MDS 3.0CAT’s, CAA’s, & Care Plans

Ellen-Jean Butler RD LDN CSGVice President of Quality of Life and Nutrition

ServicesSunBridge Healthcare

December 3, 2010

Learning Objectives‣Review MDS 3.0

‣Review MDS 3.0 section K

‣Review and discuss CAT’s & CAT logic

‣Review and discuss CAA’s

‣Review and discuss care plan development

MDS 3.0

• Effective October 1, 2010

• RUGS IV also implemented (surprise!)

• Transition from 2.0 to 3.0 created a huge churn with Medicare assessments

• Working through OBRA assessments

• How did it go?

MDS 3.0 Overview• Captures the “resident’s voice”

• Shift from staff observation to resident interview and record review

• Interviews include cognitively impaired residents

• Supports increased individuality and accuracy of care

• Supports quality of care and culture change

Resident Assessment Instrument• Three components:

• Minimum Data Set (MDS) Version 3.0

• A collection of basic physical, functional, psychosocial information about residents

• Care Area Assessment Process

• Provides a framework for guiding the review of triggered areas, and clarification of a resident’s functional status and related causes of impairment.

• RAI Utilization Guidelines

• Instructions for when and how to use the RAI

• Provides the foundation for integrating the MDS and other clinical information

Minimum Data Set• Starting point

• Standardized instrument to assess nursing home residents. Collection of information:

• Basic physical – medical conditions, mood, vision, etc.

• Functional – ADL’s, behavior

• Psychosocial – preferences, goals, interests.

• Identifies actual or potential areas of concern

• Does not constitute a comprehensive assessment

Section K: Swallowing/Nutrition Status

• K0100

• Loss of liquids/solids from mouth when eating or drinking

• Holding food in mouth/cheeks or residual food in mouth after meals

• Coughing or choking during meals or when swallowing medications

• Complaints of difficulty or pain with swallowing

• None of the above

Section K: Swallowing/Nutrition Status

• K0100: Swallowing Disorder

• Observation of the residents

• Interview with resident and staff

• Medical record review

• Identifies “possible swallowing disorder”

• Not an assessment

K0100: Swallowing Disorder

• K0100 coding

• Do not code if interventions have been successful in treating the problem

• Code even if the symptom occurred only once in the 7 day look back

K0200 Height & Weight• Measured on admission (not stated or

hospital weight!)

• Height in inches to the nearest whole inch and measured annually

• Weight in pounds

• Mathematical rounding is used for both

• For subsequent assessments enter the last weight taken within 30 days of the ARD

• If last recorded wt is > 30 days from ARD - reweigh

K0300: Weight Loss• Loss of 5% in the last month or loss of 10%

or more in the last 6 month

• 1. No or unknown

• 2. Yes, on physician prescribed weight loss regimen

• 3. Yes, not on physician prescribed weight loss regimen

• Note: mathematical rounding of weight to the nearest whole pound is done prior to calculating % change.

K0300: Weight Loss• Compares the residents weight in the

current observation period with his/her weight at two snapshots in time.

• At a point closest to the 30 days preceding the current weight

• At a point closest to 180 days preceding the current weight

• This item does not consider weight fluctuation outside of these two time points.

K0300: Weight Loss• New admissions

• Interview resident, family, or significant other about wt loss at 30 and 180 days

• Consult physician, transfer documents

• If the admission weight is less than prior wt, calculate change

• Subsequent assessments

• Compare current weight to prior wt in medical record

K0300: Weight Loss• Physician prescribed weight loss regimen

• A weight reduction plan ordered by the MD with the care plan goal of weight reduction

• May include calorie controlled or other weight loss diets and exercise.

• Includes planned diuresis.

• It is important that the weight loss is intentional

K0300: Weight Loss• Calorie restricted or diabetic diet plan to

control blood sugar without inducing weight loss is not coded as MD prescribed wt loss.

• Amputation

• Adjusted calculation

• Calculate weight loss % based on the current wt +wt of amputated limb vs. prior weight.

K0500: Nutritional Approaches• K0500A, parenteral/IV feeding

• Includes any and all nutrition and hydration received by the nursing home resident in the last 7 days, in the nursing home or at the hospital, provided they were administered for nutrition or hydration.

• Supporting documentation must be noted in the medical record

• Includes IV’s, TPN, hypodermoclysis

• Can be coded if used to prevent dehydration

K0500: Nutritional Approaches

• K0500B, feeding tube

• Should not be coded as a mechanically altered diet

• Should only be coded as K0500D, Therapeutic diet when the enteral formula is altered to manage a problematic health condition, e.g diabetes

K0500: Nutritional Approaches

• K0500C, Mechanically altered diet

• A diet specifically prepared to alter the texture or consistency of the food to facilitate oral intake.

• Should not be automatically considered a therapeutic diet

• K0500D, Therapeutic diet

• Altered nutrient content of diet to manage a problematic health condition

K0700: Percent Intake by Artificial Route

• K0700A, proportion of total calories the resident received through parenteral or tube feeding

• Calculate based on 7 day look back

• Calculate the proportion of total calories from IV or tube feeding.

• Code:

• 1. 25% or less

• 2. 26% to 50%

• 3. 51% or more

K0700:Nutrtional Approaches

• K0700 B, Average fluid intake per day by IV or tube feeding.

• Calculate based on 7 day look back

• Code for the average number of cc’s received, not ordered.

• Code 1 for 500 cc/day or less

• Code 2 for 501 cc/day or more

Care Area Triggers• Upon completion of the MDS, a set of Care

Area Triggers are identified (CAT’s)

• Flag for IDT that the triggered area needs to be assessed more completely

• 20 Care Area Triggers

• Triggers are based on CAT logic

• Most facilities will use software programs that match the trigger definitions for identification

CAT Logic• Nutrition Status CAT Logic Table

• Dehydration as indicated by: J1550C=1

• BMI is too high or too low: BMI<18.5 or BMI>24.9

• Any weight loss as indicated: K0300=1 or K0300=2

• Parenteral/IV feeding is used: K0500=1

• Mechanically altered diet is used: K0500C=1

CAT Logic

• Nutrition continued

• Therapeutic diet is used; K0500D=1

• Resident has one or more unhealed pressure ulcers at stage 2 or higher, or unstageable:

• Section M0300

Care Area Assessment• Must be a standardized tool. Specific tool is

not mandated

• Must be completed within 14 days of admission.

• Required only for OBRA comprehensive assessments (admission, annual, significant change, sig change correction prior to full.)

• Not required for Medicare PPS assessments (except when combined with OBRA comprehensive assessment)

Care Area Assessment• The CAA process provides a framework for

guiding review of triggered areas.

• Provides clarification of the resident’s functional status and related causes of impairment.

• Provides a basis for additional assessments of potential issues and related risk factors.

• Provides information for the development of and individualized care plan

Care Area Assessments• Delirium

• Visual function

• ADL functional rehab potential

• Psychosocial wellbeing

• Falls

• Feeding tubes

• Dental care

• Psychotropic meds

• Pain

• Cognitive loss/dementia

• Communications

• Urinary incontinence

• Mood state

• Activities

• Nutritional status

• Dehydration/fluids

• Pressure ulcer

• Physical restraints

• Return to community

CAA 12. Nutritional Status• Identifies triggering conditions

• Analysis of findings section:

• Problem actual or potential?

• Includes MDS elements and other data points

• Current eating pattern

• Functional problems

• Cognitive, mental status, and behavior problems that interfere with eating

CAA 12. Nutritional Status• Communication problems

• Dental/oral problems

• Other diseases and conditions that can affect appetite or nutritional needs

• Abnormal laboratory values (from clinical record)

• Medications

• Environmental factors

• Resident/family representative input

CAA 12. Nutritional Status• Care Plan Considerations

• Will nutritional status be addressed in the care plan? Y or N

• If yes, what is the overall objective

• Improvement

• Slow or minimize decline

• Avoid complications

• Maintain current level of function

• Minimize risk

• Symptom relief or palliative care

CAA 12. Nutritional Status• Describe impact of this problem/need on the resident

and your rationale for the care plan decision.

• Simple summary statement

• Description of the problem

• Causes and contributing factors

• Risk factors related to the care area

• Do not need to make duplicative medical record entries

• Can refer to comprehensive nutrition assessment

• Referral to another discipline

• Explain rationale for decision not to proceed with care planning

Care Planning• MDS (data collection) + CAA’s (decision

making) = Care plan development

• Goal is to promote the resident’s highest practicable level of functioning.

• Goals may be:

• Improvement – building on strengths

• Maintenance

• Prevention – managing risk factors

• Palliation

Care Planning• Care plans may be for actual or

potential areas of concern

• Must address the medical, nursing, and psychosocial needs of the resident

• Approaches must include precise and concise instruction to staff for care delivery

• Must include measurable objectives, time frame, and outcome of care

CAA link to Care Plan

• Medical needs:

• Dental/oral

• Disease conditions that affect appetite or nutrition needs

• Abnormal labs

• Medications

CAA link to Care Plan

• Nursing

• Functional problems

• Communication

• Environmental factors

• Psychosocial

• Current eating patterns

• Cognitive/mental/behavioral

RAI & Nutrition Care Process

• Problem identification process is the same

• Assessment process is the same

• Nutrition diagnosis and standardized language – problematic!

Survey experience

• Limited time frame

• No obvious issues here

• Your experience?

Questions?

• Thank you for sharing your morning with me. Best wishes for a joyous holiday season!