this job. i love taking care of the residents and learning about them. and really looking back at the process from

the beginning is that the mds has a minimal data tool. but if you use it the way that it's designed to be used, is that you're gathering information. you're putting it on the mds. it triggers things that lead you to writing your care plan. and it really does drive the care plan on the care of your resident. and i think over the years, like i said before, with reimbursement, with the survey processes, with quality measures, with publicly reporting, i think we lost the focus of taking care of the resident and why we're doing this mds and who is important. so

when i heard about the resident voice being one of the major things that's going to be in the mds, the interview part, i was very excited about hearing about that. some of the experiences that i had when i was doing the pilot test, i'll talk about the dentist. he made everyone demonstrate back to him that we knew how to do an oral assessment so that when we did our training in the facilities that we could train those nurses how to do it accurately. and i really think that in our group i was the very first one that

had to do with it. i pushed her. i was the first one. i went you go first. i put on the gloves and we went in and meet the resident. of course he's standing there watching me. you explain everything to the resident what you want to do. she was very cooperative, thank goodness. but the very first thing that i saw when i had my penlight looking up in her mouth, in the roof of her mouth, she

had this large, i would say, three-centimeter mass in the roof of her mouth that no one knew about. i said, "do you know that you have a mass on the top of your mouth?" she said, "yeah, i rub it with my tongue all the time." i said, "have you ever told anyone that that's there?" she said, "no, i didn't really know what it was." but come to find out that it was cancerous, and she may have died if we hadn't have found that. so it's very important that you are taking the time, even though it's kind of not the best thing that people like to do, is to pull the dentures out and look around in

the mouth and things like that, but it really is necessary. it was very pertinent to a resident's well-being that you are looking at those type of things. one of the other experiences that i had with the mood, the phq-9â©, is that i went into a resident's room, and she was kind of down. you could tell just by looking at her. sometimes you can read people when you go in. you introduce yourself, yeah, okay, what do you want to ask me. well, the very first, when i was trying to explain to her what we were there for and why we were asking her

these questions that we asked them for everyone, and that we were there to help her, to help her get better care. and she said, "well, did you bring me a gun because that's all i need to be taken care of. that will help me a lot. did you bring me a gun? if you didn't, then you might as well leave." i said, "no, i didn't bring you a gun. but can we go ahead and go through these questions?" not that i was ignoring her, but i wanted to kind of find out where she was coming from. and the more that we went through the questions and answers, this

woman was severely depressed. and nowhere in the chart was there anything about depression. nobody knew about it. the staff, when i talked to them, they were like no we didn't know anything about that. so it really is important with this one-on-one face-to-face relationship with the resident that we all have found through our pilot test that the residents do look and appreciate you sitting down with them one-on-one and taking the time to care about them, and a lot of it was with the preferences, that was a positive experience as well. there's lots of times when i would say --

well, i can't really give you a time or a percentage, but it seemed like a lot of times that residents picked the option that said that it was important to them but they couldn't do it. and you know you would ask is it because of your health? they say no it's because everybody's busy and i just kind of go along with it. so it really is important that these -- i love the interview piece. we've learned so much even though we didn't know the residents, we did know the residents very well before we left, and we've talked a little bit about the time issue. and with us not

knowing the resident, not knowing where anything is in the chart and you're going into a new facility you've never been in before, it really did, in the beginning, it was kind of haphazard. you're like oh my gosh how are we going to start this, but the more we did it, the more familiar we were with the form. you didn't have to think about what you were going to say. it just kind of flowed out of your mouth and you surprised yourself after a while that you could really just go in and go through the questions and it really flowed very easily.

so i feel your pain. i feel your fear, because we all were there when we started out. but the more you do it, the better it gets. guaranteed. in follow-up to one of the things that terry just said about it flowing and after a while you just are knowing what's on the form. sock, blue and bed. [laughter] and invariably they'd say sock, blue and red. and i'd go, "did i not speak clearly enough?" so immediately i learned to enunciate

very, very clearly the word "bed" and not "red". so that then if they answered "red", i knew they just weren't getting it. and then after a while, i got just so comfortable with it that i said, "i'm going to say three words and then i want you to say them. they're sock." she said, "sock." i'm like oh no. she just invalidated the test. she was supposed to wait until after i said all three, but i didn't read it from the form. i didn't say it exactly like it was written on the form, and so i didn't get the answers i was supposed to get. and so i didn't get quite as comfortable with just -- i

stuck to the form after that. >> tracy: that's one thing that's really helpful is the scripted pieces; if you follow the script, you'll be able to go right through it. just follow what it says with the script and explain to the resident why you're there. it does -- i mean, it flowed easily, but we did always have the script with us. we took the mds and i guess that's the other thing that they've been trying to stress, the 38 pages. everybody's looking at it. everybody i've talked to, because i'm a consultant now. so places that i go

they're very freaked out about the 38 pages. but it has skip patterns in it. the font is larger. it's what we used to do was we actually would mark the interview sections with little tabs so that when we would go into the resident's room we could go right to the interview sections from the tabs to be able to pull it through to get it go easier. that's a little tip if you start to do it on paper versus doing it electronically at first. we found that it was easy to mark where our interview pieces were going to be so that we could go through and do that piece with it. but following

the script, it was really helpful. i think what we want to do is open it up for some questions. we have lots of stories about what we did. but we really wanted to -- this is really to help you. so if any of you have any questions, we'll take some questions. see, they did it. reminds me of listening to the stories when i was a new grad with the nurses, oh, yeah, you just put them on the life pack and set the joules. and how do you get from here to there. and then you do. so we're going to go ahead, and i see

hands coming up everywhere. so the first hand in the back, so i'm going to start back here. i am totally excited about the 3.0. i think the interviews are wonderful. so you're speaking to the choir in terms of converting to it. what my struggle is operationalizing it. and i was wondering how -- one of my questions is how often will were you actually able to do all of them in one sitting? meaning the bims, the mood preferences and pain? well, i can tell you that's how we did it. i don't know if other

people conducted it differently. but when we did our piece, with our interviews, we did them right straight through. we started with the bims and then went through to the phq-9 t o the preferences, to the pain questions. we just, in one sitting, went right through it. our biggest challenge and i don't want to take up all the time, but our biggest challenge from an operational standpoint, was finding a place to interview the resident. but you need to have a private area because you need the resident to be comfortable, you need to

be comfortable. they don't want to overhear people or have somebody overhear them and what they're saying. i don't know if you have anything to add to that i was going to say we did the same thing in georgia. we started it with the first and went straight through. so most residents were able to go through the entire -- yes that's my question. how many actually held up and of course ,we're going to have to do 14-day, five-day

discharge. you know, and i think that is what is so overwhelming, is asking the person two, three and potentially four times if they're suicidal. i'm having a real hard time with that piece. so any suggestions you have on making that work i'd appreciate it. do you want to answer that? i think the key to it is in preparing them. and if you tell them up front that this is something that is being asked of everyone in the country, and everyone that has this type of a stay has this number of assessments. and so even though it may seem

like we're being repetitious, it's what we've been instructed to do. and i don't think it will be a problem. like i said, they treated me like i was a doctor. whatever i asked, they were very cooperative. we're going to go up to the next question. it looked like from the videos today and from what you've said this evening that it was one person conducting these interviews. my concern is you know when we're looking at the mds we're looking at it as being an interdisciplinary process.

and we're looking at the social service person, the activities person, the nursing person. so are you recommending it be one person, or how do we still bring that interdisciplinary process into the interview process? i personally, this is terry reiser speaking, i feel it needs to be interdisciplinary. i don't think one person should be doing all the interviews. i think it's important that the team pull together and that really administration needs to buy into this as well, that it's not an arnac duty. this is an interdisciplinary team. the arnac is to oversee and conduct the process.

and it's always been really that way. but it seems like it always lands in the arnac's lap that they're the ones that have to do the majority of the work. and i know the interdisciplinary team does, in most facilities that i work in anyway, that they are participating in doing their own sections. but really it needs to be an interdisciplinary look at the resident, looking at them as a whole. and one person should not be doing it, i don't think. i believe some of the gold standard nurses did in fact teach facility nurses who in turn went out and taught other members of the team how to do that. i'm looking for a nod. yes, i got my nod. so as a part of the project, there were

some of us who, as gold standard nurses, did the entire assessment, whereas in other states and apparently not represented on this panel, but they did parse it out to the other disciplines. and so the data that you've seen, the results that you've heard, is representative of an interdisciplinary team as well. great. i think we have another -- we're working our way up. i think practically, i mean when you talk about the time and everything, you can triple the time, if you make it interdisciplinary, and i think logistically people are going to have to figure out whether that's going to be feasible, because if you're going to get all these people together and they're all going

to go do their little pieces it's not going to be some average 17-minute process like you guys had. i think each facility probably needs to set their own policy for whether one person does all of the interviews or it's separated out. the other piece operationally, since that was one of the questions with it, is that i feel strongly about -- this is just tracy montag, is that as the management team of the facility is making sure you have the right person in the right position. and i mean that by you need to have people in your facility that are buying into this first of all, but you need to have people that

are willing to talk to the residents. and i know that that sounds like well everybody should be able to talk to the residents. i'm a consultant. i'm in 100 buildings. and i know that the mds coordinator, arnac that we call them in pennsylvania, i know with the movement of the electronic systems, that there are arnacs and mds coordinators that can sit in an office do an entire mds without walking out of their office. i know that that happens. it was never intended to be that way. it was always intended to see the resident and talk to the resident. so this is a huge change. and

i know that it's a huge change that people are going to have to get out of their offices and go. i met social workers that are not comfortable talking to residents. they're all about the discharge plan and doing all those kinds of things. and so that's what i'm looking at from an administrative management standpoint is that in order for this to work, in order for people to be able to ask the questions and move through the interviews, they have to buy into it and be willing to talk to the residents and ask the residents the questions.

it's tough. i mean, i said from the very beginning, i was one of the people that was not comfortable asking those phq-9 questions. i did not want to talk to somebody about hurting themselves or if they'd rather be dead -- if it would be better off if they were dead, you know. and i had a resident that said to me, a bilateral amputee, god bless her, said to me if she could get in her wheelchair and wheel herself out on the highway in front of the place and throw herself in front of a truck, she would do it. you know, so you get those kind of answers. i had the same situation as terry had. i went out and talked to this social worker. he said there's

nothing on the chart, wasn't on anti-depressant. there was no record anywhere that this woman had any problems with depression or that anybody thought that she wanted to do that. so it's just really cool stuff that we were learning about the people to be able to better take care of them. i'd like to say one thing that if you're not out looking at the resident in and interviewing them, the way you should have been doing really, i mean, all along, how do you write a care plan, an individualized specific care plan for that resident? i also am a consultant. i'm in multiple facilities, and lots of times what you see is

canned care plans, the same thing over, over, and over. every resident has basically the same type of care plan. i'm not saying every facility is like that, but a lot of facilities are still unfortunately like that. when you read the rai manual, the new mds manual, a lot of the care planning issues are in this manual. they give you tips on what you should be covering in your care plan. so then you look at the survey process, and if they're telling you that you need to be care planning these things and you're not, i bet the surveyors are going to be reading that manual, too.

so you really need to make sure that your care plan looks like your resident. i'm going to move up to, keep moving up the aisle. we definitely have questions in the corner. before i keep moving, do we have any questions in the back wings? okay. we do. it might be easiest if you want to go up to the mic. can you hear me? is the mic off? that's good is it on. i'm an mds coordinator.

i think the 3.0 is a great thing for from the patient's perspective. on the other hand, i have to stop and think, you know, the days that i have six admissions, two quarterlies, three discharges, you know, and the company on your back, you know, over reimbursement, which unfortunately reimbursement is a part of the 3.0, and we all have companies that worry about the bottom line also. so my concern is, you know, how am i going to get all of these done with taking a look at what we have to do on a discharge now. it's not just, you now, one paper or to discharge somebody prior, you know, it's

not on the medicaid patient, it's not one paper. it's almost a full assessment. you know? that's a lot -- i mean, i don't know what we need to do as mds coordinators you've got medicare people coming in and out. you've got rehab people coming in two days, they're going home. you've got somebody else coming in. how to get all of this done in the time constraints? i think maybe one of the first things to keep in mind is that it truly took us significantly less time to do the assessment. and so i hear you about the discharge assessment. but it didn't

take us near the time that it took to do the 2.0. and so where we saved time in one place it might take more time in another place. and i guess time is only going to let us know how it averages out. but my hunch is that once we get into it, once we get in the swing of it, i mean, immediately is it going to take you longer? absolutely. there's a learning curve. and so to do some this summer before october 1 ever gets here, absolutely. be preparing. attend seminars. attend one after you've tried some when you know what your questions are. but once you get into the swing of it, i

think you're going to find that they're not as time-consuming as you fear that they'll be. thank you. i'm going to keep going up. y'all have some positive relationships with the patients. and you all were doing the entire assessment. do you think the fact that you were doing the entire assessment and that the patient resident only had to relate to one person on some of those more difficult questions helped establish a much better

resident assessor relationship and maybe we should look at how we used the interdisciplinary team? and my second question is that did you have any comments on section m? yes, our comment was we were not going to comment on it. when we were first called to come up and do the panel and sit here, i had to contact every one of them and say, okay, which sections do you feel good about talking about, et cetera, they all emailed me they said please do not have me answer any questions on section m. but the reason for that is it's changed since we tested it. not a whole

lot. not really too much. but it has changed since we tested it. the thing that i will comment about section m was that it was the challenge for us, which charge to you to go out and go into your centers now and start looking at this, is that we went into centers that did not have guidelines in place for wound care. wound care teams, for measuring their wounds, for looking at treatments, for looking at systematic methods of looking at those things, and that was a challenge for us, because we, first of all, didn't know their charts or didn't know where they kept stuff.

and then we'd ask them and say, well, we don't do that. so these are things, in looking at the mds over the past days and what you're going to get tomorrow is going back and saying you know what, i gotta start doing this now. i gotta put in wound care protocol or guideline and that kind of stuff. so i am talking about section m in that way. do you have a piece for the other question? i was just going to say section m, i like the way it's laid out, although it took a while to get used to it when we were doing it.

but i mean, once you really get used to it, i really do like the way it's laid out and i think it does give a little more detailed information basically about what we really need to be looking at. but it did take a bit of a time to get used to that section, in particular. and i've actually forgotten -- the first part of her question was one person doing it versus the team? one person doing the assessment versus the entire id team, do you think that has an impact either way, going one way or

the other because obviously we're going to have to look at our system, the relationship betweenã– of trust and the resident answering the difficult questions. that's why i alluded to the fact that in looking at the people who are actually going to be asking the questions, that the person who is going to be asking the questions, that they've had the training, that they feel comfortable going in and doing it. it's true. we did the entire assessment. so we did -- we went right through all of it. and unfortunately our facility nurses, at

least in our state, in pennsylvania, the facility nurses did the entire document as well. so i don't think that any of us here at this -- any of you -- did your facility nurses have the team do it? so we can't really speak to that because we did do it. but we followed the scripted interview. scripted word that was there i think that has to be the facility decision, and also you need to make sure, as tracy said, that whoever is doing your interviews is comfortable interviewing residents and is trained in interviewing residents. and whether it's the one person or

whether it's two or three people, really depends on the training, their training and what the facility, i think, how the facility wants to handle it. and one other comment, and that is we were there as strangers. they'd never seen our face before. in fact, some of them thought we were surveyors. and they were afraid to talk to us until we explained otherwise. hopefully they've seen your social worker. they know your activity director. they're not talking to strangers. they're accustomed to all the interdisciplinary team

members talking to them. being there at the care conference, being a part of their care planning. so i don't see where breaking it up should create any kind of a problem at all. i want to say one thing. you may look at residents that are difficult. let's say that they're difficult to talk to to begin with, and you may have a staff member that they have great rapport with and maybe you want to make sure that they're trained to be able to do the interviews that they have that already that connection with that resident that could be an idea, too, to look

at. we have a gal that has to run. we have had people that stayed from the earlier conference. actually one person pushed her flight back to be able to be here. i was really touched by that. so go ahead. i'm breaking my own rule. i want to thank you actually for being gold standard nurses. i think it's very impressive that -- yes. and i think it's really impressive that the mds coordinators that also interviewed those residents that you interviewed actually had

very close information. and i think that speaks very well to all mds coordinators out there, that they're actually doing a good job. my question is that my understanding with the 2.0 is that we would interview the resident and have always done that. and i've always taught people to do that. my question, then, is with the scripted dialogue, how is that different and how do you get more information from that than i get from the 2.0 which i think i get great data from? i always interviewed the resident. i always went in with my

legal pad and took notes and the conversation went wherever it went, and i came out with the data to respond to the items on the 2.0. the scripted interview caused me to take the conversation in directions that i've never gone before. and it forced me, if you will, to ask more personal, more intimate questions than i might, than i had ever asked before. i don't recall ever having a resident cry. i know i never cried with a resident. the 3.0 changes the focus of the assessment. when we're doing the 2.0, as

a nurse, i'm thinking about, all right, here's what i'm hearing, what does this mean? what do i need to do, what do i need to make sure happens for this resident? with the 3.0, my thinking switches to what does the resident need? what's the resident's perspective on this? it's no longer me deciding what they need, but it's them telling me what they need. does that make sense? did that answer your question? i think the interview part is probably the most interesting and the most exciting part of the whole mds. i mean, it's what connects us to the resident and what helps us develop a better plan of care for them. i guess my question

is, and i've gone down that path with the tears and gathering that data that you think oh my gosh, without even asking those questions, getting that kind of feedback. because they do appreciate somebody who is sitting down with them, face to face, without any pressures of having to go do something else and spending that one-on-one time with them is just incredible. it's what we became nurses for. exactly. and we talk about the interview items. the interview items, the interview items. but the truth of the matter is any mds item they could answer for us, we have them answer. sometimes we just put the form in front of them. if they were cognitively intact

and say these are the questions or we'd say the question and then we'd say here's your choices. and so we got them real involved in it. and so it wasn't just the interview items that they helped us answer. i think it's great that the 3.0 is actually forcing people, actually, to get in there and get to know their residents just a little bit more intimately. because i think with the 2.0, it was kind of lax, and where we didn't have the scripted interview, we got to make up our own three items out of the blue. and now we have to become familiar with the language that doesn't roll off the tongue so freely, if you will. with practice, we've already started. so i want

to thank you. i think it's been really great. thank you very much. it's been a good experience. and we look forward to it. i have a question over here. i'll be bouncing over here. i wanted to thank the gold standard nurses as well. and i have been so excited about the 3.0, and i am still. not only have i been a nurse for 37 years, a don in a 300-bed facility, i have been a daughter and a caregiver to my mother who died of alzheimer's. and the 3.0 finally gives the resident a voice, and that is the only word you can say for it. the 2.0 and all of the assessments, not only that i did but that i watched when my mother went through the care system, she

had no voice. i was her voice, but never was it asked what's important to you. and we talk about operational, how are we going to do this and what time is involved, but the assessment is really about the resident. in the end, it's about the resident. the end of our eight or ten or 12-hour shift, we go home. but the resident stays in that facility, and they stay within their body and their incapacities to what levels they are, and the 3.0 forces us to give more than lip service to being resident-centered. for a resident to look at you and say nobody's ever asked me what's important, that's a sad commentary on where we are. but it's also an extremely positive on where we're going. and thank god

we're headed that way because our elders deserve it and approaching elderly myself in a few years, i appreciate that somebody's going to care what's important to me. thank you very much. i've been in this field since the '70s, and i can just tell you as a medical record consultant, being here since monday night and listening to you all, i have to say that i finally feel inside that those 38 pages might be paper. but we're going to go away from paper care, and we're finally going back to patient care. amen. even though it's paper, whatever we're filling out, the outcome is that that

person in the bed is finally being -- the most important thing that's been said is go in and be the cheerleader for this assessment. my daughter is a clinical social worker at a large facility in maryland. and i need to go home and tell her what i learned, because she's going to be responsible for this. she's heard my stories over the years, and that's why she's a geriatric social worker. so now i can go and say, "you are going to be able to talk to your residents and get that meat that you always wanted to rather than doing that discharge process, rather than just talking about and rushing around and doing that paperwork. you are going to be able to be that clinician and sit down and talk

to your residents." and that's what patient care is all about. so i'm very pleased. i'm going to be a cheerleader, and i'm going to encourage everybody to go and be that as well. great. thank you. i just want to say one thing. as you were stating, it seems like over the years we've become very task-oriented and the resident got lost in the shift. so any administrators out there? i challenge you to go back to your facilities and change the mindset of the people that are in your facility and make it resident-centered. look at your policies, your procedures, your processes and change it. we have to start the change somewhere, and this is a good place to

start. great lead-in for my comment which was i'm so happy cms finally came out with the mds 3.0 because they came out with qis in maryland last year. and one of the things you think about is the interview process in the qis survey process, the first thing i heard was oh my god it's going to take forever. going back for the numbers and the second thing is that the residents look forward to it, because we've actually started asking what care is acceptable to them rather than what we think is acceptable to them. and i think that's a huge difference in this. and the mds 3.0 coming out this year just sort of cements

that whole process for us, at least in the qis states, because now we really do have both sides of it where you're not just doing paper compliance, you're actually talking to them. i guess the other thing i want to say is once the residents get over the initial shock of us asking them what they really want, and the staff getting over the shock of them saying well that's not what i really -- that's not the care i really wanted, i wanted this kind of care, as far as my preferences go, then you can get dialogue going, and you can develop a care plan that's meaningful and not that plan old check off box that we put in and we try to personalize by putting mrs. jones' name in it.

hi, everybody. you know, dealing with the communities back home, i know a lot of you are consultants up there, what they want to know is about the transition and getting going and even before it starts, you know, october 1st, what can we do to help prepare them? so i'm looking at where would you highlight for educational programs for us to start internally? what i've been telling people, first of all, make sure they know how to work the raps today. because there's a lot of facilities that have never learned how to work the raps. if they know how to work the raps today, working the caas tomorrow will be a shoe-in. the second thing is interviewing. they can start practicing interviewing, and then, again,

i recommend that they start practicing the 3.0. that's really what i'm recommending as well, is that moving the interview pieces from the 3.0, moving that into the assessments that your team is currently doing. use the bims for the cognitive assessment, because you can get the information for the 2.0 right from the bims. use the phq-9, because social workers generally ask those kinds of questions.