MDS 3.0 and PASRR - PASRR Technical Assistance Center

MDS 3.0 and PASRR10/12/2010 Webinar for NAPP membersDan Timmel CMSPASRR Technical Assistance CenterSlides prepared by Breck Douglas (9/10)

Agenda• What is MDS? How and why does it affect me?• Review MDS 3.0 changes related to PASRR• How will MDS 3.0 affect Change in Status Evaluations• Review criteria for Change in Status Evaluations• Questions and answers• Resources2

What is MDS?• MDS: Minimum Data Set. Actually quite a robust set of data onevery resident in Medicaid certified nursing facilities.• The MDS is a powerful tool for implementing standardizedassessment and for facilitating care management in nursinghomes (NHs)... Its content has implications for residents,families, providers, researchers, and policymakers (CMS, 2010).• The MDS assessment is completed at admission and then onceevery quarter, and upon a significant change, for all NFresidents. The assessment is used in care planning.https://www.cms.gov/NursingHomeQualityInits/25_NHQIMDS30.asp#TopOfPage3

A view of page one of the MDS 3.0, and thenew PASRR question on page three:4

How will MDS 3.0 affect me?• MDS 3.0 is designed to improve the reliability, accuracy, andusefulness of the MDS. These improvements support the intent thatMDS be a tool to improve clinical assessments.• MDS 3.0 issued by nursing facilities starting October 1, 2010.• New to MDS 3.0 is question A1500 which documents if a PASRRLevel II determination has been issued.• This is the first time PASRR has been specifically addressed in the MDS process andwill bring individuals identified by PASRR to heightened awareness.5

MDS 3.0 PASRR Item A15506CONFIDENTIAL

How will MDS 3.0 affect PASRR?• Better defined scenarios for nursing facilities illustrating whena change in status (CoS) may require PASRR evaluation shouldlead in most states to an increase in referrals from NFs:• For Level II resident reviews for persons already identifiedthrough PASRR, (A1500 = Yes) whenever the residentexperiences a significant Change of Status (CoS)• For Level II evaluations for NF residents with newly identified orsuspected SMI, ID or DD who have never before been identifiedthrough PASRR, when the resident experiences a significantChange of Status (CoS)7

MDS 3.0 instructs NF staff that…•If an MDS significant change in statusassessment (SCSA) is completed for a residentfor whom A1500 is YES, or for whom mentalillness, mental retardation, or a relatedcondition is suspected, then a referral to thestate mental health or mental retardationauthority is required, for possible ResidentReview, a Level II evaluation.8

MDS triggered Level II referrals• The purpose of this instruction is to make therelationship explicit between the facility’sobligation to perform SCSAs under MDS 3.0, andthe facility’s obligation under PASRR to refer forpossible Level II Resident Reviews.• The instruction is not an MDS requirement but apractical instruction to facilities about how theycan meet their PASRR obligation whileperforming MDS activities.9

MDS triggered Level II referrals• The challenge is that NF staff have not been able todetermine whether the individual requires a first timeor an updated Resident Review. So the law at§1919(e)(7)(B)(iii) of the Social Security Act is broadand says that all CoS should be referred for Level IIevaluation.• State agencies may wish to collaborate on developingsome criteria permitting facilities to omit referralsunder certain conditions not related to PASRR10CONFIDENTIAL

How might this affect your PASRR program?• Plan for a likely increase in CoS Level II evaluation referrals• Possible need for a process to review requests for CoS LevelII evaluations sent by nursing facilities as a result of MDS 3.0• It is possible that not all requests will need a full PASRRevaluation:• For some requests, you will thank the NF for their diligence, and explainwhy a Level II PASRR is not needed• For some you may gather information and update the extant PASRRSummary of Findings• For some requests you may initiate a full comprehensive Level IIevaluation and issue a new Summary of Findings11

Criteria for CoS referral for RRReferral for RR evaluations are required for residents previously identified byPASRR in any of the following circumstances: (Please note this is not anexhaustive list.)• transferred, admitted, or readmitted to a NF following an inpatient psychiatric stay orequally intensive treatment.• increased behavioral, psychiatric, or mood-related symptoms.• behavioral, psychiatric, or mood related symptoms have not responded to ongoingtreatment.• an improved medical condition, that may require modifying the plan of careor placement recommendations. See example• CoS is physical, but behavioral, psychiatric, or mood-related symptoms, or cognitiveabilities, may influence adjustment to an altered pattern of daily living.• indicates a preference (may be communicated verbally or through other forms ofcommunication, including behavior) to leave the facility.• condition or treatment is or will be significantly different than described inthe resident’s most recent PASRR Level II evaluation and determination. Seeexample12

CoS example: Improvedmedical conditionExample: an improved medical condition, such that theresident’s plan of care or placement recommendations mayrequire modifications.Mr. L has a diagnosis of serious mental illness, but his primary reasonfor admission was rehabilitation following a hip fracture. Once thehip fracture resolves and the he becomes ambulatory, even if otherconditions exist for which Mr. L receives medical care, he should bereferred for a PASRR evaluation to determine whether a change inhis placement or services is needed.13

CoS example: Prior LII outcome isno longer appropriateExample: condition or treatment significantly differentthan described in the resident’s most recent PASRRLevel II evaluation and determination :• Ms. K has mental retardation. She is normally cooperative,but after she sustains a fall requiring a cast, she has becomeagitated and combative with the physical therapist and withstaff who try to clean the area. She does not understand whyher normal routine has changed and why staff needs to toucha painful area of her body.14

Criteria for COS evaluations: Residentsnot previously identified by PASRRReferral for Level II Resident Review evaluations are requiredfor residents who may not have previously been identifiedby PASRR to have mental illness, mental retardation, or acondition related to mental retardation in the followingcircumstances: (Please note this is not an exhaustive list.)• exhibits behavioral, psychiatric, or mood related symptomssuggesting the presence of a diagnosis of mental illness (anddementia is not the primary diagnosis).• mental retardation or condition related to mental retardation wasnot previously identified and evaluated through PASRR.• transferred, admitted, or readmitted to a NF following an inpatientpsychiatric stay or equally intensive treatment.15

Questions and answers16CONFIDENTIAL

What’s next?• Educate NFs in your state about change of statusguidelines.• Ensure NFs know who to contact when they believea PASRR CoS resident review might be necessary.• Create a notification form that allows your state toidentify trends and analyze in status changereporting• Be ready to use the data available under MDS 3.0!17

ResourcesCMS MDS PASRR training slides and The Assessment Schedule for theRAI:https://www.cms.gov/NursingHomeQualityInits/45_NHQIMDS30TrainingMaterials.aspYou tube video of MDS section A training:http://www.youtube.com/watch?v=mlAlVKVY21IVideo for interviewing vulnerable eldershttp://www.youtube.com/watch?v=mlAlVKVY21I• Slides prepared by Breck Douglas (9/10)