Planning, communication, fiscal preparation ensures smooth transition

The big news this summer and fall is the conversion of the Resident Assessment Instrument (RAI) process from the MDS 2.0 to the MDS 3.0 and the related operational and fiscal changes.

Many in the field have identified these changes as one of the largest operational changes since July of 1999 when electronic transmission and the Prospective Payment System began.

This is a significant change for all facilities as a new database is created from the new assessment document with many new definitions, data collection processes, and the introduction of “Resident Voice” with the inclusion of four specific resident interviews as well as numerous questions that require direct inquiry from the residents and staff.

Impact to daily operations

Facility managers, operational professionals, ownership, and corporate consultants need to approach these new tasks with an understanding of the size of the change as it impacts daily operations. The first task is to realize that the RAI process is an operational responsibility that must be managed with administrative leadership and problem solving as the new assessment document is prepared for transmission. Time lines for changes in software, forms and formats for documentation, assessment assignments, and training as well as fiscal planning for payment changes will all impact the entire operational platform and could have significant negative outcomes if not managed properly. Many new policies will need to be developed as well as current policies may need to be revised or changed because of new definitions and processes with the 3.0 assessment process.

First, all team members must understand that the RAI process is not clinical; it is a total functional assessment that creates the database for the facility’s care planning, regulatory, and payment outcomes. It must be managed as such and not delegated as a clinical task. This change in the assessment also requires a budget for software changes, training and, for many facilities, additional hardware to process a larger, more complex database with shorter windows for transmission. These are all facility management decisions and must be timed carefully so compliance can be achieved by the Octo-ber 1 implementation date.

The person managing the assessment tasks in the facility must be accountable to the facility administrator and be competent to initiate, plan, collect, and coordinate the transmission of data, and meet the time lines and requirements in the process. Many of these formats and requirements have changed presenting the facility with the need for increased efficiency and accuracy. For example, the transmission time for completed documents for validation has been cut to 14 days from the date the assessment is complete or the care plan is completed on comprehensive assessments.

Interviews

Four new interviews have been introduced (Brief Interview for Mental Status, Mood Interview, Customary Routine and Activity Preferences, and Pain Interview) that require structured one-on-one contact with each resident every time an assessment is completed. Training needs to be complete and policies for the interviews need to be established as well as procedures for staff assessments and tracking if interviews cannot be completed. At the least this will require preparation for the staff, residents, and families as this process is going to change the way assessments are completed from this time forward.

By December 2010, all residents will have experienced the new interviews and data collection at least once or multiple times if they are in a Medicare Part A stay.

Facility managers must be aware of the components of the MDS 3.0 form that will change clinical documentation processes, create new outcome reporting for regulators and payers, as well as define services with new definitions. For example, the coding of therapy services into three types of minutes-individual, concurrent, and group-all with specific values as they contribute to the total therapy minutes. Improved standards of clinical documentation will result related to pressure ulcer identification and care, pain management, and measurement of functional performance and outcomes as well as determination of cognitive performance from a standard scale. This is all very positive but must be introduced into the operational platform with proper training and support so all members of the interdisciplinary team are prepared and work together to complete the assessment on time, accurately, and within the structure of the new manual instructions.

Key steps

So what are the key steps managers need to address?

The interdisciplinary team must meet with the administrator to discuss time lines and steps to prepare for the change. Start short weekly meetings now to set goals and report progress.

A budget for training and materials needs to be created-the team will need new manuals, new software, and specific training for different levels of coding and data collection tasks. Start now. Some team members will need multiple training experiences because of the size and impact of the new assessment tasks, definitions, and formats for data collection. Online training after the implementation of the new process will support the knowledge base of current staff and train new staff members so the quality of the assessment process does not deteriorate and will provide a practical solution for ongoing training.

Current MDS activity needs to be identified so software and hardware needs can be established. This is a more complex database. Make certain your hardware is adequate for the size and demands of the data formulation and processing. You cannot afford to have inadequate hardware that will impact your overall assessment process efficiency when time lines for transmission have been shortened and noncompliance with transmission deadlines could result in payment issues.

The assessment process is very operational (not clinical) and it impacts all members of the interdisciplinary team. All staff members must be accountable.

Installation of MDS 3.0 software and training needs to be scheduled now so members of the assessment team can be familiar with the system, tasks, and reports. System security is important and must be documented. Team members need time to familiarize themselves with the new formats and software as well as the reports they will use as they identify the components of the new database. This change in formats will affect all members of the team and their documentation and reporting habits and process.

Facility leadership must initiate open discussions with vendors that will impact the data collection and database content of the building. Therapy, pharmacy, and other contractors must be ready to discuss data collection issues as well as how to prepare staff to participate with the new document, definitions, and data collection time lines. Accountability is the key and lines of report for data reporting and setting assessment reference periods need to be established by the administrator and monitored for compliance.

The current Resource Utilization Groups (RUGs) distribution needs to be documented and prospective RUG-IV distribution needs to be discussed-there will be many changes and risk for significant payment loss when the MDS 3.0 is implemented. Operations need to look at the system now to project changes in payment amounts and the impact of coding in the new system.

The MDS manager should report to the facility administrator. The assessment process is very operational (not clinical) and it impacts all members of the interdisciplinary team. All staff members must be accountable for assigned assessment tasks and timelines for completion. Clerical tasks must be evaluated and assigned appropriately. Professional time needs to be delegated for professional tasks.

MDS completion and transmission statistics need to be tracked and the overall efficiency of the MDS process must be monitored by the MDS manager and administration. The negative consequences of a poorly managed system could be overwhelming fiscally. Current transmission and validation issues must be identified and resolved before the transmission of the 3.0 is initiated. The timing of transmissions needs to be monitored as well as overall MDS activity so proper staffing for the MDS office is determined. Do you know, administrators, how many MDS documents are being completed in your facility each week and what your transmission activity and history are? This is important as you plan for the longer, more complex database on a more aggressive time line for validation.

Data collection

Data collection processes, formats, and documentation must be addressed. ADL scoring must be accurate and represent 24 hours of functional support during the assessment reference period. Interviews must be scheduled, completed according to the specific guidelines in the manual, and documented on the form to show actual resident responses, not interpretation. I suggest you use color-coded MDS 3.0 documents for teaching staff awareness now so they can be familiar with the form and the database utilization and payment qualifiers.

Many team members working with the MDS 3.0 will need multiple training opportunities to fully understand the new form, tasks, definitions, and documentation processes. Remember, everyone has to change their mind-set, skills, and documentation to comply with the new document, manual instructions, and timing of the assessments. One person cannot do this. It must involve the team.

Other activities and areas of focus will develop as you begin the problem-solving for this transition to the new assessment document and database that will identify your facility’s services, outcomes, and demographics. With proper planning and communication as well as fiscal preparation, the facility will be able to comply with the increased demands and efficiency that are part of the MDS 3.0 conversion. You must respect the fact that this is not a new assessment tool; it is a new assessment process with significant risk and liability for facility management and fiscal stability. It is the middle of summer and you have until October to prepare your staff. Start now and manage this process operationally. It will pay off with a smooth transition in October.

Leah Klusch is the founder and Executive Director of the Alliance Training Center, Alliance, Ohio. As an educator and consultant, she has extensive experience in presenting motivating programs for a variety of healthcare professionals. She is a highly sought after speaker and a recognized nurse leader. Long-Term Living 2010 August;59(8):18-22

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