Success without silos

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A stable, high-quality workforce enhances a provider's eligibility for capital.
A stable, high-quality workforce enhances a provider's eligibility for capital.

While this autumn won't bring nearly as many MDS changes as last year, documentation and coding due-diligence remains crucial. And despite coordinators' knowledge and leadership role in the MDS process, they shouldn't be shouldering the responsibility alone, experts say.

“Any discipline that contributes to the MDS should understand the ‘tell me more' about the MDS information they are contributing,” says Kelton Swartz, MDS Strategist for Cerner. “Dietary Services, for example, should not just understand how to answer Section K, but also understand how those items impact quality measures, RUG calculations and resident satisfaction. Transferring knowledge beyond basic compliance helps everyone involved engage in a more holistic approach to quality resident care.”

Expand the roster

Virtually all interdisciplinary team members — from nursing aides, therapists and dieticians to social workers, finance professionals, activities directors, and more — must be MDS proficient if operators are to stay compliant and quality-focused. And, of course, facilities must be reimbursed for the care provided. After all, the information coded by the MDS manager or coordinator will be only as good as the information logged on MDS forms by the individuals on the care team.  

“A much more comprehensive operational understanding is necessary than many organizations have today. It's not enough to have a good MDS nurse — although that is a must,” stresses Leah Klusch,  RN, BSN, FACHA, executive director for The Alliance Training Center. “The whole team needs to understand how to collect the data, so we have an accurate MDS.” 

A strong team that's collectively well-versed on the MDS and firmly grasps the magnitude of the assessments and data going into the MDS creates a more seamless process. It also allows others to more comfortably step in and take over if someone in the MDS office isn't available, she says.

Bringing all members of the team fully up to speed won't happen overnight, but the right approach can fast-track MDS success. MDS education should begin at orientation, according to Klusch: “Put the form in their hand. Show how broad and interdisciplinary it is. Build it into the fiber of every staff member's job.”

Because coordinators have a better understanding of the MDS process, they can help other interdisciplinary team members turn data into information and improve resident care through effective clinical assessment processes and quality improvement activities, says Teresa Chase, president of American HealthTech. But that's not to say others can't play a key role in MDS education. Chase suggests facilities adopt a preceptor education model, where a designated peer is tasked with teaching, motivating and troubleshooting issues. 

“Good training is important, of course, but in our experience, the day-to-day coaching is what makes or breaks staff experiences with MDS,” Chase says, noting that peers are more naturally accessible and often have more credibility within the clinical team.

Post-training that embeds MDS-related learning into everyday tasks is also important. Jan Wilson, VP of learning design and outcomes at Redilearning, suggests leaders and supervisors of all kinds engage staff by developing games or competitions that create a dynamic, enjoyable experience. Beyond that, she recommends simply asking learners how they will apply what they learned about MDS — including which areas they envision will be affected by what they've learned and whether there are any variances they may need to grapple with. 

“Asking someone what they learned causes the learner to further absorb the knowledge and also sets the expectation that someone cares about their learning and subsequent outcomes,” Wilson says.

Documentation dilemmas

Diligent documentation is essential for improving resident quality of life and ensuring proper reimbursement. According to Kim Ross, senior director of marketing for MDI Achieve/MatrixCare, “accurately documenting care provided is an important piece of evaluating and updating a resident's care plan to adjust for changes in their condition. Their documentation efforts are also key to making sure that the facility is adequately reimbursed, so that the resident can remain in the facility and get the care they need.”

Each employee responsible for completing the MDS should be taught how to correctly code for each section of the assessment. Take Section G, Functional Status, as an example, says Linda Elizaitis, president of CMS Compliance Group Inc. CNAs are expected to understand the concepts of self-performance and support provided by staff, and then accurately complete documentation of care provided.

 “A great resource to help with this education is CMS's training website, which includes training videos for difficult sections, such as G, M and O,” she notes. 

Nurses must be informed and empowered to fully grasp what documentation is necessary to support the MDS, and the same is true of CNAs. “Many CNAs do not give themselves credit in the documentation for the amount of care they deliver. When nursing staff, as well as CNA staff, are documenting out of an empowered and informed paradigm, this will have a positive impact in all areas residual to the MDS,” says Joel VanEaton, BSN, RN, RAC-CT, MDS educational coordinator, Extended Care Products Inc.

A simplified questioning approach can help CNAs with self-performance categories and more accurate capture of Activities of Daily Living data. It's often difficult for staff to remember the small differences that put a resident into a higher classification. That's why Gloria Brent, RN, an MDS nurse and consulting veteran who now serves as president and CEO of MDS Solutions Inc., created and tested simple questions about the care delivered, without using the words “Limited” or “Extensive.” When answered, these questions follow an algorithm that provides staff with the level of care delivered. 

“They no longer need to know the complex definitions of the care levels, but simply what they did with the resident as they delivered care,” Brent says. 

She used these question-and-answer sessions to develop an application called Scores ADL Calculator. When a person wants to add up a few numbers, they use a simple calculator to get their answer — no training on the calculator required.

Renee Loenen, MS, RN, C-NE, clinical product manager for HealthMEDX LLC, recommends MDS coordinators perform rounds with aides to observe documentation as care is provided.  

“By observing nurse aides as they document, you can ask probing questions about why they answered an item a particular way and provide immediate feedback if they are coding incorrectly,” she says. “Often, the aides either document what they've been told the resident can do or document what they feel the resident can do instead of what actually happened that shift.” 

Loenen also finds educational value in participating in local or regional MDS support groups. “These groups are typically small and provide an opportunity for users to network with others in the local area who are experiencing the same challenges.”

Aside from regular interactions with clinical staff, MDS coordinators also must know how to interact with finance and therapy — and provide detailed explanations on why certain information is needed and must be submitted accurately. These interactions alone can serve as valuable teaching tools, according to Elizaitis. 

“Staff need to know how negative outcomes, which could be attributed to a poor plan of care, impact data on these reports,” she notes.

Facilities shouldn't forget the important role that other non-clinical staff can play in the MDS, either. Housekeepers and beauticians are in close contact with residents and may actually be more likely to hear things from the resident that may indicate depression or another concern, notes Debi Damas, RN, senior product manager, Senior Care, Relias Learning. 

“Educating all staff on the importance of reporting observations to the nurse so it can be documented and/or reported to the physician [is vital],” she says.

Soft educational opportunities can also pay big dividends. MDS coordinators should consider running MDS-related news, updates and tips in the facility newsletter or posting information on employee bulletin boards, says Elizaitis. 

Beyond the RUG

Rewarding behavior that results in better RUG scores and QM outcomes can become a compliance nightmare if staff members perceive there's a reward for charting to an outcome rather than charting to a resident condition, warns Jeremiah Johnson, VP of business development for BlueStep/BridgeGate Health. 

Sharing quality measure information with vital staff at QAPI meetings and educating staff on triggers optimizes awareness of specific areas requiring greater focus, he says. “The same method can be employed with regard to RUG data at QAPI or clinical/financial operational meetings.” 

“Special assessments” that feed an MDS should also populate other documents that are actually used by hands-on caregivers, notes John Ederer, NHA, president of American-Data, an LTC EMR software company. “Otherwise, these ‘special assessments' are too much done for the sake of the MDS and regulations (minimal standards of compliance).”

Staff also must appreciate how MDS data can directly affect resident care and outcomes. Long-term care operators increasingly are relying on collective MDS data to build a detailed snapshot of resident care and status changes, improve care coordination and decision-making, and drive positive change. facilities are recognizing the gems of data found in the MDS and can now convert that clinical data to a true electronic care document that can be instantly shared with referral providers and used for broad quality improvement initiatives, says Zane Schott, VP of business development for BlueStep/BridgeGate Health. 

Long-term care providers that use MDS-gathered clinical information in this way gain a competitive advantage. This is especially so, Schott explains, now that accountable care organizations and other providers across the care continuum seek care partners that share a quality focus and have sophisticated solutions in place to facilitate the flow of pertinent clinical information. BlueStep/BridgeGate Health's open market Clinical Care Exchange EHR solution converts previously inaccessible disparate content, data and care activities into meaningful information that can be delivered to providers, caregivers and payers. 

New changes, old challenges

Changes to the MDS this year are going to have a greater impact on EHR providers than on healthcare providers, assures Johnson. Providers will find minor changes to Section A, addressing the admission/readmission dates of residents. This will require basic training on form requirements for MDS staff, but these changes will not require changes to structure, design or practice, he adds. 

Another coming change is revised delineations of who is considered rural versus urban (with applicable Metropolitan Statistical Areas defined). In determining which Medicare rates a provider will be using as of October 1, it should be noted whether the organization has converted from urban to rural status or rural to urban, has maintained its status, or possibly moved into a new statistical area, says Swartz.  

What's more, providers who use Section S should check with their state RAI coordinator for specific changes that apply to this section.  

“CMS has added a number of new questions for this section that states may require to be completed,” notes Loenen.

Even with the fewer MDS changes, the interdisciplinary care team must remain diligent to sidestep problems. According to Elizaitis, administrators' and operators' first concern should be ensuring that their computer system meets the minimum requirements for MDS data submission to the Quality Improvement and Evaluation System (visit www.qtso.com for system requirements). 

“The ability to submit MDS data per CMS directives should be a high priority. If system requirements aren't met, the provider won't be able to access the CMS system,” Elizaitis says.

Many agree that changes implemented in the last year have resulted in better planning and resident care, particularly for residents requiring therapy, but some common problems continue to plague providers. Some still struggle to understand COT, SOT and EOT needs, and additions to Section O for therapy co-treatment also cause confusion, leading many to believe that co-treatment minutes were being excluded from the RUG calculation. 

“Concurrent minutes were reduced in the RUG calculation, not co-treatment minutes,” confirms Chase. “Co-treatment minutes were added to the MDS solely to collect information to see what part they play in therapy.”

Klusch sees a large number of MDS managers operating without ready access to all MDS resources and updates. Often, she sees managers attempting to complete the MDS process by memory — a surefire route to non-compliance given the manual's complex and hybrid nature.

“If you're coding the MDS today the same way you coded a year ago, you're in trouble because there are so many different issues and definitions. In 2013 alone, there were 12 massive MDS updates and enormous amounts of changes made to the RAI manual, and you can't keep track of these by memory,” Klusch says. 

She further stresses that surveyors have initiated a pilot program to review MDS data for accuracy. This program, which Klusch predicts could move out of the pilot phase and become fully implemented nationwide by the end of this year or early 2015, further underscores the importance of adopting a solid interdisciplinary education approach.

“An MDS coordinator's job is to coordinate the assessment process, but all parties involved with the MDS need to be responsible for ensuring that the MDS is completed thoroughly, consistently and accurately,” Klusch emphasizes. “If the facility doesn't have the latest manuals and have all the latest updates organized and accessible, staff can't be educated properly and the MDS won't be coded correctly.”


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