Speaking the same language: based on an interview with Robert Norcross, COO, Symphony Health Services

Nursing Homes, March, 2004 by Robert Norcross

Accurately compiling an MDS assessment is challenging enough. Having CNAs and rehabilitation therapists actually understand one another and communicate properly when assessing residents is even more difficult to achieve. Common therapist-oriented terms such as "min-assist" and "max-assist" don't match up with the MDS terminology with which CNAs are (hopefully) familiar. A therapist's reference to "contact guard" means nothing to a CNA evaluating a resident's need for standby assist.

The RAI Manual--the assessment "bible" for those compiling MDSs--is very good about defining restorative nursing and listing the services that would be performed in that discipline in language that is readily understandable by all. This is certainly important to Rehab Works, a contract therapy provider that uses tools to attempt to bridge the gap between therapy language and MDS language. Even so, in communicating the amount of support needed or the frequency or duration of an assist, language barriers can arise.

Often a CNA's documentation won't make the proper distinction between the MDS columns headed "support" and "assist" and will mis-score one or both. It may be that the resident ambulates with considerable independence after only a single, brief one-person assist. If "support" and "assist" are both given the same score in this situation--as sometimes happens--there will be serious miscom munication of the resident's status.

Interpretive difficulties can occur. For example, if a resident in bed required help lowering her feet to the floor, but was then able to rise with the aid of a walker and use the walker in dependently, some might define this as a transfer assist. If (more accurately) it is defined as a bed mobility assist, it would be scored differently on the MDS.

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Facilities are making other common errors with respect to the MDS. Two of the most frequent, in our experience, are: (1) not knowing when or how to take proper credit for the rehab/restorative services they provide by coding them appropriately--they may be providing dining services, padding, positioning, or toileting assistance that are simply not acknowledged in the MDS--and (2) second-guessing themselves in trying to meet third-party payers' perceived requirements. Even senior clinicians will disagree on what is required or on a proper score to describe a resident's status (I have seen ranges vary by as much as 7 to 13 points during quality assessment reviews).

One thing is sure: Interpretations such as these should not be required of CNAs; they have enough to do just to perform daily caregiving. They can note, by check mark or score, when someone needs an assist, but they should not be expected to analyze the assist by the resident's functional status or activity. It is the job of the staff nurse or the therapist--or both--to evaluate the duration, frequency, pace, and strength involved in the assist, so that each resident can be assessed accurately and maintained at the highest practicable level of function.

All of which explains why Rehab Works has begun a major outreach initiative with SNFs to understand how their staffs compile their MDSs, whether their scores indicate what they say they do and if there is a discrepancy, why it occurred. If a resident is reported to have had a decline in late-loss ADLs with a score change of 2 or more, for example, therapists will not only screen the resident, but communicate with the staff on their scoring process. Questions will be addressed: What was observed? Do the therapists and CNAs have to work harder to report their observations in commonly understood language? Is there a need for more staff education on recording assessments, perhaps even an in-service? Or was the discrepancy simply a matter of a new MDS coordinator coming on board and having his or her own interpretations?

But the initiative goes beyond staff discussions. RehabWorks' evaluation forms are MDS-based. Clinical specialists provide restorative-aide training for CNAs who will be administering the forms. Most importantly, the initiative involves therapists personally visiting facilities, accompanying the nurses to bedside, and saying, "Let's take a look at Mabel." They may note, for example, that whereas Mabel once required only a brief lift by one elbow to position herself on a walker, the lift today is applied with more force and duration--that Mabel has indeed experienced a decline in late-loss ADLs. However, if Mabel had been independent and suddenly became wheelchair-bound, personal observation might reveal that nothing more serious had occurred than a sprained ankle.

Personal observation of this nature doesn't have to take much time for the therapist or nurse, even if it is facility-wide. Let's say that in a 100-bed facility, 10 patients are on Medicare and require frequent MDSs, but the remaining 90 are also being tracked by an MDS. Typically, a new MDS is done every 90 days, and because these residents were admitted at different times, perhaps staff are doing 30 MDSs a month. This is not a major time commitment. Working with one facility recently via a local area network, I pulled the most recent Quality Indicators from the facility's records, identified within four minutes four people in need of personal observation, and notified the facility by phone of my findings.