MDS 3.0 CAT’s, CAA’s, & Care Plans Ellen-Jean Butler RD LDN CSG Vice President of Quality of Life and Nutrition Services SunBridge Healthcare December 3, 2010

Learning Objectives Review MDS 3.0 Review MDS 3.0 section K Review and discuss CAT’s & CAT logic Review and discuss CAA’s Review and discuss care plan development

MDS 3.0 Effective October 1, 2010 RUGS IV also implemented (surprise!) Transition from 2.0 to 3.0 created a huge churn with Medicare assessments Working through OBRA assessments How did it go?

MDS 3.0 Overview Captures the “resident’s voice” Shift from staff observation to resident interview and record review Interviews include cognitively impaired residents Supports increased individuality and accuracy of care Supports quality of care and culture change

Resident Assessment Instrument Three components: Minimum Data Set (MDS) Version 3.0 A collection of basic physical, functional, psychosocial information about residents Care Area Assessment Process Provides a framework for guiding the review of triggered areas, and clarification of a resident’s functional status and related causes of impairment. RAI Utilization Guidelines Instructions for when and how to use the RAI Provides the foundation for integrating the MDS and other clinical information

Minimum Data Set Starting point Standardized instrument to assess nursing home residents. Collection of information: Basic physical – medical conditions, mood, vision, etc. Functional – ADL’s, behavior Psychosocial – preferences, goals, interests. Identifies actual or potential areas of concern Does not constitute a comprehensive assessment

Section K: Swallowing/Nutrition Status Loss of liquids/solids from mouth when eating or drinking Holding food in mouth/cheeks or residual food in mouth after meals Coughing or choking during meals or when swallowing medications Complaints of difficulty or pain with swallowing None of the above

Section K: Swallowing/Nutrition Status K0100: Swallowing Disorder Observation of the residents Interview with resident and staff Medical record review Identifies “possible swallowing disorder” Not an assessment

K0100: Swallowing Disorder K0100 coding Do not code if interventions have been successful in treating the problem Code even if the symptom occurred only once in the 7 day look back

K0200 Height & Weight Measured on admission (not stated or hospital weight!) Height in inches to the nearest whole inch and measured annually Weight in pounds Mathematical rounding is used for both For subsequent assessments enter the last weight taken within 30 days of the ARD If last recorded wt is > 30 days from ARD - reweigh

K0300: Weight Loss Loss of 5% in the last month or loss of 10% or more in the last 6 month 1. No or unknown 2. Yes, on physician prescribed weight loss regimen 3. Yes, not on physician prescribed weight loss regimen Note: mathematical rounding of weight to the nearest whole pound is done prior to calculating % change.

K0300: Weight Loss Compares the residents weight in the current observation period with his/her weight at two snapshots in time. At a point closest to the 30 days preceding the current weight At a point closest to 180 days preceding the current weight This item does not consider weight fluctuation outside of these two time points.

K0300: Weight Loss New admissions Interview resident, family, or significant other about wt loss at 30 and 180 days Consult physician, transfer documents If the admission weight is less than prior wt, calculate change Subsequent assessments Compare current weight to prior wt in medical record

K0300: Weight Loss Physician prescribed weight loss regimen A weight reduction plan ordered by the MD with the care plan goal of weight reduction May include calorie controlled or other weight loss diets and exercise. Includes planned diuresis. It is important that the weight loss is intentional

K0300: Weight Loss Calorie restricted or diabetic diet plan to control blood sugar without inducing weight loss is not coded as MD prescribed wt loss. Amputation Adjusted calculation Calculate weight loss % based on the current wt +wt of amputated limb vs. prior weight.

K0500: Nutritional Approaches K0500A, parenteral/IV feeding Includes any and all nutrition and hydration received by the nursing home resident in the last 7 days, in the nursing home or at the hospital, provided they were administered for nutrition or hydration. Supporting documentation must be noted in the medical record Includes IV’s, TPN, hypodermoclysis Can be coded if used to prevent dehydration

K0500: Nutritional Approaches K0500B, feeding tube Should not be coded as a mechanically altered diet Should only be coded as K0500D, Therapeutic diet when the enteral formula is altered to manage a problematic health condition, e.g diabetes

K0500: Nutritional Approaches K0500C, Mechanically altered diet A diet specifically prepared to alter the texture or consistency of the food to facilitate oral intake. Should not be automatically considered a therapeutic diet K0500D, Therapeutic diet Altered nutrient content of diet to manage a problematic health condition

K0700: Percent Intake by Artificial Route K0700A, proportion of total calories the resident received through parenteral or tube feeding Calculate based on 7 day look back Calculate the proportion of total calories from IV or tube feeding. Code: 1. 25% or less 2. 26% to 50% 3. 51% or more

K0700:Nutrtional Approaches K0700 B, Average fluid intake per day by IV or tube feeding. Calculate based on 7 day look back Code for the average number of cc’s received, not ordered. Code 1 for 500 cc/day or less Code 2 for 501 cc/day or more

Care Area Triggers Upon completion of the MDS, a set of Care Area Triggers are identified (CAT’s) Flag for IDT that the triggered area needs to be assessed more completely 20 Care Area Triggers Triggers are based on CAT logic Most facilities will use software programs that match the trigger definitions for identification

CAT Logic Dehydration as indicated by: J1550C=1 Nutrition Status CAT Logic Table Dehydration as indicated by: J1550C=1 BMI is too high or too low: BMI<18.5 or BMI>24.9 Any weight loss as indicated: K0300=1 or K0300=2 Parenteral/IV feeding is used: K0500=1 Mechanically altered diet is used: K0500C=1

CAT Logic Nutrition continued Therapeutic diet is used; K0500D=1 Resident has one or more unhealed pressure ulcers at stage 2 or higher, or unstageable: Section M0300

Care Area Assessment Must be a standardized tool. Specific tool is not mandated Must be completed within 14 days of admission. Required only for OBRA comprehensive assessments (admission, annual, significant change, sig change correction prior to full.) Not required for Medicare PPS assessments (except when combined with OBRA comprehensive assessment)

Care Area Assessment The CAA process provides a framework for guiding review of triggered areas. Provides clarification of the resident’s functional status and related causes of impairment. Provides a basis for additional assessments of potential issues and related risk factors. Provides information for the development of and individualized care plan

Care Area Assessments Delirium Visual function ADL functional rehab potential Psychosocial wellbeing Falls Feeding tubes Dental care Psychotropic meds Pain Cognitive loss/dementia Communications Urinary incontinence Mood state Activities Nutritional status Dehydration/fluids Pressure ulcer Physical restraints Return to community

CAA 12. Nutritional Status Identifies triggering conditions Analysis of findings section: Problem actual or potential? Includes MDS elements and other data points Current eating pattern Functional problems Cognitive, mental status, and behavior problems that interfere with eating

CAA 12. Nutritional Status Communication problems Dental/oral problems Other diseases and conditions that can affect appetite or nutritional needs Abnormal laboratory values (from clinical record) Medications Environmental factors Resident/family representative input

CAA 12. Nutritional Status Care Plan Considerations Will nutritional status be addressed in the care plan? Y or N If yes, what is the overall objective Improvement Slow or minimize decline Avoid complications Maintain current level of function Minimize risk Symptom relief or palliative care

CAA 12. Nutritional Status Describe impact of this problem/need on the resident and your rationale for the care plan decision. Simple summary statement Description of the problem Causes and contributing factors Risk factors related to the care area Do not need to make duplicative medical record entries Can refer to comprehensive nutrition assessment Referral to another discipline Explain rationale for decision not to proceed with care planning

Care Planning MDS (data collection) + CAA’s (decision making) = Care plan development Goal is to promote the resident’s highest practicable level of functioning. Goals may be: Improvement – building on strengths Maintenance Prevention – managing risk factors Palliation

Care Planning Care plans may be for actual or potential areas of concern Must address the medical, nursing, and psychosocial needs of the resident Approaches must include precise and concise instruction to staff for care delivery Must include measurable objectives, time frame, and outcome of care

CAA link to Care Plan Medical needs: Dental/oral Disease conditions that affect appetite or nutrition needs Abnormal labs Medications

CAA link to Care Plan Nursing Functional problems Communication Environmental factors Psychosocial Current eating patterns Cognitive/mental/behavioral

RAI & Nutrition Care Process Problem identification process is the same Assessment process is the same Nutrition diagnosis and standardized language – problematic!

Survey experience Limited time frame No obvious issues here Your experience?

Questions? Thank you for sharing your morning with me. Best wishes for a joyous holiday season!