The Minimum Data Set (MDS) is part of the U.S. federally mandated process for clinical assessment of all residents in Medicare or Medicaid certified nursing homes and non-critical access hospitals with Medicare swing bed agreements. (The term 'swing bed' refers to the Social Security Act's authorizing small, rural hospitals to use their beds in both an acute care and Skilled Nursing Facility (SNF) capacity, as needed.)[1] This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home and SNF staff identify health problems.
Resource Utilization Groups (RUG) are part of this process, and provide the foundation upon which a resident's individual care plan is formulated. MDS assessment forms are completed for all residents in certified nursing homes, including SNFs, regardless of source of payment for the individual resident. MDS assessments are required for residents on admission to the nursing facility and then periodically, within specific guidelines and time frames. Participants in the assessment process are health care professionals and direct care staff such as Registered Nurses, Licensed Practical/Vocational Nurses, Therapists, Social Services, Activities and Dietary staff employed by the nursing home. MDS information is transmitted electronically by nursing homes to the MDS database in their respective states. MDS information from the state databases is captured into the national MDS database at Centers for Medicare and Medicaid Services (CMS).
Sections of MDS (Minimum Data Set):
Identification Information
Hearing, Speech and Vision
Cognitive Patterns
Mood
Behavior
Preferences for Customary Routine and Activities
Functional Status
Functional Abilities and Goals
Bladder and Bowel
Active Diagnoses
Health Conditions
Swallowing/Nutritional Status
Oral/Dental Status
Skin Conditions
Medications
Special Treatments, Procedures and Programs
Restraints
Participation in Assessment and Goal Setting
Care Area Assessment (CAA) Summary
Correction Request
Assessment Administration
MDS 3.0 Forms (Resident Assessment & Care Screening All Item Listing. Both programs reimburse Long Term Care facilities based on measures of the intensity of care and services required for each resident. Case Mix refers to the aggregate level of services and care needed by all the residents of a Long Term Care facility. Link to Case Mix Manuals. Skilled Nursing Facility Quality Reporting Program Measure Calculations and Reporting User’s Manual Version 3.0 Prepared for Centers for Medicare & Medicaid Services Contract No. HHSM-500- 2013-13015I Measures and Instrument Development & Support (MIDS) Prepared by RTI International 3040 Cornwallis Road Research Triangle Park, NC 27709. Minimum Data Set (MDS 3.0) for long-term care is a resident assessment instrument that is which of the following? Required by long-term care facilities that are certified to participate in the Medicare and Medicaid programs b. The first component of the RAI c. Used to gather information about specific health status factors and include.
The MDS is updated by the Centers for Medicare and Medicaid Services. Specific coding regulations in completing the MDS can be found in the Resident Assessment Instrument User’s Guide. Versions of the Minimum Data Set has been used or is being utilized in other countries.
References[edit]
Centers for Medicare & Medicaid Services Long Term Care Facility Resident Assessment Instrument 3.0 User’s Manual Version 1.16 October 2018
Retrieved from 'https://en.wikipedia.org/w/index.php?title=Minimum_Data_Set&oldid=905383243'
Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical, mental, and psychosocial well-being. Overview of the Assessment Tool: This is an optional template provided for nursing facilities, and if used, it may be modified. Long-Term Care Facility Resident Assessment Instrument (RAI) User’s Manual Updated December 2002 For Use Effective June 15, 2005 The Long-Term Care Facility Resident Assessment Instrument User’s Manual for Version 2.0 is published by the Centers For Medicare & Medicaid Services (CMS) and is a public document. A federally mandated resident assessment that must be done for every resident in a nursing home. They are administered in an effort to capture supporting documentation of the Resident Assessment Instrument (RAI). They include the principal components of a long-term care resident's care plan.
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Section B Intent:
The intent of items in this section is to document the resident’s ability to hear (with assistive hearing devices, if they are used), understand, and communicate with others and whether the resident experiences visual limitations or difficulties related to diseases common in aged persons. (CMS’s Resident Assessment Instrument (RAI) Manual, Chapter 3)
Select the topic to view or close the training information.
RAI Manual for MDS 3.0
The RAI Manual is CMS’s official guide to MDS 3.0. This manual contains six chapters plus appendices. Chapter 3 includes step-by-step instructions for completing each section of the MDS 3.0. Since Chapter 3 Section B relates to Hearing, Speech, and Vision, the letter B comes before all page numbers in this section. The RAI Manual could take between 3 to 10 minutes to download.
Directions: When you follow the link below, you will open the MDS 3.0 RAI Manual page on the U.S. Department of Health and Human Service, Centers for Medicare and Medicaid Services (CMS) site. Once you are on this page, scroll to the download section. Select MDS 3.0 RAI Manual.
Long-term Care Facility Resident Assessment Instrument 3.0 User's Manual
Link to the RAI Manual
MDS 3.0 Forms (Resident Assessment & Care Screening All Item Listing)
Directions: When you follow the link below, you will open the MDS 3.0 Technical Information page on the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS ) site. Once you are on this page, scroll to the download section. Sometimes you may find two releases of the Item Subsets in the download section; you will need to pay attention to the dates to get the right one to meet your needs. Select MDS 3.0 Item Subsets to download the files.
Link to MDS 3.0 Item Subset forms
MDS 3.0 Coding Training Section
Instructor Guides
This link will take you to PDF files of PowerPoint Slides with Instructor Notes used in CMS Training of Trainers. You can go through this training material at your own pace. You may find it helpful to have a copy of the MDS 3.0 forms when you review this information. Please refer to the RAI Manual and CMS Transmittals of Changes.
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Presenation Slides
This link will take you to the CMSPowerPoint Slides developed for Training of Trainers for Section B. This PowerPoint includes only the slides; it does not include trainer notes or audio of the training.
Supplemental Training Handouts
There are no supplemental training handouts or interview aids for Section B.
Training Videos
If you would like to see an one hour and five minute video of the actual CMS Training of Trainers session on Section B and C presented by Dr. Deb Saliba (held in August 2010) view this YouTube video.
For more training videos, this link will take you to a list of MDS 3.0 videos on YouTube; it is filtered by date. Beginning at the top, you can view the most videos that have been uploaded on the subject of MDS 3.0. Please note that several of the videos have been uploaded by CMSHHSGOV. While there are many videos on this YouTube channel, the videos posted by CMS would be most recommended by the State of Maine as this is the primary source of guidance on the MDS 3.0 from CMS.
Some things, such as interview techniques have not changed since the implementation of MDS 3.0 in 2011, other sections may not have current information.
CAAs and CATs
Certain responses to questions in the MDS 3.0 will point to conditions, symptoms and other areas of concern that need further assessment in order to help the facility develop a comprehensive individualized care plan. These responses will “trigger” (Care Area Trigger, CAT) the need to complete a Care Area Assessment (CAA ). Chapter 4 of the RAI Manual covers the Care Area Assessment (CAA ) Process and Care Planning.
Directions: When you follow the link below, you will open the MDS 3.0 RAI Manual page located on the U.S. Department of Health and Human Service, Centers for Medicare and Medicaid Services (CMS) site. Once you are on this page, scroll down to the download section. Select MDS 3.0 RAI Manual. See Chapter 4 in the MDS 3.0 RAI Manual.
Responses to the following Items in Section B: Hearing, Speech, and Vision may trigger the facility to conduct a Care Area Assessment.
B0200 (CAA 4 — Communication)
B0700 (CAA 4 — Communication)
B0800 (CAA 4 — Communication)
B1000 (CAA 3 — Visual Function)
Case Mix
Long Term Care facilities receive reimbursement through two government programs: Medicare and MaineCare. Both programs reimburse Long Term Care facilities based on measures of the intensity of care and services required for each resident. Case Mix refers to the aggregate level of services and care needed by all the residents of a Long Term Care facility.
Medicare reimbursement is based on a category-based classification system called Resource Utilization Group IV (RUG-IV). Certain responses on the MDS 3.0 determine assignment of a resident to a RUG-IV group. Medicare reimbursement guidelines are the same all across the country.
Medicaid reimbursement rules and guidelines differ from state to state. Currently Maine's Medicaid program (called MaineCare) uses a Case Mix system that differs from the Medicare system.
CMS does not require the completion of C0600 and C0700. However, the State of Maine does require these items to be completed in order to calculate Case Mix payment.
Some questions inSection B: Hearing, Speech, and Vision affect Case Mix for RUG-IV (Medicare) and RUG-III (MaineCare). Select the link below for a copy of the MDS 3.0 Item Subset that identifies relevant questions.