MDS 3.0IMPLICATIONS FOR RECREATIONAL THERAPY

Presented byLinda L. Buettner, PhD, LRT, CTRS, FGSAUniversity of NC at Greensboro

Goals

Participants will be able to:

1) Verbalize the changes in MDS 3.0 that impact on resident care and QOL,

2) Identify five clinical areas on the MDS 3.0 with major revisions and describe roles for recreational therapy,

3) Detail assessment and interview techniques and documentation opportunities for RT beginning in October 2010 with MDS 3.0.

History of the MDS

1986- IOM release report on quality of care in nursing homes

1987- OBRA ‘87 was passed, requiring complete assessment

1991- First MDS was introduced 1997- MDS 2.0 was introduced 2003- CMS contracts for revising to MDS 3.0 2007- CMS announces implementation plan October 2010- Implementation of MDS 3.0

Goals of the MDS 3.0

Improve clinical relevance and accuracy Increase resident voice Improve user satisfaction Increase efficiency of reports Maintain program ability of CMS

Benefits of the MDS 3.0

Larger font Fewer items per page Definitions printed directly on form Increased accuracy Increased clarity of questions Gives resident a voice through interviews Listens to resident concerns Reduced completion time by 45%

Assessment Timing

For OBRA-required assessments, regulatory requirements for each assessment type dictate assessment timing, the schedule for which is established with the Admission (comprehensive) assessment when the ARD is set by the RN assessment coordinator and the Interdisciplinary team (IDT).

Assuming the resident did not experience a significant change in status, was not discharged, and did not have a Significant Correction to Prior Comprehensive assessment (SCPA) completed, assessment scheduling would then move through a cycle of three Quarterly assessments followed by an Annual (comprehensive) assessment.

Sections with Major Revisions

Cognitive/ Delirium Mood Behavior Customary Routine & Activities Pain Assessment

Plus RT is now in Section O.

Section C. Cognitive Patterns (2 parts)

Brief Interview for Mental Status (BIMS) Repetition of three words Temporal orientation: year, month, day Recall

Staff Assessment for Mental Status CAM- delirium

Inattention Disorganized thinking Altered level of consciousness Psychomotor retardation

Potential RT Interventions Brain Fitness* Animal Assisted Therapy * Bibliotherapy Reminiscence* Card Games Matching Games Geography Map Games Board Games Computer based interventions

*Evidence-based intervention

Mood- PHQ-9

Little interest or pleasure in doing things Feeling down, depressed, or hopeless Trouble falling or staying asleep, or sleeping too much Feeling tired or having little energy Poor appetite or overeating Feeling bad about yourself- or that you are a failure or have let

yourself or your family down Trouble concentrating on things such as reading the newspaper or

watching television Moving or speaking so slowly that other people could have noticed.

Or the opposite- being so fidgety or restless that you have been moving around a lot more than usual

Thoughts that you would be better off dead or of hurting yourself in some way

Potential Interventions for Mood

Exercise* Creative Arts* Wheelchair Biking* Reminiscence* Animal assisted therapy* Life Review* Wheelchair Biking* Relaxation* Cognitive Bibliotherapy*

*Evidence-based intervention

Behavioral Symptoms Behavioral Symptoms

Physical behavioral symptoms directed towards others

Verbal behavioral symptoms directed towards others Other behavioral symptoms not directed towards

others

Impact on resident Impact on others Wandering

Presence & Frequency Impact on others

Potential Interventions

Simple Pleasures Items* Music Interventions* Life Stories* Air mat Therapy* Relaxation* Cognitive Stimulation* Social Dance Club* Expressive Arts* Gardening/ Horticulture*

*Evidenced-based intervention

Customary Routine and Activities

New interview questions replace 20 Customary Routine staff assessment items for residents who can be interviewed.

• Current importance rating replaces “check all that apply in the past year.”

• New interview for activities preference replaces12 staff assessment items for residents who can be interviewed.

Customary Routines and Activities (continued)

• New question on whether the resident wants to talk about returning to the community.

• Staff Assessment of Activity and Daily Preferences is completed only for residents who cannot complete interview.

There are major changes to several items, and staff are instructed to observe resident response during exposure to activity.

The Interview for Section F.

Can resident “Make self Understood”? Does resident need an interpreter? Code 0, no --- Code 1, yes

This is what you say:

I’d like to ask you a few questions about your daily activities. The reason I am asking you these questions is that the staff here would like to know what’s important to you. This helps us plan your care around your preferences. We want to make your stay as personal as possible”

What you say next:

I am going to ask you how important various activities and routines are to you while you are in this home. I will ask you to answer using the choices you see on this card”

READ the choices

Tips

Code 9, no response or non-responsive If 3 nonsensical responses STOP

Let’s practice

Q. How important is it to you to choose what clothes to wear?

A. “It’s very important. I’ve always paid attention to my appearance”

How would you code this?

Coded 1, very important

New resident – same question

“I leave that up to the nurse. You have to wear what you can handle if you have a stiff leg”

You probe: “you leave it up to the nurses” would you say that, while you are here, choosing what clothes to wear is [pointing to cue card] ……

A. “Well it would be important to me but I just can’t do it”

Code it - 5

How important is it to you to take care of your personal belongings or things?

A. “It is somewhat important. I’m not a perfectionist, but I don’t want to have to look for things”.

Coding? 2, somewhat important Another A. “All my nice things are at home” Clarify “your most treasured things are at home. Do

you have other things here that are important to take care of?”

A. My son gave me this CD player. It is very important to me.

Code-1, very important

Then go on to Activity Preferences

How important is it to you to have books, newspapers, and magazines to read?

How important is it to you to listen to music you like?

How important is it to you to be around animals such as pets?

Same coding

Functional StatusActivities of Daily Living Bed mobility Transfer Toilet transfer Toileting Walk in room Walk in facility Locomotion

Dressing upper body Dressing lower body Eating Grooming/ personal

hygiene Bathing

Coding ADLs

0- Independent 1- Set up assistance 2- Supervision 3- Limited assistance 4- Extensive assistance- 1 person assist 5- Extensive assistance- 2+ person assist 6- Total assistance- 1 person assist 7- Total assistance- 2+ person assist 8- Activity did not occur

Balance During Transitions & Walking

Moving from seated to standing Walking Turning around and facing the opposite direction

while walking Moving on and off toilet Surface to surface transfer

Potential Interventions Exercise Community re-entry Aquatic therapy or water exercise Walking programs

Animal assisted therapy

Balloon Volleyball Tether Ball Dancing Tai Chi

Falls Fall History on Admission

One or more times in month prior to admission One or more times in last 1-6 months prior to

admission Fracture related to fall in last 6 months

Falls since Admission or Prior Assessment Number of Falls

No injury Injury (except major) Major Injury

Potential Interventions

Air Mat Therapy* Relaxation Based* Walking programs* Exercise programs* Multi-level RT Falls Prevention* Horticulture therapy- elevated gardens

*Evidence-based interventions

Pain Assessment

Treatment Items have been added. Resident interview replaces staff observations

for residents who can report pain symptoms. Section has been added to capture the effect of

pain on sleep and day-to-day activities. Staff assessment of pain has been changed to

an observational checklist of pain behaviors and is completed only for those residents that cannot self-report.

Pain Management Scheduled pain management PRN pain management Non-medication intervention for pain Pain Assessment Interview

Any pain during the last 7 days Amount of time pain was experienced Hard to sleep at night Limited day-to-day activities

Potential Interventions

Storytelling/ Reminiscence

Bibliotherapy Somatron Airmat Therapy Relaxation Glider Rockers Animal-Assisted

Therapy* Therapy Dolls

Exercise* Chair Yoga Chair Tai Chi Aquatic Exercise/

Therapy* Life Roles Sensory Integration Expressive Arts Simple Pleasures

(comforting items)

Other Areas for Possible RT Treatment

Nutritional- weight loss Therapeutic Cooking Programs

Medications- psychotropic medications Programs to decrease disturbing behaviors

Restraints Fall reduction programs Interventions to improve gait and balance

Nursing Rehabilitation/ Restorative Care Return to Community

Community Reintegration Programs

Special Treatments & Procedures

Requirements for RT Treatment: This just doesn’t happen!

CMS Definition

“Therapy ordered by a physician that provides therapeutic stimulation beyond the general activity program in a facility and physician ordered services which must include the frequency, duration, and scope of treatment.”

-CMS

MDS 3.0 RAI Manual

CMS Requirements

Reasonable expectation for improvement Treatment services designed to restore, rehabilitate, or

remediate to improve functioning and independence as well as to reduce or eliminate the effects of illness or disability (ATRA)

Limited group size (1:4) Must be provided by CTRS Physician-ordered treatment

Scope of treatment Frequency Duration

RT Process Receive referral Obtain physician’s order for evaluation Assess client using valid, reliable tools Obtain physician’s order for treatment Establish care plan Implement treatment plan

Treatment notes

Re-evaluate using same form as assessment Continue, D/C, or revise the care plan as

needed.

Sample Order

Physician’s Order: RT: Aquatic exercise 45 minutes qday 2 x qweek for 6 weeks for increased endurance and reduction of pain symptoms.

Care Plan

EXAMPLE: I will walk 50’ daily with the help of one NA the next 30 days in order to maintain continence and eat in the dining room.

Subject Mr. Jones OR I Verb will walk Modifiers fifty feet daily with the help of one

nursing assistant Time frame the next 30 days Goal in order to maintain continence and eat in the

dining area

Documentation Develop flow sheet to monitor progress

during session Develop progress note form to help with

consistency Develop a decision tree for: continuation of

treatment, modification of treatment, or discharge.

If an intervention is NOT given document why.

Recreation Therapy Progress Note: Aquatic exercise

Date:__________Time:___________

Mobility/Endurance: Check all behaviors that apply

______Patient performs walking exercises in shallow water pool for ____minutes before rest

______Patient uses floatation device to tread water for 3-5 minutes

______Patient verbalizes awareness of decrease in pain. Pre pain____Post pain____

______Patient ambulates to/from locker room x____feet with_______assistive device

Social Interactions: Check all behaviors that apply

______Patient initiates greeting to therapist and other patients

______Patient initiates conversation with questions with other patients during rest

______Patient verbalizes desire to meet outside of pool session with other patients

______Patient demonstrates bright/flat/depressed/guarded/labile/lethargic/sad/tearful/anxious affect

Therapy Participation: Check all behaviors that apply

______Patient participates for ______minutes without prompting

______Patient attends session with limited participation

______Patient refused to participate/did not complete session

______Patient is disruptive to the session

Check Your Understanding

On the next slide you will find an example scenario of how a recreation therapist would utilize the MDS 3.0 to come up with a treatment plan.

Following that you will be given 3 scenarios for which you will: a) write the RT order. b) propose an intervention. c) write the care plan goal, d) propose an evaluation method.

Example (Delirium Section C 1300)

Scenario: Mr. Jones is a new admission to the post-acute care unit of your nursing home. He was treated for a hip fracture and was started on hospital based rehabilitation before being discharged to your facility. In his MDS 3.0 interview it became clear Mr. Jones had delirium and poor concentration.

Inattention and disorganized thinking each scored a “2” indicating delirium.

You get a request for RT treatment for mentally stimulating activities from the physician in your facility.

Example (continued) RT order: RT for poor concentration 2x per day for 5 days.

Proposed RT intervention: Use brief interactive cognitive activities twice per day until delirium symptoms improve.

Evidence: (Fitzsimmons (2008) Brain Fitness, Venture Publishing and http://www.annalsoflongtermcare.com/article/8317 Instituting Cognitive Rehabilitation in Post-Acute Care524-7929 VOLUME: 16 PUBLICATION DATE: Feb 01 2008)

Plan: Mr. Jones will focus on each cognitive activity for 30 seconds with cuing from RT twice each day for 5 days to increase concentration.

Proposed evaluation: re-interview using MDS CAM questions (Section C.1300) daily. Note time engaged and attention on task during each RT session. Note in chart daily until resolved.

Test Yourself (Section D)

Scenario: Ms. Fang is a new admission to your nursing home from her home of 60 years within the local community. She recently took a fall that caused a fractured humerous and because of that her family decided nursing home placement was best for her at this stage in her life. MDS 3.0 coded her as a person with moderate depression.

You get an order from the physician in your facility for RT treatment as a means to decrease depressive symptoms.

What does the RT order look like for Ms. Fang? What is your proposed RT intervention for Ms. Fang? (with

evidence to support this) What is your plan? What is your proposed evaluation plan for Ms. Fang?

Test Yourself (Section E)

Scenario: Mr. Jenkins is a resident on the dementia care unit of your nursing home who exhibits daily behaviors of rummaging. MDS 3.0 codes him as an individual with behavioral symptoms not directed toward others but his behavior significantly invades the privacy and activity of others. The nurse manager requests an RT referral.

You get an order from the physician in your facility for RT treatment as a means to decrease rummaging behavior.

What does the RT order look like for Mr. Jenkins? What is your proposed RT intervention for Mr.

Jenkins? (with evidence to support this) What is your proposed evaluation plan for Mr.

Jenkins?

Test Yourself (Section G)

Scenario: Ms. Smith is a new resident on the rehabilitation unit of your nursing home. She is currently recovering from the effects of a CVA that left her with decreased upper extremity range of motion on the right side. She is not motivated in PT or OT.

You get a request from the physician in your facility for RT treatment as a means to increase range of motion in the upper extremities.

What does the RT order look like for Ms. Smith? What is your proposed RT intervention for Ms. Smith?

(with evidence to support this) What is your proposed evaluation plan for Ms. Smith?

Working case 1:

Mr. Beefit, 80, is a skilled nursing home patient, who is admitted to the hospital with a new acute cardiac condition. He stays 7 days and is returned to the post-acute rehab unit with de-conditioning and depression. Lifestyle: outdoorsman.

Which section of the MDS would help you find his other active diseases?

Where would you find his mood symptoms?

Working case 2: Mrs. Right., 85, is recovering in your post-

acute care wing from a CVA and left hemiparesis. She also has a history of cognitive impairment. Lifestyle: Childcare and pets as passions in retirement. Former teacher.

What section of the MDS would provide you with cognition details you will need for your RT intervention planning?

Working case 3: Mr. P., 72, was transferred to your unit after a 14

day inpatient psychiatric stay. He has chronic PTSD and moderate dementia; has given up on his ADLs but is belligerent with care providers. He was referred to RT for behavioral interventions. Lifestyle: life long military mechanic, divorced, wants to live in community.

Where would you find details on behaviors? Which section of the MDS would provide you with

his function in the area of continence? Which section of the MDS provides community

preference information?

Working case 4:

Mrs. Hippie, 89, a long time resident from Mississippi has returned from the hospital after a hip replacement and is moaning and reporting little people walking on her ceiling overhead.

What two sections of the MDS should you review as they most probably have changed?

Resources

N.E.S.T. approach for disturbing behaviors in dementia (Venture Publishing)

Brain Fitness (Venture Publishing) Recreational Therapy for the Treatment of

Depression in Older Adults: A Clinical Practice Guideline (Weston Medical Publishing)

RT in the Nursing Home (ATRA Publication) Falls Monograph (ATRA publication)

Resources ARROW (Active Recreational Resources for

Optimal Wellness) website: www.uncg.edu/rth/arrow/arrow.html

Centers for Medicare and Medicaid Services- www.cms.gov

For MDS 3.0 Information: http://www.cms.hhs.gov/NursingHomeQualityInits/25

_NHQIMDS30.asp

Iowa Geriatric Education Center- Geriatric Assessment Tools: http://www.healthcare.uiowa.edu/igec/tools/default.asp