Nursing Home Quality Initiative-Summer 2006

IN THIS ISSUE

Improving QM Rates
Depression and the MDS
Improving the Process
Know Your Residents' Moods
Mood Scale Score Worksheet
Pain and the MDS
Physical Restraints and the MDS
High Risk Pressure Ulcers and the MDS
It's Time to Set Your STAR Target!
Visit Us on the Web
Stay in Touch

Improving QM Rates

First Step: Accurate MDS Completion

Did you know that the Quality Measure (QM) rates for each nursing home that are publicly posted on Nursing Home Compare are generated from the coding of each of the MDS components by facility staff?

Data entered into the MDS identifies residents at risk for particular problems or change in status. Incomplete or contradictory information could distort accurate assessment of the residents' clinical status. Therefore, it is critical that the information entered is accurate, current, and supported by data collection and documentation in the medical record that substantiates the coding.

Quick tips for maximizing MDS accuracy and improving Quality Measure rates include:

Use the most current version of the Resident Assessment Instrument (RAI) Manual. Each month, check for RAI manual updates on (www.cms.hhs.gov/quality/mds20). Updates are usually posted on the last Monday of the month.

Evaluate the knowledge of the MDS staff members responsible for completing each section of the MDS. Are all staff members aware of the RAI instructions that pertain to the section(s) for which they are responsible?

Devote resources to training staff on the MDS tool, observation time frames, and documentation that is compatible with MDS definitions.

Establish internal and external auditing/validation systems.

Review your facility's documentation and communication processes to accurately capture information about residents.

Know the audit capabilities of the computer program your facility uses to submit MDS data.

Routinely check your facility's MDS Submission and MDS Error reports, which are accessible via the CMS MDS QIES system.

Monitor Quarterly Quality Measure rates and outcomes.

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Depression and the MDS

Would you be surprised to learn that triggering the "Depression" Quality Measure (specifically named "Percent of Residents Who Have Become More Depressed or Anxious") is not tied to residents with a diagnosis of depression...or to those residents on medication for depression? The only event that triggers this Quality Measure is an increase in a resident's "Mood Scale Score" (MSS)...more specifically, how the following MDS items are answered:

E1a - Resident made negative statements
E1c - Repetitive verbalizations
E1e - Self deprecation
E1f - Expressions of what appear to be unrealistic fears
E1g - Recurrent statements that something terrible is about to happen
E1h - Repetitive health complaints
E1m - Crying, tearfulness
E1n - Repetitive physical movements
K4c - Leaves 25% or more of food uneaten at most meals
E2 - Mood was not easily altered

Each of these items, when coded on the MDS, may contribute to an MDS calculated "Mood Scale Score" for that particular resident. Any increase in the resident's "Mood Scale Score" (MSS) from one MDS to the next, even by only one point, will cause the resident to trigger on that QM.

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Improving the Process

Is there a timely screening process for depression upon admission and within each MDS assessment window timeframe?

Is the process for documenting a resident's mood consistent throughout the facility?

Ensure that staff members understand the depression quality measure and triggers (Resident's Mood Scale Score)

To ensure accuracy, consider consistent responsibility for coding Section E, "Mood and Behaviors" of the MDS.

Is there a standard process for documenting a resident's mood?

When answering "E3/Change in Mood" on the MDS, use this opportunity to validate the accuracy of all "E1" responses.

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Know Your Residents' Moods

One tool that could prove invaluable in your understanding of how the coding of certain mood items on the MDS contributes to the MSS is the Mood Scale Score Worksheet. This tool helps you to calculate the effects of your MDS coding on the MSS.

Because the Mood Scale Score Worksheet allows you to capture (if copied as a two-sided document), the history of six ongoing MSS "snapshots" on a resident, you can readily observe any increase in the MSS from the prior MDS, which will ultimately cause the resident to trigger the "Depression" quality measure.

This worksheet is available at www.ipro.org/nhqi, "Resources for Depression."

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Mood Scale Score Worksheet

Download Mood Scale Score Worksheet (xls)

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Pain and the MDS

The Pain Quality Measure is triggered by a resident reported to have pain daily (J2a Frequency = 2), reaching a moderate level at least once during the 7-day assessment period (J2b Intensity = 2) or horrible/excruciating pain (J2b Intensity = 3) at any frequency.

Consider the process in your facility for coding residents' pain. Is pain coded according to the resident's comfort level, the way the pain is being treated, or the frequency at which the resident takes pain medication? Remember to code for the presence or absence of pain, regardless of pain management efforts; i.e., if the resident receives around-the clock pain medication and has no pain, code "0" (No pain).

When completing the MDS, do all assessors interpret the answers on the facility-used pain scale the same way? Pain scales usually offer pain intensity choices from 1 to 5 or 1 to 10. The MDS RAI Manual describes 3 levels:

J2b = 1 Mild Pain. Although the resident experiences some pain, it does not interfere with daily routines, socializations, or sleep.

J2b = 2 Moderate Pain. The resident experiences "a medium amount" of pain.

J2b = 3. Times when pain is horrible or excruciating; the worst possible pain. Pain of this type usually interferes with daily routines, socialization, and sleep.

Examples of Pain Scale interpretation (Per the WHO 3-Step Analgesic Ladder):

10-point numerical Pain Scale. 1-3 mild; 4-6 moderate; 7-10 excruciating

5-point numerical Pain Scale. 1-2 mild; 3 moderate; 4-5 excruciating

Non-verbal expression of pain

Moaning, grimacing, sighing - Mild pain

Altered body position, restlessness - Moderate pain

Withdrawal, crying, yelling, immobility - Horrible /Excruciating pain

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Physical Restraints and the MDS

A Physical Restraint is any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily, which restricts freedom of movement or normal access to one's body. The effect the device has on the resident, rather than its name or intended use, determines whether or not it is classified as a restraint.

The Restraint Quality Measure is triggered if, during the 7-day assessment period, one

of the following is employed:

P4c trunk restraint = 2 used daily. Includes any device or equipment or material that the resident cannot easily remove (e.g., vest or waist restraint, belts use in wheelchairs).

P4d Limb Restraint = 2 used daily. Includes any device or equipment or material that the resident cannot easily remove, that restricts movement of any part of an upper extremity (i.e., hand or arm) or lower extremity (i.e., foot or leg). Mittens are included in this category.

P4e Chair Prevents Rising = 2 used daily. Any type of chair with a locked lap board or chair that places the resident in a recumbent position that restricts rising, or a chair that is soft and low to the floor. Include in this category enclosed framed wheeled walkers with or without a posterior seat and lap cushion that a resident cannot easily remove.

Record the frequency, over the last seven days, that the resident was restrained by any of the devices in this section at any time during the day or night.

What is the intent of the item used?

Is the resident able to move about freely, uninhibited?

Is the resident able to remove the item when asked? (i.e., self-releasing seat belt) What is not a restraint?

the resident has no voluntary movement
the resident can easily exit or remove the device (i.e., can release the "self- releasing" seat belt)

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High Risk Pressure Ulcers and the MDS

The "Percent of High Risk Residents with Pressure Sores" quality measure reflects the percentage of high risk residents in the nursing home who have one or more pressure sores (Stage 1-4) M2a>0 or I3a-c=7007.0. "High Risk" is defined as residents with any of the following:

Impaired transfer or bed mobility (G1a) or G1b(A) = 3, 4 or 8
Comatose (B1 = 1)
Malnutrition on (I3a-e = 260, 261, 262, 263.0, 263.1, 263.2, 263.8, or 263.9)

According to the RAI Manual (pages 3-160), for section M1 "record the number of skin ulcers, at each stage, on any part of the body" "that develop because of circulatory problems or pressure." Each skin ulcer must be staged according to how it appeared during the look-back period, which is seven days from and including the assessment reference date (ARD). Rashes without open areas, burns, desensitized skin, ulcers related to diseases such as syphilis and cancer, and surgical wounds are not coded here, but are included in Item M4 (Other Skin Problems or Lesions Present). Skin tears/shears are coded in Item M4 unless pressure was a contributing factor.

Clarifications:

Do not code a debrided skin ulcer as a surgical wound.

If necrotic tissue is present, prohibiting accurate staging, code the skin ulcer as a Stage "4."

If a skin ulcer is repaired with a flap graft, it should be coded as a surgical wound and not as a skin ulcer. If the graft fails, continue to code it as a surgical wound until healed.

In section M2, code the highest stage of ulcer listed in M1 that meets the criteria of a Pressure Ulcer M2a, "any skin ulcer caused by pressure resulting in damage of underlying tissues" or Stasis Ulcer M2b, "a skin ulcer, usually in the lower extremities, caused by decreased blood flow from chronic venous insufficiency; also referred to as a venous ulcer or ulcer related to peripheral vascular disease (PVD)." There are other types of ulcers that can be listed in Item M1 (e.g. ischemic ulcers). An ulcer coded in M1 may not necessarily be coded in M2. Consult the physician regarding the cause of the ulcer prior to coding this item and ensure proper physician documentation to support the coding.

For MDS assessment, staging of ulcers should be coded in terms of what is seen (i.e., visible tissue) during the look-back period. For example, a healing Stage 3 pressure ulcer that has the appearance (i.e., presence of granulation tissue, size, depth, and color) of a Stage 2 pressure ulcer must be coded as a "2" for purposes of the MDS assessment (i.e., Downstaging/Reverse Staging).

Facilities certainly may adopt the National Pressure Ulcer Advisory Panel (NPUAP) standards in their clinical practice. Clinical studies indicate that as deep ulcers heal, the lost muscle, fat and dermis is not replaced. Instead, granulation tissue fills the defect before re-epithelialization. Given this information (unlike MDS coding protocol), it is not appropriate to reverse stage a healing ulcer. For example, a pressure ulcer Stage 3 does not become a Stage 2 or a Stage 1 in your documentation during healing. The NPUAP standards may not be used for coding on the MDS.

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It's Time to Set Your STAR Target!

The STAR Setting Targets -Achieving Results Web site, www.nhqi-star.org, has been updated with the Quality Measure rates for nursing homes throughout New York. Rates reflect Quarter 1, 2006 as recently posted to Nursing Home Compare (www.medicare.gov).

The STAR site goes a step further, providing a secure log-in so facilities can view their individual quality measure rates for the physical restraint, high risk pressure ulcer, depression, and the chronic pain clinical topic areas. In addition, facilities can view graphs and trend reports to track progress over time and set/reset improvement targets as indicated.

Information on the STAR site is updated quarterly.

Identifying areas for improvement and setting measurable goals are the first steps towards assuring quality care and improved clinical outcomes.

If you need further information, or help setting your targets, please contact any member of the IPRO NHQI team.

In Lake Success (1-800-852-3685):

Pauline Kinney, extension 402;

pkinney@nyqio.sdps.org

Maureen Valvo, extension 308;

mvalvo@nyqio.sdps.org

Dan Yuricic, extension 458;

dyuricic@nyqio.sdps.org

In Albany (1-800-233-0360):

Dave Johnson, extension 116;

djohnson@nyqio.sdps.org

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Visit Us on the Web

For information and tools to enhance Quality Improvement at your facility, visit IPRO's Nursing Home Quality Initiative (NHQI) home page at www.ipro.org/nhqi. The site is updated regularly, whenever new tools and information become available.

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