MDS 3.0 Implications for Recreational Therapy

1. Presented by Linda L. Buettner, PhD, LRT, CTRS, FGSA University of NC at Greensboro MDS 3.0Implications for Recreational Therapy

2. Goals Participants will be able to: 1) Verbalize the changes in MDS 3.0 that impact on resident care and QOL, 2) Identify five clinical areas on the MDS 3.0 with major revisions and describe roles for recreational therapy, 3) Detail assessment and interview techniques and documentation opportunities for RT beginning in October 2010 with MDS 3.0.

3. History of the MDS • 1986- IOM release report on quality of care in nursing homes • 1987- OBRA ‘87 was passed, requiring complete assessment • 1991- First MDS was introduced • 1997- MDS 2.0 was introduced • 2003- CMS contracts for revising to MDS 3.0 • 2007- CMS announces implementation plan • October 2010- Implementation of MDS 3.0

4. Goals of the MDS 3.0 • Improve clinical relevance and accuracy • Increase resident voice • Improve user satisfaction • Increase efficiency of reports • Maintain program ability of CMS

5. Benefits of the MDS 3.0 • Larger font • Fewer items per page • Definitions printed directly on form • Increased accuracy • Increased clarity of questions • Gives resident a voice through interviews • Listens to resident concerns • Reduced completion time by 45%

6. Assessment Timing • For OBRA-required assessments, regulatory requirements for each assessment type dictate assessment timing, the schedule for which is established with the Admission (comprehensive) assessment when the ARD is set by the RN assessment coordinator and the Interdisciplinary team (IDT). • Assuming the resident did not experience a significant change in status, was not discharged, and did not have a Significant Correction to Prior Comprehensive assessment (SCPA) completed, assessment scheduling would then move through a cycle of three Quarterly assessments followed by an Annual (comprehensive) assessment.

7. Sections with Major Revisions • Cognitive/ Delirium • Mood • Behavior • Customary Routine & Activities • Pain Assessment Plus RT is now in Section O.

8. Section C. Cognitive Patterns (2 parts) • Brief Interview for Mental Status (BIMS) • Repetition of three words • Temporal orientation: year, month, day • Recall • Staff Assessment for Mental Status • CAM- delirium • Inattention • Disorganized thinking • Altered level of consciousness • Psychomotor retardation

11. Potential RT Interventions • Brain Fitness* • Animal Assisted Therapy * • Bibliotherapy • Reminiscence* • Card Games • Matching Games • Geography Map Games • Board Games • Computer based interventions *Evidence-based intervention

12. Mood- PHQ-9 • Little interest or pleasure in doing things • Feeling down, depressed, or hopeless • Trouble falling or staying asleep, or sleeping too much • Feeling tired or having little energy • Poor appetite or overeating • Feeling bad about yourself- or that you are a failure or have let yourself or your family down • Trouble concentrating on things such as reading the newspaper or watching television • Moving or speaking so slowly that other people could have noticed. Or the opposite- being so fidgety or restless that you have been moving around a lot more than usual • Thoughts that you would be better off dead or of hurting yourself in some way

14. Potential Interventions for Mood • Exercise* • Creative Arts* • Wheelchair Biking* • Reminiscence* • Animal assisted therapy* • Life Review* • Wheelchair Biking* • Relaxation* • Cognitive Bibliotherapy* *Evidence-based intervention

15. Behavioral Symptoms • Behavioral Symptoms • Physical behavioral symptoms directed towards others • Verbal behavioral symptoms directed towards others • Other behavioral symptoms not directed towards others • Impact on resident • Impact on others • Wandering • Presence & Frequency • Impact on others

18. Potential Interventions • Simple Pleasures Items* • Music Interventions* • Life Stories* • Air mat Therapy* • Relaxation* • Cognitive Stimulation* • Social Dance Club* • Expressive Arts* • Gardening/ Horticulture* *Evidenced-based intervention

19. Customary Routine and Activities • New interview questions replace 20 Customary Routine staff assessment items for residents who can be interviewed. • Current importance rating replaces “check all that apply in the past year.” • New interview for activities preference replaces12 staff assessment items for residents who can be interviewed.

20. Customary Routines and Activities (continued) • New question on whether the resident wants to talk about returning to the community. • Staff Assessment of Activity and Daily Preferences is completed only for residents who cannot complete interview. • There are major changes to several items, and staff are instructed to observe resident response during exposure to activity.

23. The Interview for Section F. • Can resident “Make self Understood”? • Does resident need an interpreter? • Code 0, no --- Code 1, yes

24. This is what you say: • I’d like to ask you a few questions about your daily activities. The reason I am asking you these questions is that the staff here would like to know what’s important to you. This helps us plan your care around your preferences. We want to make your stay as personal as possible”

25. What you say next: • I am going to ask you how important various activities and routines are to you while you are in this home. I will ask you to answer using the choices you see on this card” • READ the choices

26. Tips • Code 9, no response or non-responsive • If 3 nonsensical responses STOP

27. Let’s practice • Q. How important is it to you to choose what clothes to wear? • A. “It’s very important. I’ve always paid attention to my appearance” • How would you code this? • Coded 1, very important

28. New resident – same question • “I leave that up to the nurse. You have to wear what you can handle if you have a stiff leg” • You probe: “you leave it up to the nurses” would you say that, while you are here, choosing what clothes to wear is [pointing to cue card] …… • A. “Well it would be important to me but I just can’t do it” • Code it - 5

29. How important is it to you to take care of your personal belongings or things? • A. “It is somewhat important. I’m not a perfectionist, but I don’t want to have to look for things”. • Coding? 2, somewhat important • Another A. “All my nice things are at home” • Clarify “your most treasured things are at home. Do you have other things here that are important to take care of?” • A. My son gave me this CD player. It is very important to me. • Code-1, very important

30. Then go on to Activity Preferences • How important is it to you to have books, newspapers, and magazines to read? • How important is it to you to listen to music you like? • How important is it to you to be around animals such as pets? • Same coding

31. Functional StatusActivities of Daily Living • Bed mobility • Transfer • Toilet transfer • Toileting • Walk in room • Walk in facility • Locomotion • Dressing upper body • Dressing lower body • Eating • Grooming/ personal hygiene • Bathing

33. Coding ADLs • 0- Independent • 1- Set up assistance • 2- Supervision • 3- Limited assistance • 4- Extensive assistance- 1 person assist • 5- Extensive assistance- 2+ person assist • 6- Total assistance- 1 person assist • 7- Total assistance- 2+ person assist • 8- Activity did not occur

34. Balance During Transitions & Walking • Moving from seated to standing • Walking • Turning around and facing the opposite direction while walking • Moving on and off toilet • Surface to surface transfer

35. Potential Interventions • Exercise • Community re-entry • Aquatic therapy or water exercise • Walking programs • Animal assisted therapy • Balloon Volleyball • Tether Ball • Dancing • Tai Chi

36. Falls • Fall History on Admission • One or more times in month prior to admission • One or more times in last 1-6 months prior to admission • Fracture related to fall in last 6 months • Falls since Admission or Prior Assessment • Number of Falls • No injury • Injury (except major) • Major Injury

37. Potential Interventions • Air Mat Therapy* • Relaxation Based* • Walking programs* • Exercise programs* • Multi-level RT Falls Prevention* • Horticulture therapy- elevated gardens *Evidence-based interventions

38. Pain Assessment • Treatment Items have been added. • Resident interview replaces staff observations for residents who can report pain symptoms. • Section has been added to capture the effect of pain on sleep and day-to-day activities. • Staff assessment of pain has been changed to an observational checklist of pain behaviors and is completed only for those residents that cannot self-report.

41. Pain Management • Scheduled pain management • PRN pain management • Non-medication intervention for pain • Pain Assessment Interview • Any pain during the last 7 days • Amount of time pain was experienced • Hard to sleep at night • Limited day-to-day activities

42. Potential Interventions • Storytelling/ Reminiscence • Bibliotherapy • Somatron • Airmat Therapy • Relaxation • Glider Rockers • Animal-Assisted Therapy* • Therapy Dolls • Exercise* • Chair Yoga • Chair Tai Chi • Aquatic Exercise/ Therapy* • Life Roles • Sensory Integration • Expressive Arts • Simple Pleasures (comforting items)

44. Other Areas for Possible RT Treatment • Nutritional- weight loss • Therapeutic Cooking Programs • Medications- psychotropic medications • Programs to decrease disturbing behaviors • Restraints • Fall reduction programs • Interventions to improve gait and balance • Nursing Rehabilitation/ Restorative Care • Return to Community • Community Reintegration Programs

49. Special Treatments & Procedures

50. Requirements for RT Treatment: This just doesn’t happen!