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An introduction to the MDS (Minimum Data Set) Assessment Instrument for Medical Directors

An introduction to the MDS (Minimum Data Set) Assessment Instrument for Medical Directors. George Heckman MD MSc FRCPC Assistant Professor of Medicine McMaster University Schlegel Research Chair in Geriatric Medicine, University of Waterloo. Disclosures.

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An introduction to the MDS (Minimum Data Set) Assessment Instrument for Medical Directors

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  1. An introduction to the MDS (Minimum Data Set) Assessment Instrument for Medical Directors George Heckman MD MSc FRCPC Assistant Professor of Medicine McMaster University Schlegel Research Chair in Geriatric Medicine, University of Waterloo

  2. Disclosures • Consultant and speaker fees from Janssen-Ortho, Novartis, and Pfizer • Research support: Heart and Stroke Foundation of Ontario, CHANGE Foundation, Canadian Institutes of Health Research, Novartis • Primary panelist: Canadian Cardiovascular Society Consensus Conference on Heart Failure

  3. Objectives • Terminology : MDS? RAI? • Why is this important to know? • To familiarize clinicians with the content, reliability and validity of the RAI-MDS • To understand the role of Clinical Assessment Protocols (CAPs) in resident assessment • To understand the role of CAPs in following resident progress

  4. RAI MDS 2.0 What is it? Where does it come from?

  5. Policy directive • January 7 2009: MOH-LTC announces roll-out of MDS-RAI to all Ontario LTC homes • 217 early adopters • Ironed out the bugs • 12 month implementation / training program with facility RAI coordinators • Expected completion Summer 2010

  6. RAI / MDSHawes et al Age Ageing 1997 • Developed in response to 1987 US Omnibus Budget Reconciliation Act addressing quality of nursing home care and need for standardized assessment • Targets frail seniors, disabled adults in LTC homes • MDS: Minimum Data Set • RAI: Resident Assessment Instrument • includes the MDS

  7. What is in the RAI-MDS 2.0?www.interRAI.org Intake/ initial history Cognition Communication / senses Mood / behaviour Psychosocial well-being Functional status Elimination MDS: includes approximately 300 items: • Diagnoses • Medications • Health conditions • Oral / nutritional • Skin • Activities • Treatments / procedures • Care directives • Health outcomes scales

  8. RAI 2.0 scales • Cognitive Performance Scale • Depression Rating Scale • Index of Social Engagement • ADL Self-Performance Hierarchy Scale • CHESS Scale: health instability • Pain scale

  9. Clinical Assessment Protocols • CAPs • Best-practice guidelines designed to assist assessor • Identify and interpret key clinical issues • Develop a plan of management • Developed by expert panel with validation from focus groups and research • More on CAPs later

  10. Software • Software vendors licensed by InterRAI • Automated entry • Print out patient / resident summaries • Demographics • Medications • Diagnoses • CAPs +/- scales

  11. interRAI • International, not-for-profit network of 60+ researchers and health/social service professionals • Design instruments for comprehensive assessment of care needs • Multinational collaborative research to develop, implement and evaluate instruments and their related applications

  12. interRAI Countries Europe Iceland, Norway, Sweden, Denmark, Finland, Netherlands, France, Germany, Switzerland, UK, Italy, Spain, Czech Republic, Poland, Estonia, Belgium, Lithuania, Portugal, Austria, Portugal North AmericaCanada US Mexico Pacific Rim Japan, China, Taiwan, Hong Kong, South Korea, Australia, New Zealand Central/ South AmericaBelize, Cuba, Brazil, Chile, Peru Middle East/South AsiaIsrael, India

  13. The interRAI Family of Instruments • Home Care (HC) • Contact Assessment (CA) Screener • Acute Care (AC） • Emergency Department (ED) Screener • Mental Health (MH) • Inpatient • Community • Emergency Screener • Forensic Supplement • Community Health Assessment (CHA) Common “core” items, as well as specialized ones • Complex Continuing Care & Long Term Care Facilities (LTCF & 2.0) • Palliative Care (PC) • Post-Acute Care-Rehabilitation (PAC) • Intellectual Disability (ID) • Assisted Living (AL)

  14. Implementation & Testing of interRAIInstruments RAI 2.0 RAI-HC RAI-MH interRAI CMH interRAI ESP interRAI PC interRAI ID interRAI ED/AC interRAI CA interRAI CHA interRAI AL interRAI LTCF DB Solid symbols – mandated or recommended by govt; Hollow symbols – research/evaluation underway

  15. Can you rely on the data? reliability and validity

  16. Reliability • Reliability: is this data reproducible, with a measurement error small enough compared to true value? • test-retest • inter-observer: particularly important for RAI Streiner & Norman, Health Measurement Scales: A practical guide to their development and use

  17. Validity • Validity: does the information actually reflect what it was intended to reflect? • Face validity: what do “experts” think? • Content validity: is everything important measured? • Criterion validity: • Does the data correlate as expected with other assessments (concurrent validity)? • Does the data predict the expected outcomes (predictive validity)?

  18. How is this data collected? • Trained clinicians conduct the RAI-HC assessments • Accuracy of information recorded through • discussions with MDs • family and caregivers interviews • review of medical records if necessary • Exercise clinical judgment as to most appropriate answer based on guidelines in manual • Is this reliable??

  19. International reliability studyHirdes et al BMC Health Services Research 2008 • 12 countries • Trained individuals completed dual assessments on 783 individuals • RAI-LTCF 8 countries 31% of assessments • RAI-HC 6 28% • RAI-PAC 5 16% • RAI-PC 4 13% • RAI-MH 1 11% • Canada 147 individuals assessed • 2 blinded assessments within 72 hours

  20. Patient characteristics - LTC • Age • 65 to 84 years 50.9% • 85 years+ 45.6% • 72.3% women • Selected characteristics • 83.4% impaired decision-making ability • 17.3% any aggressive behaviour • 65.8% hygiene problems • 57.7% walking problems • 21.8% feeding problems

  21. Weighted Kappa • Measure of degree of agreement • <0.40 poor • 0.41-0.60 moderate • 0.61-0.80 substantial • >0.81 excellent Landis & Koch, Biometrics 1977

  22. RAI-LTCF Inter-observer reliabilityWeighted Kappa • Gender 0.96 (!! ;-)) • ADL 0.87 • Pressure ulcer stage 0.85 • Standing ability 0.83 • Continence 0.90 • Cognition 0.77 • Falls/fractures 0.86 • Pain 0.63 • Advance directives 0.63

  23. Reliability of RAI-LTCF • Overall reliability of individual items substantial to excellent • Core / common items more reliable than specialized items • Not unexpected: in development longer • Reliability across languages, countries • Bottom line: The data is trustworthy

  24. Is the RAI-MDS data valid? • Face validity • Content validity • Concurrent validity: do the scales correlate with more established tools? • Predictive validity: do the scales predict expected outcomes?

  25. CHESS ScaleHirdes et al JAGS 2003 • Changes in Health, End-stage disease, Signs and Symptoms • Reliable • Predicts 3-year mortality in LTC, physician activity, medical procedures, i.e. health instability • Items include: • Symptoms/signs: shortness of breath, edema, weight loss, leaving food uneaten, vomiting, dehydration • End-stage disease • Decline in cognition • Decline in ADLs

  26. Heart Failure is characterized by instability CHESS measures instability Figure from Goodlin JACC 2009 Does RAI 2.0 predict mortality better than the NYHA class?(predictive validity)

  27. The StudyTjam et al, abstract CCS 2006 • Secondary analysis of HF educational intervention for LTC • 149 residents with HF, 68% over age 85 years, 79% female • Multiple comorbidities • 6 month mortality: 22.1%

  28. Results • Logistic regression • C-statistic: measures Goodness of Fit of model • 1.0 is perfect fit • NYHA: C-statistic = 0.686 • Pretty good • MDS/RAI: CHESS plus “requires help walking in room: C-statistic = 0.838 • Better! • Speaks to predictive validity

  29. Depression Rating ScaleBurrows et al Age Ageing 2000 • The scale • Negative statements • Persistent anger • Expression of unrealistic fears • Repetitive health complaints • Repetitive anxious complaints • Sad, pained, worried expression • Tearfulness • Scoring items • 0 if not present • 1 if present at least once in last 30 days or up to 5 days /week • 2 if 6-7 days a week

  30. Validation studyBurrows et al Age Ageing 2000 • 108 LTC residents from 2 homes • Semi-structured interview • Trained assessors • Correlation: • 0.69 with Cornell Scale for depression • 0.70 Hamilton Depression Rating Scale • Compared to DSM-IV geriatric psychiatry assessment • Sensitivity 91% • Specificity 69%

  31. DRS as a predictor of depressionMartin et al Age Ageing 2008 • 7818 patients admitted to Ontario CCC beds and for > 3 months • 65 years and over, average age 81 years • Not depressed on admission, not on antidepressants, not severely cognitively impaired • At f/u, 7.5% new diagnosis of depression • Odds ratios for new depression: DRS range of • 1-2 1.45 (1.16-1.80) • 3-5 2.08 (1.63-2.67) • 6+ 2.07 (1.47-2.92)

  32. Comments • Examples of validity • CHESS: predictive validity • DRS: concurrent validity, predictive validity • A few other studies dispute this for the DRS • 1 did not adhere to RAI/MDS administration methodology (Hendrix et al, JAMDA 03) • 1 did not report on whether methodology followed (Anderson et al, Age Ageing 2003) • Tools should be used appropriately and correctly

  33. Clinical applications Clinical assessment protocols to Screen Follow outcomes

  34. CAPs • Clinical Assessment Protocols: provide guidance on care for particular clinical problems and identify those • at risk of decline • who may improve • “Triggered” by MDS items, scales • On average, LTC residents trigger 4 CAPs interRAI Clinical Assessment Protocols (CAPs) – For use with interRAI’s Community and Long-Term Care Assessment Instruments, March 2008 (Ottawa: CIHI, 2008)

  35. CAPs • ADLs • Restraint use • Delirium • Communication • Cognitive impairment • Mood • Behaviour • Falls • Cardiopulmonary conditions • Activities • Social relationships • Pain • Pressure ulcers • Nutrition • Feeding tube • Dehydration • Medication use • Elimination • Prevention

  36. Activities of Daily Living CAP • Goal: Maintain or possibly improve function • Triggers: • Recent clinical event from which functional recovery possible • Need some, not total, ADL help; not imminently dying • Cognitive reserve present • 2+ of chronic disease flare, delirium, changing cognition, pneumonia, fall / hip fracture, receiving PT, recent hospitalization, fluctuating ADLs / care needs • Functional decline potentially preventable • As above, with at most 1 risk factor

  37. Why bother? • 20% trigger when functional recovery possible • 1/3 improve • 1/3 decline • 60% trigger to prevent functional decline • 1/3 improve • 1/3 decline

  38. CAP elements • Target nursing and MD • Rule out concurrent medical problem • Review medications • Consider depression • Consider orthostatic hypotension • Consider pain • May trigger other CAPs • Delirium, falls, pain, malnutrition • Consider physiotherapy (formal, family)

  39. Cardiorespiratory CAP • Triggered if any MDS item present • Chest pain • Shortness of breath • Irregular pulse • Dizzy • Additional trigger • Systolic BP > 200, < 100 • RR > 20 • 50 < HR < 100 • O2 sat < 94% • Triggered by 15% LTC resident

  40. Cardiorespiratory CAP Guidelines • Provides guidelines on RN, RPN interventions but promotes MD assessment • Consider undertreated chronic disease (e.g. HF) • Acute exacerbation of chronic disease • Acute problem: pneumonia, PE

  41. Comments on CAPs • For complex patients, identifies priority problems • Focus on patients in whom intervention may maintain / restore / improve health • Provide best-practice guidelines • Intend as an aid to, and not as a substitute for, clinical judgement • Can also be used to monitor resident progress

  42. Following Progress Another use for CAPs

  43. Example: Behaviour CAP • Triggered if daily • Wandering • Verbal abuse of others • Physical abuse of others • Socially inappropriate or disruptive behaviour • Inappropriate public sexual behaviour or public disrobing • Resistive to care • Triggered in 10% of LTC residents • Present but less than daily in 8%

  44. Behaviour CAP • 3 trigger levels • Daily problem: 1/3 may improve over 90 days • Less than daily problem • No problem • Care plan provides extensive documentation and advice on behavioural management and when to consider medications • Opportunity to monitor progress q 3 months

  45. Example: Pain CAP • Validated against pain scale Visual Analogue Scale • 0 no pain • 1 less than daily pain • 2 daily pain but not severe • 3 severe daily pain • 3 trigger levels • High priority 3 (5%; 45% may improve; 15% pain-free) • Medium priority 1-2 (12%; 35% may improve; 15% pain-free) • Low priority 0

  46. Pain CAP • Provides guidelines on • Further assessment, physical exam, diagnostic testing • Concurrent / aggravating comorbidities • Functional implications • Treatment options review • Pharmacological • Non-pharmacological • Progress can be monitored over time

  47. Broader Considerations The bigger picture

  48. interRAI suiteHirdes Age Aging 2006;35:329 • Integrated set of information systems • Common core elements • Across sectors within a health care system • E.g. Acute care, Home care, Long-Term care • LHIN to LHIN • Across borders • Interprovincial • International

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