Guest Columns

Evaluating extensive versus moderate assist

Renee Kinder
Renee Kinder

It's the Monday morning meeting at your skilled nursing facility. Team members are sitting around the table discussing a new admission over the weekend. Mrs. Clark was admitted following acute care stay secondary to RCVA with resulting left hemiparesis of her UE and weakness in LE, left visual neglect, and episodes of impulsivity. Prior to onset she was residing in her home with her husband of 63 years. She has medically complexities including vascular dementia and COPD and is hard of hearing. So the conversation begins… Her certified nursing assistants who worked over the weekend say she completely dependent with her bed to w/c transfers, she is combative with any activity requiring movement and she is only eating half of her meals. Physical therapy reports that she transfers with moderate assistance for stand pivot transfers from bed to w/c and Occupational therapy reports she consumed 100% of her meal this morning. Why the difference in abilities across disciplines with activities of daily living?

In mid-2014, the Centers for Medicare & Medicaid Services piloted a short-term focused survey to assess Minimum Data Set, Version 3.0 (MDS 3.0) coding practices and its relationship to resident care in nursing homes in five states. After completing the pilot, CMS announced they would expand surveys to be conducted nationwide in 2015 in conjunction with CMS' efforts strengthen the Nursing Home Five-Star Quality Rating System (Ref: S&C: 15-06-NH).

Pilot results revealed there is room for improvement in MDS 3.0/medical record agreement in four of seven clinical conditions reviewed, including: 1) the severity of injury associated with falls; 2) pressure ulcer status; 3) restraint use; and 4) late loss activities of ADL status. Review of these four clinical conditions showed levels of disagreement between the resident's medical record and their MDS 3.0 assessment of 15 to 25 percent (Ref: S&C: 15-25-NH).

 

  • 25% of MDS 3.0 assessments reviewed for falls showed disagreement between the MDS 3.0 and the medical record;
  • 18% of MDS 3.0 assessments reviewed for pressure ulcers showed disagreement between the MDS 3.0 and the medical record;
  • 17% of MDS 3.0 assessments reviewed for restraints other than side rails showed disagreement between the MDS 3.0 and the medical record; and
  • 15% of MDS 3.0 assessments reviewed for late loss ADLs (including bed mobility, toileting, transfer, and eating) showed disagreement between the MDS 3.0 and the medical record

The rate of disagreement in late loss ADL status is concerning at 15.4% representing approximately one in every seven cases of late loss ADLs being coded differently than would be expected based on information in the resident's medical record. As late loss ADL status is already included in the Five-Star Quality Rating System, these disagreements directly affect facilities' QM ratings (Ref: S&C: 15-25-NH).

Step one for improving accuracy for Section G ADL coding is to improve understanding between the language MDS uses to define levels of function and impairment in comparison to how rehab teams and nursing define these areas. As outlined in table below, for cases of extensive assist on the MDS, rehabilitation services have 3 separate measures including minimal, moderate and maximum assist. Additionally, this may differ from the language used in nursing documentation related to level of assistance, MDS must adhere to the “rule of three” for their measures and they assess ADLs in 2 manners

(self and supported)

MDS Language

Self-Measures

Rehab Language

Nursing & CNA Language

MDS Supported Measures

Total Dependence

Total Dependence

Two Person Assist

Extensive Assist

Maximum Assist

Two Person Assist

Extensive Assist

Moderate Assist

One or Two Person Assist

Extensive Assist

Minimal Assist

One Person Assist

Limited Assist

Contact Guard

One Person Assist

Supervision

Supervision or Stand By Assist

One Person Assist

Independence

Independence

Independent

 

Let's look at a basic case study example for bed mobility. To begin, a physical therapist will breakdown bed mobility measures by assessing ability to roll right and left, scoot, bridge (i.e., lie with knees bent while the individual plants feet on a firm surface and lifts the buttocks off the surface), and move from sit to supine and supine to sit. The RAI Manual for MDS 3.0 defines bed mobility for section G0110 as how resident moves to and from lying position (i.e., sit to supine and supine to sit); turns side to side (i.e., rolls right and left); and positions body while in bed or alternate sleep furniture. Therefore, if we are assessing an individual's bed mobility with morning routines and a CNA provided weight bearing assistance (i.e. extensive assistance) x3 for moving to and from the lying position; physical therapy provided minimal assistance x1 for rolling left, and maximal assist x1 for supine to sit the coding for day will = 5 episodes of extensive assist for this morning in the 7 day lookback for the MDS. Easy enough.

Now let's consider Mrs. Clark's medically complex case. Communication between all team members for ensuring MDS accuracy would include: potential need for monitoring greater weight bearing assistance for stand to sit and sit to stand into wheelchair when resident is fatigued, short of breath or presents with reduced oxygen saturations; effects of left visual neglect and basic modifications such as turning her plate 90 degrees if she only eats items on the right; variations across shifts, subsequent to sun downing or after activities such as rehab; differentiations in resident abilities that can be achieved during use of simplified instructions, appropriate vocal intensity from caregivers, and use of closed versus open ended questions when communicating during tasks. Considering these areas can be crucial for ensuring the MDS paints a clear picture of the individuals' unique and individualized needs.

In closing, think and ask these questions:

 

  • How can my facility improve communication from all team members in order to evidence the individual's limitations and abilities? 
  • How can we promote greater levels of function and increase independence within tasks? 
  • Does my facility's current method for coding of Section G truly tell an individualized story for each resident?

Renee Kinder, M.S. CCC-SLP RAC-CT, is a clinical Specialist at Evergreen Rehabilitation in Louisville, KY.

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