Development of MDS-Based Module for Short-stay and Clinically Intense SNF Patients, Rehabilitation Hospitals and Long Term Care

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Development of MDS-Based Module for Short-stay and Clinically Intense SNF Patients, Rehabilitation Hospitals and Long Term Care Hospitals

Since 1990, all Medicare and Medicaid certified long term care facilities have been statutorily required to use the Resident Assessment Instrument (RAI), which is comprised of the Minimum Data Set (MDS) and Resident Assessment Protocols (RAPs), to assess any individual who resides in the facility for more than fourteen days. Over the past several years, the population served by many such facilities has changed to include an increased number of individuals receiving care of a short-term, rehabilitative nature. While no parameters for defining a " short-stay " have been established, the industry has generally viewed this as approximately 30 days or less. Many providers of what the industry refers to as " subacute " care have long called for an exemption from the statutory requirement or an alternative to the RAI that is tailored more to the needs of this growing population.

The Health Care Financing Administration (HCFA) has begun work on developing an MDS-based assessment instrument for use with this population. Under contract with the Hebrew Rehabilitation Center for Aged (HRCA) in Boston, HCFA estimates a work schedule of approximately eighteen months to develop and field test the " short stay " MDS, as well as develop related training materials. During this period, HCFA expects to develop an MDS-based module consisting of core screening and assessment items, to revise existing RAPs to include content appropriate for this population, and to develop RAPs that address new clinical problems, if warranted. As the Omnibus Budget Reconciliation Act of 1987 requires all certified long term care facilities to use the MDS and RAPs, HCFA expects that some core data elements from the original MDS will be maintained, and to use the MDS " skip pattern " logic to branch into the alternative data elements.

HCFA is currently analyzing data in order to understand better the clinical characteristics of this population, as well as to determine if there are major groupings into which individuals can be categorized. One other population receiving care by " subacute " providers has been dubbed the " clinically intense. " These individuals receive care that requires skilled monitoring, is often highly technological in nature, provided over an extended period of time, and which previously may have occurred only within a hospital (e.g., individuals who are ventilator dependent). HCFA's efforts to develop an MDS-based assessment module will also address this population.

This project should be viewed in terms of the bigger picture that is evolving relative to health care quality monitoring and payment systems. As HCFA moves forward with a quality assessment and improvement agenda that is based on standardized data regarding beneficiaries' clinical characteristics and care outcomes, HCFA expects to develop standardized assessment instruments across provider types. HCFA implemented a second generation RAI, known as version 2.0 of the MDS, in January 1996. Final regulations that require long term care facilities to encode and transmit MDS data to the State are scheduled to be published mid-1997. HCFA recently issued a proposed regulation that would require certified home health agencies to use a standardized core data set (the Outcome and Assessment Information Set, OASIS) as part of the comprehensive assessment that agencies perform in planning care for clients. Additionally, HCFA is moving towards implementing case-mix adjusted prospective payment systems for services provided under the Medicare post-acute care benefit (i.e., for care provided by skilled nursing facilities, home health agencies, rehabilitation hospitals, and long term care hospitals). Standardized assessment instruments are essential information sources for such payment systems. A national prospective payment system for skilled nursing facilities that is based on the MDS 2.0 has been proposed for implementation as early as July 1998.

HCFA is examining the possibility of requiring both rehabilitation hospitals and long term care hospitals to use a standardized patient assessment instrument. As HCFA's payment system of the future evolves to become " beneficiary-centered, " HCFA expects to focus more on a beneficiary's care needs, as opposed to the characteristics of the care provider. Consequently, HCFA's goals for assessment instrumentation include the use of common data elements across providers of post-acute care services. For this reason, HCFA is studying the possibility of requiring rehabilitation hospitals and long term care hospitals to use the MDS alternative instrument in assessing their patients. It is possible that this instrument will become the foundation for prospective payment systems for rehabilitation and long term care hospitals, and so the instrument will need to be constructed accordingly.

HCFA's developmental work for the MDS-based assessment module will rely on extensive solicitation of input and feedback from all affected parties (e.g., providers, clinical disciplines/experts, and consumers). HCFA has established a technical advisory group that will provide consultation throughout the duration of the project, and will also hold focus group meetings and conduct a survey to solicit additional input from the health care community. Major associations representing skilled nursing facilities, hospital-based skilled nursing facilities, rehabilitation hospitals, long term care hospitals, clinical disciplines, and consumers will be asked to identify individuals to participate in the project.

The Minimum Data Set for Post-Acute Care (MDS-PAC) instrument is currently under development to address the needs of SNF, sub-acute, rehabilitation hospitals and long-term care hospital patients. Under contract with the Hebrew Rehabilitation Center for Aged (HRCA) in Boston, HCFA estimates a work schedule of approximately eighteen months to develop and field test the " short stay " MDS, as well as develop related training materials. For more information on the data collection and pilot and field facility testing, please see the Data Collection and Testing article which follows.

, Ph.D., is the principal investigator for HRCA. Dr. Brant Fries, University of Michigan, and Dr. Hawes, Myers Research Institute, are subcontractors to the project. , Fries, and Hawes were members of HCFA's development team for the original RAI, and headed efforts to develop version 2.0 of the RAI. Questions related to the project should be directed to HCFA project officer, Sue Nonemaker, R.N., M.S. at (410)786-6825 or E-mail snonemaker@..., or other HCFA project staff, Hake, R.N., M.S. at (410)786-3404 or E-mail chake@..., or Bob Connolly, L.C.S.W., at (410)786-6882 or E-mail rconnolly@....

A final version of the instrument and item definitions is expected to be completed by late February, 1999.

R. Kovacek, MSA, PT

KovacekManagementServices, Inc.

The FOCUS Group, Inc.

20225 Danbury Lane

Harper Woods, MI 48225

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Email Pkovacek@...

<http://www.theFOCUSgroup.net>

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