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Nursing
Home Practice:
The
MDS and Behavioral Health
Since
1991, federal regulations have required that Medicare and Medicaid
certified nursing facilities perform comprehensive assessments of
all residents. The MDS
(Minimum Data Set) provides the cornerstone for this assessment and
is a critical element for patient care, quality improvement, and
reimbursement in nursing facilities. The MDS contains more than 400
data elements. Data
included are demographic variables; clinical items (including
diagnoses, syndromes, signs and symptoms, and treatments); and
indicators describing cognition, behavior, mood, psychosocial
well-being, and involvement in activities. The MDS identifies actual
or potential problem areas for each resident and forms the
foundation of development of an individualized plan of care for each
resident.
The
MDS is used not only to develop comprehensive assessments and plans
of care for nursing facility residents, but also provides
information that drives the facility survey process. The Health Care
Financing Administration (HCFA) has developed nursing home Quality
Indicators, derived from items on the MDS that indicate the presence
or absence of potentially poor care practices or outcomes in nursing
facilities. These Quality Indictors are incorporated into the
nursing facility survey process. State regulatory agencies use MDS
data to determine these potential areas of problems prior to an
on-site survey and to identify specific residents who have these
problems. It is important to note that over 1/3 of the 24 Quality
Indicators relate to behavioral health issues (see below).
The significance of
the MDS to long-term care practitioners cannot be overstated. Since
the MDS serves as the foundation for each resident’s care plan,
the MDS can also be used as a tool in determining the medical
necessity and outcome of all treatment provided.
It is essential that behavioral health practitioners in
nursing facilities ensure congruity between facility comprehensive
assessments and care plans and their own clinical assessments and
treatment. Practitioners
should integrate MDS data into their assessments and provide input
to be used by the facility care plan team during quarterly updates
of MDS information in the care planning process.
Sections of the MDS which are particularly relevant to the
behavioral health practitioner include Section B, Cognitive
Patterns; Section C, Communicating and Understanding; Section E,
Mood and Behavior Patterns; Section F, Psychosocial Well-Being; and
Section N, Activity Pursuit Patterns. Comparison of responses to MDS
questions at 90-day intervals offers a method of determining onset
of psychiatric symptoms as well as providing an independent outcome
measure during the course of treatment.
HCFA’s
Quality Indicators
QI
1 Incidence
of new fractures
QI
2 Prevalence
of falls
QI
3 Prevalence
of behavioral symptoms affecting others
QI
4 Prevalence
of symptoms of depression
QI
5 Prevalence
of depression with no antidepressant therapy
QI
6 Use
of nine or more different medications
QI
7 Incidence
of cognitive impairment
QI
8 Prevalence
of bladder or bowel incontinence
QI
9 Prevalence
of occasional or frequent bladder or bowel incontinence without a
toileting plan
QI
10 Prevalence
of indwelling catheters
QI
11 Prevalence
of fecal impaction
QI
12 Prevalence
of urinary tract infections
QI 13
Prevalence of weight loss
QI 14
Prevalence of tube feeding
QI
15 Prevalence
of dehydration
QI
16 Prevalence
of bedfast residents
QI
17 Incidence
of decline in late-loss activities of daily living
QI
18 Incidence
of decline in range of motion
QI
19 Prevalence
of antipsychotic use in the absence of psychotic or related
conditions
QI
20 Prevalence
of any antianxiety/hypnotic use
QI
21 Prevalence
of hypnotic use more than two times in the last week
QI
22 Prevalence
of daily physical restraints
QI 23
Prevalence of little or no activity
QI
24 Prevalence
of stage 1-4 pressure ulcers
The
Quality indicators in bold type directly or indirectly relate to
behavioral health problems in residents and may identify the medical
necessity of psychological and/or psychiatric treatment.
The large proportion (33%) of Quality Indicators involving
prevalence of mental health problems indicates recognition by HCFA
that good mental health is vital to good physical health.
Since Quality Indicators will be used as the starting point
for your facility survey, a high quality behavioral health program
should be considered an essential part of the care available to your
residents. ACT’s
behavioral health program can help you enhance the quality of care
for your residents and help insure regulatory compliance.
Psychotropic
Medication Use in Nursing Facilities
HCFA
OSCAR Database (12/31/98)
The figures below
indicate the per cent of nursing facility residents taking each
category of medications.
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Psychoactive
Medications
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1997
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1998
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Overall
psychoactive medicines
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46.3
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48.9%
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Antipsychotic
medicines
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17.5
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18.6
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Antianxiety
medicines
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15.4
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15.8
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Hypnotic
medicines
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5.2
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5.1
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Antidepressant
medicines
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25.5
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28.8
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The
Resident Assessment Instrument Manual,
the Health Care Financing Administration's (HCFA) guide to
completing the MDS and care planning process, suggests that 35% to
65% of nursing facility residents receive psychotropic medications
at one time or another.
 Special
Events
ACT is pleased to announce the addition of Sandra Story, PhD, to our
practice.
Happy ACT Anniversary to:
3 years: Dr. Bryan Patterson, Clinical
Psychologist
Erinn Moore, President
Bill Aiman, Operations Specialist
1 year: Dr. Craig Iversen, Clinical Psychologist
Dr. David Cook, Psychiatrist
Dr. "Jeff"rey Crawford, Clinical Psychologist
Dr. Robert "Bob" Zozus, Clinical Psychologist
Happy Birthday to:
Dr. Gretchen Belovicz 3/9
Dr. Chris Norris 3/11
Dr. Barry Moore 3/21
Dr. Jeff Crawford 3/22
Dr. Raveen Mehendru 4/13
Dr. Austin Chandler 4/22
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