MDS 3'0: An Overview for Pharmacists

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• MDS 3.0 An Overview for Pharmacists
• Carla McSpadden, RPh, CGP
• Asst. Director, Professional Affairs
• American Society of Consultant Pharmacists

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Disclosures

• I have no financial disclosures.

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Learning Objectives

• Summarize the purpose of the Minimum Data Set
  (MDS), including the timeframes and situations in
  which it must be submitted.
• Explain how the MDS can be used by consultant
  pharmacists during medication regimen reviews and
  other quality assurance activities.

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Learning Objectives

• Outline the proposed implementation timeline for
  the MDS, Version 3.0.
• Summarize the medication section of the new MDS
  3.0.
• Discuss other questions and sections of the MDS
  3.0 that pharmacists should be familiar with and
  should utilize.

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Terminology Quiz

• The RNAC asked you, the consultant pharmacist, to
  check new Section N of the MDS 3.0 to be sure
  shes filling out the questions correctly. You
  consult the RAI Users Manual.

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What is the MDS?

• MDS Minimum Data Set, currently Version 2.0
• MDS is the required standardized assessment tool
  that collects data about each residents problems
  and conditions by asking questions about certain
  clinical and functional elements
• MDS data feeds into a lot Quality Indicators,
  Quality Measures, Part A reimbursement and
  Resource Utilization Group (RUG) classification

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MDS is part of RAI

• MDS is just one component of the RAI - Resident
  Assessment Instrument RAI also consists of RAPs
  soon to be called Care Area Triggers (CATs)
• Largely based on responses from the MDS
• Help identify those potential issues and
  conditions that need additional assessment and
  review along with suggested resources
• Critical link between the MDS and care planning
• RAI Users Manual developed by CMS to provide
  clarification on answering MDS questions and
  using RAPs/CATs
• www.cms.hhs.gov/nursinghomequalityinits/20_NHQIMDS
  20.asp

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When is the MDS submitted?

• MDS completed on all residents in Medicare or
  Medicaid certified facilities
• MDS is submitted electronically by facilitys MDS
  Coordinator or Nurse Assessment Coordinator
• MDS filled out at least
• Upon admission
• Quarterly
• Annually
• With any significant change in condition

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MDS Nuances

• For Medicare Part A residents, shortened version
  of MDS is filled out even more frequently and
  forms basis for payment
• Filled out at days 5, 14, 30, 60, and 90 days
• States may require additional sections of MDS to
  be filled out - such as Section U, which requires
  medications taken within past 7 days to be listed

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MDS, Version 3.0
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Why a new MDS?

• Improve the clinical relevance and accuracy of
  MDS assessments
• Increase the voice of residents in the
  assessments more resident INTERVIEWS
• Improve user satisfaction
• Increase efficiency

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Testing DRAFT MDS 3.0

• Draft MDS 3.0 was tested in 71 NHs
• Average time spent per MDS was decreased by 45
• Version 3.0 62 minutes
• Version 2.0 112 minutes
• Assessments were found to be more accurate on
  cognitive, depression, and behavior items

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MDS Sections with Major Changes in 3.0

• Cognitive Patterns
• Brief Interview for Mental Status (BIMS)
• Delirium Confusion Assessment Method (CAM)
  standard instrument for detecting delirium
• Depression Items
• PHQ-9 Checklist of 9 depression symptoms used
  widely in hospitals and community Ends with
  total severity score 0-27 with 27 being the most
  severe

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MDS Sections with Major Changes in 3.0

• Behavior Items
• New terminology and descriptions of behavior
• Categories of behavior
• Physical behavior directed towards others
• Verbal behavior directed towards others
• Other behavioral symptoms not directed towards
  others (physical acts towards self, pacing,
  disruptive sounds, etc.)

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MDS Sections with Major Changes in 3.0

• Customary Routine
• All new questions, which can be answered by
  resident or family member
• Gait and Falls
• Falls Hx upon admission and falls since last MDS
• New questions about balance
• Pain
• Focus on self-reporting
• Number of questions increased substantially

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MDS 3.0 Timeline

• October 2009 CMS to publish FINAL MDS 3.0,
  along with RAI Users Manual
• October 2010 MDS 3.0 implementation
• October 2011 Public reporting on NH Compare
  website using MDS 3.0 data

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Medications in MDS 3.0

• Meds no longer part of Section O
• Instead New Section N
• Of course, other med-related questions in other
  sections (e.g., Section J Pain)

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Section O from 2.0 vs. New DRAFT Section N from
3.0

• OUT
• of meds received in last 7 days
• New meds within last 90 days (Y or N)
• Same/similar
• of days (within last 7) resident received an
  injection
• of days (within last 7) resident received
  various classes of meds
• NEW
• Insulin

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Section O from 2.0 vs. New DRAFT Section N from
3.0

• Pharm Classes tracked by draft Section N, 3.0
• Antipsychotics
• Anti-anxiety agents
• Antidepressants
• Hypnotics
• Diuretics
• Anticoagulants
• Antibiotics

• Pharm Classes tracked by Section O, 2.0
• Antipsychotics
• Anti-anxiety agents
• Antidepressants
• Hypnotics
• Diuretics

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Case Study
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Case Study

• MDS assessment submitted May 27 for new resident
  Mary Smith
• Medication orders upon admission May 22
• Furosemide 40mg PO QD
• KCl - 20mEq PO QD
• Enoxaparin 40mg SQ QD X 5 more days
• Insulin glargine 10U SQ QHS
• Amitripyline 25mg PO HS
• Hydrocodone/APAP 5/500 Q6H PRN

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Case Study

• Nurses notes, physicians orders, and MAR reveal
  that she recently had stomach virus and on 5/25
  was ordered and administered
• Promethazine 25mg IM X1
• NS X 1 liter
• SSI with regular insulin X 24 hours Call MD with
  BS results and insulin utilization tomorrow
• Only used one dose of regular insulin BSs WNL
  afterwards MD stops regular insulin order and
  continues insulin glargine only

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Case Study

• Coding the Medication Section of DRAFT MDS 3.0

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N0300 Injections

• N0300. Record the number of days that injections
  of any type were received during the last 7 days
  or since admission/reentry if less than 7 days.
• ANSWER?

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Injection Clarification from RAI Users Manual

• Assuming MDS 2.0 clarifications still apply
• DO count antigens, vaccines
• DO count anything administered SQ, IM,
  Intradermal - BUT NOT IV
• IV FLUIDS documented under Section K
• IV MEDS documented under Section O, Question H
• For subcutaneous pumps, count only those days
  when an injection is used to fill/restart the
  pump
• Even if multiple injections are administered on
  same day, 1 is entered on MDS - COUNT DAYS, NOT
  MEDS!

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N0350 Insulin

• N0350. Insulin
• A. Insulin injections Record the number of days
  that insulin injections were received during the
  last 7 days or since admission/reentry if less
  than 7 days.
• B. Orders for insulin Record the number of
  days the physician (or authorized assistant or
  practitioner) changed the residents insulin
  orders during the last 7 days or since
  admission/reentry if less than 7 days
• ANSWERS?

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N0400 Meds Received

• N2. Medications Received Check all medications
  the resident received at any time during the last
  7 days or since admission if less than 7 days
• a. Antipsychotic
• b. Antianxiety
• c. Antidepressant
• d. Hypnotic
• e. Anticoagulant (warfarin, heparin, or
  low-molecular weight heparin)
• f. Antibiotic
• g. Diuretic
• z. None of the above were received
• ANSWERS?

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Meds Recd Clarification from RAI Users Manual

• Assuming MDS 2.0 clarifications still apply
• Count meds given by any route in any setting
  (even ER, if known)
• If the resident uses long-acting drugs that are
  taken less often than weekly (e.g., fluphenazine
  decanoate or haloperidol decanoate) count it as
  1

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Meds Recd Additional Clarifications

• NOTE definition of anticoagulant from question
• What if amitriptyline was used for neuropathic
  painhow would you code MDS?
• What if amitriptyline was used for sleephow
  would you code MDS?

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MDS Activity
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Clinical Sections of MDS CP Considerations

• Identification info
• Reason for MDS e.g., significant change in
  condition
• Race/ethnicity
• MR/DD conditions
• Where setting they entered from
• Hearing, Speech, Vision
• Ability to understand (i.e., MTM, discharge
  instructions)
• Cognitive Patterns
• Dementia Tx justification/indication, monitoring
• Delirium info possible ADR

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Clinical Sections of MDS CP Considerations

• Mood
• Depression Tx justification/indication,
  monitoring
• Sleep
• Behavior
• Psychosis symptoms
• Supplemental info to behavior monitoring sheets
• Antipsychotic justification, monitoring
• Preferences for Customary Routine Activities
• Functional Status ADLs, Balance

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Clinical Sections of MDS

• Bladder Bowel
• Catheter use
• Bowel/bladder meds justification/indication,
  monitoring
• Constipation possible ADR/MRP
• Active Disease Diagnosis
• Indication clarification, f not present elsewhere
• Contraindications
• Untreated indications

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Clinical Sections of MDS

• Health Conditions
• Pain justification/indication for analgesics,
  untreated indication, monitoring
• SOB monitoring COPD, HF meds
• Tobacco use
• Prognosis, less than 6 months
• Acute/short-term conditions possible ADR/MRP
• Falls history possible MRP if Hx, alter drug
  choice

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Clinical Sections of MDS

• Swallowing/Nutritional Status
• Height and Weight
• Swallowing difficultiesdo meds need to be
  crushed?
• Weight loss possible ADR/MRP
• IV fluids, TPN
• Enteral feeding medication administration via
  enteral tubes
• Oral/Dental Status

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Clinical Sections of MDS

• Skin Conditions
• Pressure ulcer risk medications that may
  interfere with or promote wound healing
• Oral vitamins to promote wound healing Question
  M1200-D
• Topical meds
• Medications

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Clinical Sections of MDS

• Special Treatments and Procedures
• Chemo
• Respiratory Tx
• IV meds
• Dialysis
• Hospice
• Vaccines influenza and pneumococcal
• Therapies Restorative Nursing Care
• How often MD orders have changed
• Physical Restraints

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Clinical Sections of MDS

• Participation in Assessment and Goal Setting
• Residents expectations/goals
• Discharge plan
• Care Area Trigger (CAT) Summary (previously known
  as RAPs)
• Prior BIMS, PHQ-9 scores
• CATs can MRPs

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Assessment Questions

• 1. The MDS stands for
• Minimum Drug Standards
• Maximum Daily Supply
• Minimum Data Set
• Minimum Drug Supply

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Assessment Questions

• 2. T/F. The MDS is filled out every time a
  resident experiences a significant change in
  condition.
• a) True
• b) False

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Assessment Questions

• 3. Pharmacists can use the MDS data during their
  medication regimen review to identify residents
  with
• Untreated indications
• Medication-related problems
• Unnecessary medications, as defined by F-Tag 329
• All of the above

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Assessment Questions

• 4. The MDS 3.0 will be/was finalized by
  _____, and will be implemented in _____.
• a) October 2008, October 2009
• b) October 2009, October 2010
• c) October 2010, October 2011

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Assessment Questions

• 5. Based on the DRAFT MDS 3.0, which of the
  following medications will be newly tracked or
  documented? (more than one answer may be correct)
• a) Diuretics
• b) Antibiotics
• c) Anticoagulants

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Assessment Questions

• 6. In which of section of the MDS might you find
  a height and weight for a resident, if not found
  elsewhere in the chart?
• a) Section A Identification Info
• b) Section G Functional Status
• c) Section J Health Conditions
• d) Section K Swallowing/Nutritional Status

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Thank you!!---------------------------------Ques
tions?