You might also be interested in these files. Skilled Nursing Facility Fee-for-Service. Read more. Search form. Advanced Search. Resdac umn. All rights reserved. Search for data files. Beneficiary Enrollment and Summary. Medicaid Utilization. Medicare Encounter. Medicare Fee-For-Service Claims. An additional concern about the MDS data collection process involves time frame. Residents are required to be assessed on admission and then every 90 days. Major resident changes that happen after the 7- or day look-back period are supposed to trigger a new assessment.
Thus, efforts by nursing home staff to use MDS data to monitor resident changes in condition and provide timely responsive care are hampered by a considerable amount of missing observations.
Given the important and myriad uses of the MDS, state surveyors are expected to audit MDS data during facility reviews. In sum, the reports reviewed here—singly or together—are insufficient to either wholly deflate confidence in MDS data or inspire confidence in it. Consequently, questions about the data's integrity persist.
A series of studies reported in evaluated the effect of MDS use on selected resident outcomes Fries et al. On the whole, the researchers found improvement in outcome measures from pre- to post-MDS implementation. Three response editorials, however, questioned the MDS's value as a quality improvement tool, citing problems with its reliability and its dearth of quality-of-life indicators Ouslander, ; Schnelle, ; Uman, Introduction of the nursing home QIs in and quality measures in has not settled matters.
In both cases, there was hope that facilities would use these MDS-based measures to strengthen their improvement efforts, but the data are problematic on two counts. First, this quality improvement information also serves a policing function, alerting surveyors via the QIs and consumers via the quality measures to poorly performing facilities. This dual use bucks a basic tenet of continuous quality improvement that the data required to improve care should not be used to punish the service providers Deming, These results suggest that the QIs are limited in their value for quality assessment and improvement purposes.
Research has also shown that simply reporting quality information to facilities does not lead to care improvements Rantz et al. However, subsequent research has found that QIs improve when researchers pair information with clinical consultations Rantz et al. In recent years, CMS has adopted this model, supporting more intensive interventions for quality improvement Lynn et al. Thus, although the MDS may have triggered improvements in resident care and outcomes immediately following its national implementation, more recently these data have proved to be an insufficient catalyst for change.
Instead, more intensive multifaceted interventions appear to hold greater promise Rantz et al. Unintended consequences of the MDS's design and multipurpose use could theoretically undermine the instrument's manifest functions. As early as , researchers warned that paper compliance was a potential unintended consequence of MDS use R.
Kane, A number of studies have reported evidence that facilities tend to document higher levels of care toileting, restraint release, repositioning than they actually deliver while underestimating the prevalence of certain problem conditions such as pain, depression, and low oral intake Bates-Jensen et al.
Schnelle, Ouslander, and Cruise argue that these results are indicative of a paper compliance culture that has flourished in a flawed system: Workers respond to pressure to provide quality care by underreporting problems and documenting service levels that are not met and care plans that are not honored because they lack effective feasible interventions and because surveyors rely so heavily on MDS and medical chart reviews.
Critics suggest that this mindset results in MDS compliance procedures becoming the lens through which nursing home staff view resident care, replacing good clinical judgment. This criticism is coupled with other concerns, including that many nursing homes lack sufficient numbers of staff to provide quality care Harrington et al. These are the very problems that Schnelle and colleagues have argued can lead to paper compliance. Certainly, many administrators are keenly aware of how MDS data can affect their operations e.
Critics have argued that quality of care, rather than quality of life, has been the dominant concern in nursing homes R. Although critics acknowledge that the MDS has made contributions to long-term care, this review reveals questions about the instrument's reliability, validity, and usefulness for quality improvement.
These questions appear to stem from the MDS's design in concert with its multipurpose use. Relying on staff discretion for some assessments, for instance, may not be problematic—unless the system includes incentives to over- or underestimate problem conditions, which may increase the likelihood that unintended consequences will result.
Teasing out the separate contributions of these influences is impractical in such a complex system, and none of the numerous MDS studies—together or separately—has reported sufficient evidence to definitively confirm or refute underlying concerns.
The third revision of the MDS represents an attempt to respond to these ongoing concerns. The draft MDS 3. Designed to give residents voice and to improve clinical relevance, accuracy, efficiency, and clarity, draft MDS 3.
In the final development phase, the instrument was tested in 71 facilities in eight states using 3, residents. The facility nurse data were shown to be reliable and in comparisons, as reliable as the data collected by the gold standard nurses; Saliba. Overall Kappa values for the sections that underwent the most revision—mental status, mood, pain, behavior, and customary routines and activities—ranged from.
Similarly, the vast majority of nurses who conducted assessments reviewed the MDS 3. In the following sections, we examine whether the new MDS, with changes that directly address previous criticisms, is likely to fulfill its manifest functions while avoiding the unintended consequences associated with its predecessor.
In a departure from earlier versions, draft MDS 3. The MDS 3. The pilot evaluation found high completion rates and good to excellent reliability results for these items, demonstrating that most residents can participate meaningfully in interviews Saliba, Additionally, instructions for these items are designed to prevent possible selection and response biases. Thus, nurses are directed to ask all residents standardized questions that are scripted word for word e.
Exceptions apply only if the resident is rarely or never understood, fails to complete the section, or needs an interpreter but none is available CMS, a ; Saliba. In these cases, nurses assess the items. There are two interrelated concerns.
The first is that nurses could sidestep the intended protocol because professional discretion is needed to determine whether some exceptions apply. For example, there is no standardized protocol within the MDS 3.
The second concern is that many nurses in the pilot evaluation were initially hesitant to attempt resident interviews because they viewed the questions as too personal Saliba, Both concerns raise questions about whether assessment nurses will circumvent MDS protocol.
Compared with previous versions, MDS 3. The delirium items, for example, have been previously validated for frail adults. The pain assessment uses resident ratings on the commonly used 0—10 scale. Additionally, the highly structured interviews for the new preference assessment tool PAT and the cognitive assessment constitute standardized procedures. There has been some concern that standardized procedures will require more staff time and training to implement reliably and regularly than many nursing homes can commit to.
Evaluation findings, however, suggest that the 3. If these findings hold true following national implementation of the MDS 3. At the same time, nursing homes could face increased scrutiny by surveyors and consumers if the use of standardized assessments leads to increased prevalence rates for common but heretofore underreported conditions.
Such was the case in the national evaluation, where the MDS 3. As noted earlier, this detection quandary arises when the same data are used to punish providers and improve care and could unintentionally prompt providers to thwart the new assessment procedures. Despite the potential improvements included in MDS 3. For example, will facility nurses exclude too many residents from the interview process? Will prevalence rates for certain conditions, such as pain, be underreported?
Many of these challenges can be addressed through the development of a sound audit process involving an independent validation assessment of a sample of residents using external staff. Such a system could be implemented on a state or national basis on a sample of facilities. Even if MDS 3.
The new MDS will inherit the old system, with its incentives to use MDS data for purposes other than assessment and quality improvement. It will also not increase staffing levels, strengthen the survey process, or identify new care processes that are both effective and feasible to implement—all reforms that some say are necessary to improving care and combating paper compliance.
The tool includes 16 interview items divided into two categories: daily preferences and activity preferences Figures 3 and 4. If you are under- or overcoding, find out what the problem is and fix it. Constantly review and, if necessary, revise policies and procedures to fit the new assessment tool. Learn from your mistakes. The MDS 3. Rather than sweep those mistakes under the rug and forget about them, analyze what happened and use that knowledge to prevent similar situations from occurring in the future.
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