MDS 3.0 CAT’s, CAA’s, & Care Plans

MDS 3.0CAT’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 • K0100 • 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 • 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

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 Care Area Assessments

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!

MDS 3.0 CAT’s, CAA’s, & Care Plans