It has been said that, “A little bit goes a long way”. And, as an industry, that little bit has been quite a lot as we have geared up for and implemented the PDPM. I for one am feeling the effects of the long way this “little bit” has taken us. Now that we have just begun to adjust to the realities of this new payment system, it’s time to gear up for a “little bit” more.
In the spring of 2019, as we were in the throes of preparing to cross the PDPM threshold in October, CMS quietly spent two thirds of the FY 2020 Proposed Rule introducing us to Standardized Patient Assessment Data Elements or SPADEs. SPADEs is a catchy acronym that encapsulates all of the elements that will ultimately be included in the assessment tools for all Post-Acute providers (SNF, Home Health, LTCH, IRF) so that places of care can be compared, “apples to apples”, and so that there can be more robust interoperability. This is the IMPACT Act in action via Quality Reporting.
Please see our blog on the proposed rule here for a complete analysis of the then proposed SPADEs. Also, as you begin to get up to speed regarding the specifics, the Proposed Specifications for SNF QRP Quality Measures and Standardized Patient Assessment Data Elements, located here, will be essential. The importance of getting ahold of this now is that the MDS 3.0 data set has been revised to accommodate all of the SPADEs that were introduced in the Proposed Rule as well as revised and a new QRP measures. A DRAFT version of the MDS has been posted here. This version, v1.18.0, is slated to become effective October 1, 2020.
This is the biggest revision to MDS 3.0 since MDS 3.0. The DRAFT comprehensive assessment is 61 pages in length, an increase of 10 pages from the current 51. Make no mistake about it, the leap to be skilled at completing this revised tool will take some time so the sooner you get started the better. As my mom always used to say, “no rest for the weary”. The PDPM is here and we continue to assimilate. The new game we now have to learn is SPADEs.
A very significant change to the MDS is the elimination of most of Section G in federally required assessments. Functional limitation in range of motion and mobility devices have been retained and added to section GG. Section GG has also been revised to add a new section that requires section GG to be assessed relative to the resident’s performance in the last 7 days. Section Q has also undergone a much-needed revision for clarity.
Along with these changes, CMS is proposing standardized patient assessment data elements for five categories specified in the IMPACT Act. These categories are:
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Cognitive function (e.g., able to express ideas and to understand normal speech) and mental status (e.g., depression and dementia)
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Special services, treatments, and interventions (e.g., need for ventilator, dialysis, chemotherapy, and total parenteral nutrition)
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Medical conditions and co-morbidities (e.g., diabetes, heart failure, and pressure ulcers)
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Impairments (e.g., incontinence; impaired ability to hear, see, or swallow)
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Other categories as deemed necessary by the Secretary
The table below will introduce you to the revised new QRP measures as well as the SPADEs, cross walked with the appropriate MDS revisions that CMS recently posted to accommodate them. As you navigate his table, you would be well served to have a copy of the revised MDS 3.0 in hand. A copy of the Proposed Specifications for SNF QRP Quality Measures and Standardized Patient Assessment Data Elements might also be helpful.
| Revised QRP Measure | Revised MDS Section A |
|---|---|
| Discharge to Community–Post Acute Care (PAC); assesses successful discharge to the community from a PAC setting, with successful discharge to the community including no unplanned rehospitalizations and no death in the 31 days following discharge. This measure has been revised to exclude baseline NF residents or Residents who had a long-term NF stay in the 180 days preceding their hospitalization and SNF stay, with no intervening community discharge between the long-term NF stay and qualifying hospitalization | New MDS items at A1805 and A2105 have been added to assess for where a resident entered from and the resident’s discharge status to accommodate more specifically this revised QRP measure exclusion of baseline NF residents. |
| New QRP Measure | Revised MDS Section A |
|---|---|
| Transfer of Health Information to the Provider–Post-Acute Care (PAC); assesses for the timely transfer of health information, specifically a reconciled medication list. This measure evaluates for the transfer of information when a patient is transferred or discharged from their current setting to a subsequent provider | New items at A1805, A2105, A2121, A2122 have been added to accommodate this QRP measure. |
| Transfer of Health Information to the Patient–Post-Acute Care (PAC). This proposed measure assesses for and reports on the timely transfer of health information, i.e., a current reconciled medication list, to the patient/resident when discharged from their current setting of post-acute care | New items at A1805, A2105, A2121, A2123, 2124 have been added to accommodate this QRP measure. |
| SPADEs for Cognitive Function | Revised MDS Sections C & D |
|---|---|
| The Brief Interview for Mental Status (BIMS) | Along with the current BIMS, new MDS items at C0220, C0320, C0420 and C0520 have been added to accommodate a completion of the BIMS on discharge. |
| The Confusion Assessment Method (CAM) | Along with the current CAM, new MDS items at C1320 has been added to accommodate completion of the CAM on discharge. |
| Mental Status (Depressed Mood) PHQ-2 to 9 | New MDS items at D0150, Resident Mood Interview (PHQ-2 to 9) have been added to accommodate the new PHQ-9 format and skip patterns. New MDS items at D0120 and D0170 have been added to accommodate completion of the new Resident Mood Interview (PHQ-2 to 9) on discharge. |
| SPADEs to Assess for Special Services, Treatments, and Interventions | Revised MDS Sections K, N and O |
|---|---|
| Chemotherapy | New MDS items at O0110A1 have been added to indicate the rout of chemotherapy administration and if this was administered on admission, while a resident and at discharge. |
| Radiation | New MDS item at O0110B1 has been added to indicate Radiation Administration and if this was administered on admission, while a resident and at discharge. |
| Oxygen Therapy | New MDS items at O0110C1 have been added to indicate the type of flow of oxygen administration and if this was administered on admission, while a resident and at discharge. |
| Suctioning | New MDS items at O0110D1 have been added to indicate the timing of suctioning that is provided and if this was administered on admission, while a resident and at discharge. |
| Tracheostomy Care | New MDS items at O0110E1 have been added to indicate the that tracheostomy care was administered and if this was administered on admission, while a resident and at discharge. |
| Invasive Mechanical Ventilation | New MDS items at O0110F1 have been added to indicate the type of non-invasive mechanical ventilation that is administered and if this was administered on admission, while a resident and at discharge. |
| Non-invasive Mechanical Ventilation | New MDS items at O0110G1 have been added to indicate the type of non-invasive mechanical ventilation that is administered and if this was administered on admission, while a resident and at discharge. |
| IV Medications (Antibiotics, Anticoagulation, Vasoactive Medications, Other) | New MDS items at O0110H1 have been added to indicate the type/class of IV medication that is administered and if this was administered on admission, while a resident and at discharge. |
| Transfusions | New MDS items at O0110I1 have been added to indicate that Transfusions were administered and if they were administered on admission, while a resident and at discharge. |
| Dialysis (Hemodialysis, Peritoneal dialysis) | New MDS items at O0110J1 have been added to indicate the type of dialysis that is administered and if this was administered on admission, while a resident and at discharge. |
| IV Access (Peripheral IV, Midline, Central line) | New MDS items at O0110O1 have been added to indicate the type of IV access that was provided and if this was provided on admission, while a resident and at discharge. |
| Parenteral/IV Feeding | In addition to the choices for indicating nutritional approached provided while not a resident and while a resident, New MDS items have been added at K0520A (Parenteral/IV Feeding) to indicate whether nutritional approaches were also provided at admission and on discharge. |
| Feeding Tube | In addition to the choices for indicating nutritional approached provided while not a resident and while a resident, New MDS items have been added at K0520B (Feeding Tube) to indicate whether nutritional approaches were also provided at admission and on discharge. |
| Therapeutic Diet | In addition to the choices for indicating nutritional approached provided while not a resident and while a resident, New MDS items have been added at K0520D to indicate whether nutritional approaches (Therapeutic Diet) were also provided at admission and on discharge. |
| High-Risk Drug Classes: Use and Indication (anticoagulants; antiplatelets; hypoglycemics (including insulin); opioids; antipsychotics; and antibiotics) | New MDS items have been added at N0415 to indicate whether the resident is currently taking a high-risk medication, and if an indication for the medication is noted. A new MDS item N0425 has also been added to assess this information on discharge. |
| SPADEs to Assess for Medical Conditions and Co-Morbidities | Revised MDS Section J |
|---|---|
| Pain Interference | New MDS items at J04120, J0510, J0520 and J0530 have been added to determine more specifically how pain interferes with sleep, therapy and day-to-day activities. New MDS items at J0320, J0420, J0550, J0560 and J0570 have been added to assess for pain/interference on discharge. |
| SPADEs to Assess for Impairments | Revised MDS Section N/A |
|---|---|
| Hearing Impairments | No new MDS items or revisions. This SPADE will use the current MDS item B0200. |
| Vision Impairments | No new MDS items or revisions. This SPADE will use the current MDS item B1000. |
| SPADEs to assess for a new category: Social Determinants of Health | Revised MDS Sections A, B & D |
|---|---|
| Race and Ethnicity | New MDS items at A1005 and A1010 have been added to determine more specifically a resident’s ethnicity and race. |
| Preferred Language and Interpreter Services | New items at A1110 have been added to more specifically determine a resident’s preferred language and whether he or she needs or wants an interpreter. |
| Health Literacy | New items at B1300 have been added to help determine the resident’s health literacy, which is how often he or she needs to have help when reading written material provided by a doctor or pharmacy. New MDS item B1320 has been added to assess for health literacy on discharge. |
| Transportation | New MDS items at A1250 have been added to assess for whether a lack of transportation has kept a resident from medical appointments, meetings, work, or from getting things needed for daily living. New MDS items at A1270 have been added to assess for this on discharge. |
| Social Isolation | New MDS items at D0700 have been added to assess for social isolation, that is how often a resident feels lonely or isolated from persons around them. New MDS items at D0720 have been added to assess for this on discharge. |
Along with these changes, CMS also posted concepts of Proposed future QRP measures and SPADES that are under consideration.
