With the introduction of the Minimum Data Set (MDS) through the Omnibus Budget Reconciliation Act (OBRA) of 1987, Centers for Medicare and Medicaid (CMS) implemented a method of standardized, comprehensive, and reproducible data collection for long term care residents that addressed medical conditions and functional status. This data collection tool has morphed into a means of reflecting long term care and rehab facility compliance with federal regulations, facility quality measures, resident health needs, and resident quality of life. In addition, the MDS is the basic means for facility reimbursement through both HIPPS codes for Medicare beneficiaries and case mix (CMI) for Medicaid beneficiaries in states that utilize CMI. Currently, the MDS 3.0 data points are revised annually by CMS, with updates to the MDS implemented on the first day of October, at the start of the fiscal year.
Resident Assessment Instrument
The Resident Assessment Instrument (RAI) is composed of the MDS as well as Care Area Assessments (CAAs), which are resident assessment protocols for 20 common problem areas for residents in long term care. Care areas are triggered based on individual resident strengths and needs drawn from items coded on the comprehensive MDS. The CAAs that impact the resident are used as a guideline to develop the comprehensive care plan to support resident preferences, health needs, and safety.
The RAI requirements of MDS timing, data collection (including resident interviews), encoding, completion, and submission to CMS, as well as care planning, are governed by the RAI manual, ICD10 coding manuals for long term care, the State Operations Manual (SOM), and interpretive guidelines for the SOM. MDS data items and interviews on the MDS are standardized to support validity and reliability and to ensure that the coded MDS can be reproduced based on the resident health record.
Because the MDS is an interdisciplinary collection of information that is governed by specific regulations, all members of the interdisciplinary team (IDT) who are responsible for interviews and data collection for the MDS should understand the instructions, requirements, and regulations that impact those items and/or sections. A fundamental knowledge of the impact those sections have on quality measures and reimbursement is necessary as well, because quality measures and reimbursement require a team effort to ensure facility success. Facility administration should have at least a baseline understanding of all the items on the MDS, the CMS regulations that govern the MDS, and how quality measures are affected by the MDS.
What is RAI Management?
Each completed and submitted MDS has a potential impact on resident care planning, facility quality measures, facility surveys, public reporting, and reimbursement. MDS data collected from the resident health record, resident interviews, coding, and care plan development is supported and completed by the IDT.
- A well trained and competent RAI System Manager – often the Nurse Assessment Coordinator (NAC) – ensures facility policies align with CMS regulations that impact the MDS and care planning.
With the NAC managing MDS timing, completion, and submission and ensuring OBRA requirements are met, the facility staff are following facility policy and meeting CMS regulations. Compliance with CMS regulations and facility policy can lead to successful facility surveys.
- The NAC often also manages Prospective Payment System (PPS) timing for Medicare reimbursement and case mix for Medicaid reimbursement, which may entail adjusting MDS timing to maximize HIPPS or RUGS scores.
Accurate and timely clinical documentation in the health record is critical to support MDS coding for improved reimbursement. The NAC is often able to capitalize on changes in resident needs and conditions to improve PDPM and CMI outcomes.
- With the completion of MDS, the NAC – often in collaboration with the Social Services (SS) team member – sets dates for care plan meetings and/or care plan reviews with residents/resident representatives.
Care planning that includes the resident and/or the resident representative can lead to improved care plan outcomes and resident satisfaction, which can potentially impact resident quality of life.
- The NAC and the administrative team often work together to manage and improve quality measures that are a result of MDS coding; this may also require managing MDS timing and data collection to include additional scheduled MDS.
Quality reports available in the Internet Quality Improvement and Evaluation System (iQIES) should be utilized to review individual residents who trigger specific quality measure items and incomplete MDS data element items that can impact the Annual Payment Update (APU). iQIES also has facility-level quality measure reports that help facility leaders pinpoint specific quality measures that have an impact on the publicly reported items in Care Compare.
What to Do
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- Stay on top of updates
CMS usually updates MDS coding items and quality measure specifications every year. With updates, the IDT must prepare for those changes to ensure that clinical documentation is in place that will support capture of all the MDS data requirements, since clinical documentation is crucial to ensuring the MDS coding is accurate and reproducible. The IDT must have a good understanding of updates so quality measures and reimbursement are not negatively impacted by missing, incomplete, or incorrect documentation. - Work as a team
Managing the multiple components of the RAI and the impact the RAI has on various other areas of the long-term care and rehab takes a team of dedicated and well-trained individuals working together in the RAI system. Successful RAI system management results in improved resident care, facility quality, quality measures, compliance with regulations and facility policy, public reporting, and reimbursement.
- Stay on top of updates