Nutrition Connection: MDS 3.0: Embracing Changes for Resident-Centered Care

(reprinted from Dietary Manager, October 2011)

The Centers for Medicare & Medicaid Services (CMS) spent almost a decade deciding how to improve MDS 2.0. MDS 2.0 was a huge undertaking designed to formalize the assessment process and provide tools to use in the development of care plans and to improve care delivery. MDS 3.0 takes the process to the next level. MDS 3.0 was implemented October 1, 2010. For most facilities, it was a steep learning curve transitioning from ‘the way we have always done it with MDS 2.0’ to a new way of looking at resident-centered care. Perhaps we forgot how difficult it was to learn MDS 2.0 back in 2000!

CMS Goals for MDS 3.0
CMS identified several goals for MDS 3.0 to include:

• To improve the clinical relevance and accuracy of MDS assessments
• To increase the voice of residents in assessments
• To improve user satisfaction
• To improve the efficiency of the reporting process

MDS 3.0 was tested in over 70 nursing homes in eight states to determine if its initial goals were achieved. The national trial demonstrated a resounding success for all its goals. In addition, it took about 45 percent less time to complete MDS 3.0!

MDS 2.0 vs. MDS 3.0
There are many differences between MDS 2.0 and MDS 3.0. Here are some of the key changes:

• Standardized ‘look back dates’
• Assessment Reference Date (ARD)—last day of observation period
• Resident interviews to complete in these sections:
  • Cognitive Patterns—Section C
  • Mood—Section D
  • Preferences for Customary Routine & Activities— Section F
  • Pain—in Health Conditions—Section J
  • Return to Community/Overall Goals—Section Q
• RAPs become the CAAs
• New CAAs: Pain & Return to Community

MDS 3.0 integrates nutrition-related issues into many sections beyond Section K. These include:

• Section D
  • D0200e Poor appetite or overeating (resident interview)
  • D0500e Poor appetite or overeating (staff assessment)
• Section F
  • F0400D interview Daily Preferences Snacks between meals
  • F08000G Customary Routines/Preferences Snacks
  • F08000H Customary Routines/Preferences Staying up past 8 p.m.
• Section i
  • i5600 Malnutrition
• Section J
  • J1550 Dehydrated
  • J1700 Fall history
• Section M
  • M1200D nutrition or hydration intervention to manage skin problems

One thing that has not changed is that a registered nurse (RN) is required to conduct/coordinate individual assessments to complete MDS 3.0. The assessment includes observations, interviews with all shifts of direct care staff, and interviews with each resident. CDMs may be asked to conduct interviews or sections of MDS 3.0 other than Section K. The RN responsible for the MDS assessment uses the RAi guidelines to set the dates when the MDS, CAAs, and care plan must be completed. Just like in MDS 2.0, the coded responses on MDS 3.0 will trigger Care Areas that require further assessment called Care Area Assessments (CAAs).

There are 20 CAAs in MDS 3.0 noted below. The CAAs challenge the CDM to look at the ‘big picture’ to see how multiple triggered conditions are related. Looking for cause and effect relationships helps the CDM determine if more information is needed, or perhaps the triggered condition does not affect the resident’s function and quality of life. The CAAs serve as the framework for the care plan.

CAAs in RAI, version 3.0

Written documentation of the CAAs findings and decision-making process may appear anywhere in the resident’s medical record. The CAA documentation helps to explain the basis for the care plan by showing how the IDT determined underlying causes, contributing factors, and risk factors to develop an individualized care plan. Use the ‘Location and Date of CAA Documents’ column on the CAA Summary (Section V MDS 3.0) to keep track of the specific location where the CAA information and decision-making documentation can be found. Also note the column ‘Care Planning Decision- Addressed in Care Plan’ to indicate whether the triggered care area is addressed in the care plan. These two sections provide a ‘paper trail’ to the original source of the information.

CAT Logic & Triggering Conditions
Undernutrition is not a response to normal aging, but it can arise from many causes, often acting together. It may cause or reflect acute or chronic illness, and it represents a risk factor for subsequent decline. Triggering conditions associated with undernutrition include nutritional status, feeding tubes, dehydration and fluid maintenance, dental care, and pressure ulcer.

Nutritional Status
The Nutritional Status CAA process reflects the need for an in-depth analysis of residents with impaired nutrition and those who are at nutritional risk. This CAA triggers when a resident has or is at risk for a nutrition issue/condition. Some residents who are triggered for follow-up will already be significantly underweight and thus undernourished, while other persons will be at risk of undernutrition. This CAA may also trigger based on loss of appetite with little or no accompanying weight loss and despite the absence of obvious, outward signs of impaired nutrition.

Feeding Tubes
The Feeding Tubes CAA focuses on the long-term (greater than one month) use of feeding tubes. It is important to balance the benefits and risks of feeding tubes in individual residents in deciding whether to make such an intervention part of the plan of care. In some acute and longer term situations, feeding tubes may provide adequate nutrition that cannot be obtained by other means. In other circumstances, such as in individuals with advanced dementia, feeding tubes may not enhance survival or improve quality of life. Moreover, feeding tubes can be associated with diverse complications that may further impair quality of life or adversely impact survival. For example, tube feedings will not prevent aspiration of gastric contents or oral secretions, and feeding tubes may irritate or perforate the stomach or intestines.

The care plan should address the resident’s status and underlying issues/conditions that necessitated the use of a feeding tube. In addition, the CAA information should be used to identify any related risk factors.

Dehydration/Fluid Maintenance
Dehydration is a condition in which there is an imbalance of water and related electrolytes in the body. As a result, the body may become less able to maintain adequate blood pressure and electrolyte balance, deliver sufficient oxygen and nutrients to the cells, and process waste products. In older persons, diagnosing dehydration is accomplished primarily by a detailed history, laboratory testing (e.g., electrolytes, BUN, creatinine, serum osmolality, urinary sodium), and to a lesser degree by a physical examination. Abnormal vital signs, such as falling blood pressure and an increase in the pulse rate, may sometimes be meaningful symptoms of dehydration in the elderly. When this CAA is triggered, the focus of the care plan should be to prevent dehydration by addressing risk factors, to maintain or restore fluid and electrolyte balance, and to address the underlying cause or causes of any current dehydration.

Dental Care
The ability to chew food is important for adequate oral nutrition. Having clean and attractive teeth or dentures can promote a resident’s positive self-image and personal appearance, thereby enhancing social interactions. Medical illnesses and medication-related adverse consequences may increase a resident’s risk for related complications such as impaired nutrition and communication deficits. The dental care CAA addresses a resident’s risk of oral disease, discomfort, and complications. It is triggered when a resident has indicators of an oral/dental issue/condition. The focus of the care plan should be to address the underlying cause or causes of the resident’s dental problems and/or conditions.

Pressure Ulcer
The CAA for Pressure Ulcer requires an interdisciplinary approach including nutrition care services. The individualized care plan will be written by nursing with input from the CDM or RD. It is based on the status of a resident’s pressure ulcer(s) and related causes and contributing and/or risk factors to skin breakdown. If a pressure ulcer is not present, the goal is to prevent them by identifying the resident’s risks and implementing preventive measures. If a pressure ulcer is present, the goal is to heal or close it. For some individuals at the end of life, the goal may include comfort care and pain management.

When any of the CAAs are triggered, nursing home staff should follow their facility’s chosen protocol or policy for performing the CAA. The care plan outlines the steps by which care will be delivered.

When is the RAI Not Enough?
Experienced CDMs and RDs know that sometimes nutrition-related problems exist, but the care area does not trigger. It may be due to a coding error, an oversight, or some other reason. CDMs and RDs have a duty to address all nutrition-related care areas whether they trigger or not. Federal Quality of Care regulation requires that “each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care” (42 CFR 483.25 [F 309]). This means facilities are responsible for assessing and addressing all care issues that are relevant to individual residents, regardless of whether or not they are covered by the RAI (42 CFR 483.20(b)), including monitoring each resident’s condition and responding with appropriate interventions.

The completed Resident Assessment instrument is not a diagnostic tool and may not address all possible issues that require interventions to successfully manage the care of individual residents. The MDS may not trigger every relevant issue and not everything the MDS triggers is necessarily clinically significant or requires an intervention. Even if the MDS does not trigger a particular care area, the CDM or RD can use the CAA process to further assess the resident.

Implications for Practice
The guiding principle undergirding every aspect of MDS 3.0 is to ensure resident rights. The RAI Manual and other CMS documents go into great detail describing aspects of resident’s rights. Included in those rights are the right to choose a treatment plan, the right to participate in decisions and care planning, and the right to refuse treatment including a therapeutic diet or consistency-modified diet. As healthcare professionals, CDMs have a duty to honor resident wishes and ensure their rights are preserved in the healthcare unit.

By Mary D. Litchford, PhD, RD, LDN

Mary Litchford, PhD, RD, LDN is a nationally-recognized speaker and the author of various articles and books, including Common Denominators of Declining Nutritional Status.