THE ROLE OF THE CLINICAL LEADERSHIP PROFESSIONAL WITH THE MDS 3.0 ASSESSMENT PROCESS ‘ Everything you need to succeed ’

1. THE ROLE OF THE CLINICAL LEADERSHIP PROFESSIONAL WITH THE MDS 3.0 ASSESSMENT PROCESS‘Everything you need to succeed’AND THEN SOME ! Leah Klusch, RN, BSN, FACHCA

2. About Leah… ‘I Focus on Learning, not teaching’ • Leah Klusch is the founder and the Executive Director of the Alliance Training Center. As an educator and consultant, she has extensive experience in presenting motivating programs on operation issues for individual ownership groups, facility managers, state, regional, and national associations • Leah & Redilearning have partnered to provide an exclusive, comprehensive MDS 3.0 Program available ONLINE and accessible anytime! This program will be shown in this presentation via a live demo!

3. POTENTIAL ISSUES Impacting clinical managers related to MDS 3.0

4. AWARENESS & KNOWLEDGE ARE KEY *If assessments are not correct, in sequence and on time, they will not be validated and the services can not be billed and the facility may face regulatory risk.

5. Evaluate how the mds 3.0 assessment process is managed • MDS Assessments and management of the process is not a nursing responsibility • At the beginning of the process in 1987, the assessment was nursing assigned and was not interdisciplinary • Now the MDS 3.0 process is much larger than a clinical assessment and the responsibilities of the MDS Manager are very operational and interdisciplinary. • Operational and clinical managers need to discuss the structure of the assessment process, team members assignments and performance and proper delegation of tasks as well as accountability. • Payment and regulatory implications for Nursing Leadership

6. DO YOU KNOW…

7. EVALUATING THE IMPACT OF MDS 3.0

8. EVALUATING THE IMPACT OF MDS 3.0 • Software should be able to generate many reports that will isolate problems and identify patterns of care and outcomes • Staffing habits and documentation tools were not substantiating the data = big risk on audit. • Staff didn’t have resources /training to complete assessments accurately. This is a very important issue. • Rehab services were not evaluated for documentation accuracy. Now we have a new process, new data set and definitions in place, which requires a change in the processes and knowledge base of our staff and our documentation tools.

9. CHANGES NEEDED FOR A SUCCESSFUL ASSESSMENT AND DATA BASE DEVELOPMENT PROCESS • Operational and clinical leadership must manage the transition to the MDS 3.0 and identify the changes necessary to minimize payment and regulatory risk.:

10. THE REALITY OF THE MDS 3.0

11. THE TRANSITION TO THE MDS 3.0

12. THE TRUTH ABOUT THE MDS 3.0 • Revised ADL scoring and calculation as well as ADL ranges.. (Now 0 - 16 ADL scale) New definitions Section G • Increased regulatory definition.. • Section J – Falls • Section P – Restraints • Section H – Toileting programs • Staff awareness and documentation formats must be revised to fit the assessment process. • New payment system for Part A Medicare with new qualifiers and many changes in groupers.

13. MANY OF THESE CHANGES REQUIRE YOU TO LOOK AT YOUR PROCESSES, FORMS, POLICIES AND PROGRAMS

14. WHAT PAIN ARE YOU FEELING NOW?

15. WHAT PAIN ARE YOU FEELING NOW?

16. Lets Look at the Issues from a 40,000 Foot Viewpoint.. • CMS has created a new assessment process and data base that connects to a new Medicare payment system. • The purpose for many of the changes is to improve oversight and reduce payment to the facilities… OUCH!! • The new process requires all new resource and processing systems which send data to a central server for validation, processing and storage.

17. THIS REQUIRES PREPARATION AND PROACTIVE MANAGEMENT

18. STAFF SUPPORT IS CRUCIAL

19. PRIMARY STEPS

20. MANUALS MUST BE IN NUMEROUS LOCATIONS IN THE FACILITY AND BE A CENTRAL REFERENCE FOR STAFF UNTIL THEY ADAPT TO THE NEW DEFINITIONS AND ASSESSMENT PROCESS.

21. QUESTIONS TO ADDRESS

22. Managing Payment • How do you manage and document RUGs distribution – prior to 10-01-10 and after? • What are the predictable changes and the real changes in RUG groupers and payment levels. • Do you understand RUG IV payment and the changes in the CMI levels , payment levels and ADL coding?

23. ADL CHANGES – BIG DEAL! Changes will be seen in: • Definitions • Total number of codes utilized for calculation of the ADL score. • The calculator – new values and lower ADL scores for common levels of support. • New ADL ranges for payment categories.

24. HOW ACCURATE ARE YOUR ADL SCORES?

25. START AT THE SOURCE • What is the documentation behavior of your front line care givers? • History, Forms, & Formats • Just imagine they had the CMS checkbook and were writing the facilities reimbursement checks…Far fetched? NO! • Do you know the ADL scores for your Part A Medicare cases and your total census? • How about ADLs for Rehab cases – over time! • Are ADL scores discussed at the Medicare Meeting? • This is necessary!

26. A FEW FACTS ABOUT ADL SCORES

27. 2.0 to 3.0 ADL Score Calculation MDS 2.0 ADL Calculation MDS 3.0 ADL Calculation Total ADL Score = 10! Total ADL Score = 3!

28. 2.0 to 3.0 ADL Score Calculation MDS 2.0 ADL Calculation MDS 3.0 ADL Calculation Total ADL Score = 13! Total ADL Score = 8!

29. 2.0 to 3.0 ADL Score Calculation MDS 2.0 ADL Calculation MDS 3.0 ADL Calculation Total ADL Score = 15! Total ADL Score = 10!

30. WHAT IT MEANS FOR YOU… • First you must identify the documentation process and the requirements of ADL performance and support provided by your staff to determine if the ADL scoring in the MDS data set is accurate • Second you must monitor ADL levels in the facility data base and on a case by case basis.

31. IMPORTANT QUESTIONS.. • Which members of your IDT and Rehab staff understand the formation and use of ADL scores? • How are ADL scores reported to the team and utilized during Medicare coverage discussions? • What specific impact do ADL scores have on payment levels in the RUG IV payment system? • Do any members of your team clinical or financial document ADL scores on RUG distribution reports? • This is essential documentation!

32. WHAT IT MEANS FOR YOU… • Is ADL documentation training included in all front line staff orientation with competency testing? • Do front line staff use electronic point of care documentation systems correctly? You should hear the stories! • Since ADL scores drive payment – up to $100 per day –could your ADL codes on the MDS withstand audit? • Reproducible documentation is REQUIRED by the regulation • Are any ADL performance scores or support coded from staff interviews? Big Problem!

33. STEPS TO YOUR SOLUTION • Identify the problem • Front line documentation must be accurate during the ARP – 24/7 • Accountability is necessary • You need to know the quality of your coding first and then focus on correcting the errors and incomplete documentation.

34. STEPS TO YOUR SOLUTION • Key members of the data collection, processing and billing team must have a complete understanding of the processes, rules and definitions. • Who Reads and Understands the RAI Manual? • Communication within this team is essential as well as regular contact for problem solving. • Software must be integrated so data is moved seamlessly between the data collection, MDS Data Set, transmission and billing processes.

35. BE CAREFUL WITH MINUTES! • The minutes of therapy that are documented on the MDS are attested to for accuracy according to the rules in the RAI manual. Does this correspond with therapy staffing levels? • People who code minutes of skilled therapy need to code the type of minutes delivered with each treatment. Be VERY Careful! • Total minutes of delivery are not necessarily billable to the RUG. • Operational Leadership needs to visit and observe the therapy department

36. RESOURCES FOR OPERATIONS • RAI manual Chapter 3 – Section O – Pages 14 to 24. Skilled therapy definition and coding minutes of therapy directions. • RAI Manual Chapter 6 – Payment System pages 19-21 – September 2010 update – calculation of billable minutes from total minutes. • Example in the manual can be entered into therapy software to check that calculations are correct.

37. RESOURCES FOR OPERATIONS • Have therapy show you how the minutes are documented in their records – which go into the medical records – and then how the minutes are collected for the MDS and tracked for payment levels • These are three separate tasks which have all been adapted or changed in the new process. • Problems include the reduction of concurrent and possibly group minutes. • THERAPY SIGNS THE MDS ATTESTATION FOR THERAPY MINUTES. • Monitoring is essential – IT IS YOUR RISK !

38. WHAT HAPPENS IF WE GET THIS WRONG? • Validation may be difficult or not possible, and without validation, the MDS is not complete. • Unexpected delays or reduction in payment or default rates – none of which is advisable • The facility assessment process can be out of compliance impacting payment and producing citations or audits. • New Survey and Cert letter telling surveyors how to monitor compliance – no forgiveness here even though CMS was not processing. • The data base for the facility can be wrong impacting PAYMENT AND COMPLIANCE. THAT MEANS AUDITS AND SURVEY ACTIVITY.

39. STEPS TO TAKE • The MDS process is operational, change the structure if necessary and manage it carefully • Look at the assessment activity – the numbers, the time lines for validation and the efficiency of the process. • Is the data base accurate – if not – why not? • Inaccurate data reduces payment. • Review RUG distribution with ADL scores

40. KEY POINTS TO REMEMBER • Look at the MDS office for efficiency, and work space quality. • Monitor wasted time in the data entry process • What resources does the MDS manager need to complete the assessments? • Meet with the MDS Manager weekly to discuss assessment activity, documentation issues and data flow. • Identify the communication between the MDS office and billing as well as the software performance in these areas. • Check the compliance of the billing process • Map out the data transfer process for late month Part A admissions.

41. CLINICAL MANAGERS HAVE A SIGNIFICANT RESPONSIBILITY IN THE PROPER IMPLEMENTATION OF THIS INTERDISCIPLINARY FUNCTIONAL ASSESSMENT TOOL AND THE REVIEW OF THE DATA BASE IT CREATES. • What data do you need reported ?

42. REMEMBER THE SURVEY AND PAYMENT TEAMS HAVE ALL THE DATA AND VERY SOPHISTICATED SOFTWARE TO PULL OUT SPECIFICS THAT RELATE TO THEIR PROCESS. • WHAT DATA ARE YOU MONITORING – LIKE FALLS WITH INJURY EXCEPT MAJOR, WANDERING, REFUSAL OF CARE, SIGNIFICANT BEHAVIOR OUTCOMES, ADL SCORE CHANGES, SHIFT OR CHANGES IN BIMS AND MSS SCORES……………. • HOW DOES THE DATA SET REPRESENT THE FACILITY AND ITS SERVICES AS WELL AS THE OUTCOMES FOR ITS ELDERS? VERY IMPORTANT QUESTION.

43. Thank You!QUESTIONS???????????

44. Presented by • Leah Klusch • Executive Director • The Alliance Training Center • 330-821-7616 • leahklusch@sbcglobal.net