Start NOW to Prepare for MDS 3.0 Changes Coming This Fall! July 20, 2016 Mary Madison, RN, RAC-CT, CDP Clinical Consultant, Long-Term/Senior Care Briggs Healthcare®

Learning Objectives 1. Identify the new Item Set and when it should be encoded/transmitted. 2. Understand the importance of GG and how it will be used. 3. Locate training resources to prepare for the October 2016 changes.

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What’s New? v1.13.2 since 10/1/2015

v1.14.0 as of 10/1/2016

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May 11, 2016DRAFT DRAFT “A new DRAFT RAI Manual v1.14 has been posted in the Related Links section below so that users can preview significant changes before they become effective October 1, 2016. There are many item set changes, including the new Chapter 3, Section GG: Functional Abilities and Goals. Chapter 2 and Chapter 3 (as well as) Section A provide information on the new Part A PPS Discharge assessment. The draft manual is a single PDF file with bookmarks that you can click on to take you to each section of the manual. It includes the manual chapters, sections, appendices, and the change tables that crosswalk the changes made to v1.14. Please note that it does not include Appendices F and H or replacement pages, which will be published with the final version 1.14 in September 2016.”* https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/MDS30RAIManual.html

* During July 14, 2016 SNF Open Door Forum, CMS said the final version will be posted in the next few weeks. 4

The RAI Manual has many clarifications and verbiage changes that you/your staff need to be aware of. There are 81 pages of Change Tables in the draft manual (pages 813 through 894). Review the draft now and make sure you have a copy of the final version when it’s released. Review the final version as well as there will be changes. Everyone involved in the MDS/RAI process must have a copy of the manual accessible to them for use when encoding the MDS Item Set. 5

Look for… • Chapter 2 • MDS completion for new facilities – with change of ownership • Completing COT assessments around discharges • Change in hospice providers

• Chapter 3, Section F • Clarification to conducting interview during the 7-day look-back period

• Chapter 3, Section I • Use of Z codes for aftercare following hospitalization

• Chapter 3, Section J • Coding major injury after a fall – clarification instructions (beyond ARD)

• Chapter 3, Section M • Clarification on coding healed pressure ulcers

• Chapter 3, Section X • Clarification on error in coding reason for assessment 6

Section A

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NPE/SPE

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When Do I Complete the Part A Discharge/End of Stay? This is the set of items active on a standalone nursing home Part A PPS Discharge assessment for the purposes of the SNF QRP. It is completed when the resident’s Medicare Part A stay ends, but the resident remains in the facility. 9

C0900

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C1300 – C1310 No longer a valid item in v1.14.0

This was C1600 in v1.13.2

New credit verbiage for CAM© 11

Pressure Ulcers Items in M0300 will be added to the current all Discharge and the new PPS Part A Discharge/End of Stay Item Sets
M0300B…Stage 2
M0300C…Stage 3
M0300D…Stage 4
M0300E…Unstageable - Non-Removable Dressing
M0300F…Unstageable - Slough and/or Eschar
M0300G…Unstageable – Deep Tissue Injury

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M1040H

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N0410

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Q0490 V1.13.2

V1.14.0

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X0600

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The Biggest Change of All…

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And…

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Why GG and Why Now? IMPACT Act of 2014 • Improving Medicare Post-Acute Care Transformation • Requires reporting of measures pertaining to resource use, hospitalization and discharge to the community • Standardized/uniform data elements across all post-acute providers o Enable interoperability and access to data to facilitate coordinated care o Improve outcomes o Improve overall quality comparison

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QM Domains Related to IMPACT Act

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Completion of GG
Required at start of SNF PPS Stay


Only required for traditional Medicare Part A stays
Assessment period:

days 1 through 3 beginning with A2400B

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And… • Required upon discharge from the facility at the end of a SNF PPS stay • Assessment period: last 3 days of SNF stay (ends on A2400C) • Must be a planned discharge AND the end of the SNF PPS stay AND • SNF stay must be greater than 2 days AND not resulted in a discharge to the hospital

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Also… • New item in A0310 Section A to reflect end of SNF stay on Discharge Item Set when resident leaves the facility • Not every resident is discharged from the facility after a Part A stay – some remain in the facility • New Item Set

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GG Components • Functional Abilities and Goals • Admission Performance • Usual – don’t code best or worst • Higher up the scale, the more independent the resident is

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Discharge Goals Discharge Performance Self-Care Category Mobility Category Safety and Quality of Performance 24

Section GG – 2 Categories Self-Care

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Section GG – 2 Categories Mobility

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Coding – Not the Same as G Start of SNF Stay

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Coding – Not the Same as G End of SNF Stay

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GG Item Coding Rationale During a Medicare Part A SNF-stay, residents may have selfcare limitations on admission. In addition, residents may be at risk of further functional decline during their stay in the SNF.

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Self-Care: Admission

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Performance Coding Steps 1.

Assess resident’s self-care status based on:





2. 3. 4.

5.

Direct observation Resident’s self-report Family reports Direct care staff reports documented in resident’s medical record

Assessment period: days 1 through 3 starting with the date in A2400B – start of most recent Medicare stay. Allow resident to perform activities as independently as possible – as long as they are safe. Helper includes facility staff and contracted employees; not individuals hired outside facility management (includes nursing/CNA students). Consider only facility staff when scoring amount of assistance provided. Activities may be completed with or without assistive devices. 31

Performance Coding Steps (cont’d) 6. Usual or baseline performance



Not the most independent or dependent performance during assessment period If fluctuation, performance won’t be the worst nor the best – what’s usual for that resident

7.

Facility policies/procedures as well as Federal and State regulations for completion of an assessment. 8. Use 6-point scale to code resident discharge goal based on admission assessment, discussions with resident/family, professional standards of practice. 9. Goals should be part of resident’s care plan. 10. A minimum of one self-care or mobility function goal must be coded.

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Codes  06 – Independent  Resident completes the activity by him/herself with NO assistance from a helper

 05 – Setup or clean-up assistance  Helper sets up or cleans up then resident completes the activity  Helper does not assist during the activity; only before or after  Cutting up food, opening containers, setting up hygiene or assistive devices

 04 – Supervision or touching assistance  Helper provides verbal cues or touching/steadying assistance as resident completes activity  Assistance may be provided throughout or intermittently  Verbal cueing, coaxing, supervision for safety

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Codes (cont’d)  03 – Partial/moderate assistance  Helper does less than half the effort  Lifts, holds or supports trunk or limbs but provides less than half the effort

 02 – Substantial/maximal assistance  Helper does more than half the effort  Lifts or holds trunk or limbs and provides more than half the effort

 01 – Dependent  Helper does all of the effort  Resident does none of the effort to complete activity or  2 or more helpers are required for completion of activity

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Coding Tips: Admit/DC/End of Stay • When coding performance, use 6-point scale or code reason why an activity was not attempted • Usual not worst or best • Do NOT record staff assessment of potential capability to perform the activity • Code the reason activity was not attempted if resident doesn’t attempt the activity and a helper does not complete • • •

07 – resident refused to attempt activity 09 – activity not applicable 88 – resident not able to attempt activity due to medical condition or safety concerns

• If 2 or more helps are required to assist in completing the activity, code as 01 – Dependent • Dash (-) is used when there is no information • •

This should be rare Use of dashes may result in a 2% reduction in the annual payment update 35

Mobility: Admission

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Steps and Coding Same performance coding steps as for SelfCare Same codes as for Self-Care Refer back to Slides 30 through 34 of this presentation 37

Self-Care: Discharge

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Mobility: Discharge

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Discharge Coding 1. Complete only if A0130G = 1 and

2. A0310H = 1 and

3. A2400C minus A2400B is greater than 2 and A2100 is not = 03.

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Discharge Coding (cont’d) 4. 5.

Assessment period is the last 3 days of the SNF PPS Stay ending on A2400C. Use same 6-point scale or code reason why activity not attempted

Mobility

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Section GG and Discharge from Facility

When a resident discharges from the facility within one day of the Medicare Part A stay, the Part A PPS Discharge may be combined with the OBRA Discharge assessment.

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What to Do Now?  Review the draft RAI manual for new items and verbiage changes to become familiar with items and definitions.  Start conversation now between the Nursing and Therapy departments on how best to code the new Section GG and who will be responsible to gather the data.  Examine current processes with gathering Section G data and determine what changes might be needed for Section GG.  Check with your software vendor to see if they will be providing documentation capabilities for Section GG data.  Start educating staff on new items and verbiage changes now. Don’t wait until October 1st! 43

Anything else?  Practice gathering data for Section GG on Medicare admissions and discharges before October 1, 2016.  Audit the process(es) you’ve developed for Section GG to identify weaknesses and revise process as needed.  Watch for any/all CMS training opportunities and participate! Share these opportunities with your staff.  Be alert for notifications from CMS on when v1.14.0 will go live – instructions based on ARD/admission date. It may not be 10/1/2016 but a week earlier.  Watch for the final version of the RAI User’s Manual to be posted. Ensure all staff working with the MDS Item Sets have access to and actually utilize the manual as a guide when encoding. 44

Two Words About Dashes… Don’t Use!!

The use of dashes has no direct impact on RUG rates HOWEVER… a 2% penalty to the market basket increase beginning FY2018 (10/1/2017) will be in effect if more than 80% of MDSs submitted do not contain 100% of the data elements needed to calculate all 3 of the new QRP Quality Measures. 45

MDS 3.0 v1.14.0 Resources  https://downloads.cms.gov/files/draft_mds_30_rai_manual_v114_may_2016.pdf (May 11, 2016 Draft of MDS Manual)  https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/NursingHomeQualityInits/MDS30RAIManual.html (MDS 3.0 RAI Manual landing page)  https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/NursingHomeQualityInits/Downloads/MDS-30-Item-subsets-V1-14-0October-1-2016-Release.zip (MDS 3.0 Item Subsets – zip file)  https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/NursingHomeQualityInits/NHQIMDS30TechnicalInformation.html (MDS 3.0 Technical Information - landing page)  https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/NursingHomeQualityInits/Downloads/SNF-Quality-Reporting-ProgramProvider-Training-6-21-16-.zip (CMS SNF QRP Training Information, June 2016 – Atlanta) 46

6 New QMs - NHC Claims-Based

MDS-Based


Percentage of short-stay residents who were successfully discharged to the community
Percentage of short-stay residents who have had an outpatient emergency department visit
Percentage of short-stay residents who were rehospitalized after a nursing home admission


Percentage of short-stay residents who made improvements in function
Percentage of long-stay residents whose ability to move independently worsened
Percentage of long-stay residents who received an antianxiety or hypnotic medication*

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New QM Resources  https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2016-Pressreleases-items/2016-04-27.html (Press Release: CMS Adds New Quality Measures to Nursing Home Compare; April 27, 2016)  https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/CertificationandComplianc/Downloads/New-Measures-TechnicalSpecifications-DRAFT-04-05-16-.pdf (Nursing Home Compare Quality Measure Technical Specifications; April 4, 2016)  https://www.cms.gov/Medicare/Provider-Enrollment-andCertification/CertificationandComplianc/Downloads/Improvements-NHC-April-2016.pdf (Further Improvements to the Nursing Home Compare Five-Star Quality Rating System; March 3, 2016)  https://www.cms.gov/Medicare/Quality-Initiatives-Patient-AssessmentInstruments/NursingHomeQualityInits/Downloads/MDS-30-QM-Users-Manual-V10.pdf (MDS 3.0 Quality Measures User’s Manual, v10.0; March 25, 2016) 48

Next Webinar Wednesday September 21, 2016 1pm -> 2pm (Central Time)  In-depth Look at Section GG  Changes in Final RAI Manual Watch for eBlast from Briggs to register!

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Mary Madison, RN, RAC-CT, CDP is a Clinical Consultant, LongTerm/Senior Care, for Briggs Healthcare®. Mary has held positions of Director of Nursing in a 330-bed SNF (also managed the RAI/MDS process in this facility), DON in two 60-bed SNFs, Reviewer with Telligen (Iowa QIO), Manager of Clinical Software Support, Clinical Software Implementer and Clinical Educator. Mary has conducted numerous MDS 2.0 and 3.0 training sessions across the country in the past two decades and remains passionate about the RAI process, providing consultation and education on the Item Sets and related activities. [email protected]

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