ADL Coding: Outcomes and Improvement

The Federal Government is hot to trot on defining and depicting patient outcomes with a direct impact on SNF payment as a result of improvement. The essential question that every facility should be asking: 

Is the MDS An Effective Tool To Measure Improvement?

The MDS is a comprehensive collection of a multitude of extremely relevant data points central to the patient's medical profile.  It is wildly informative and categorically articulate.    The Initial implementation of the MDS followed the OBRA 87' ruling mandating that all patients need to maintain their highest level of function and overall practical state of well being.  In other words, it is not acceptable to decline in function once admitted to a skilled nursing facility. The MDS over the last 18 years has been used to determine improvement or decline through a defined algorithm including a simple proclamation "the patient has declined or improved." 

With that said, let's evaluate Section G of the MDS and its ability to depict improvement or decline.   Consider the following two scenarios and ask yourself: 

• How would you code on the MDS?
• Did the patient improve?
  

Scenario #1 

Mr. Jones is admitted to the skilled nursing facility after a Left CVA with Right Hemiparesis. 

On a daily basis, the patient is transferred with maximum assistance (70% weight bearing support) by all care givers for the wheelchair to chair transfer requiring a stand pivot technique.  Each transfer requires the caregiver to lock the brakes, swing the leg rests, and position the chair at a 45 degree angle. The caregiver squats, bends her knees, embraces the patient and physically lifts the patient with 70% effort.  The patients helps with 30% of his effort.  It requires exertion and sweat from the caregiver's perspective.  Every transfer in the last 7 days requires this exact same amount of assistance. 

Scenario #2 

90 days later, the same patient is sitting in the hallway, dressed in street clothes.  He is sitting in a chair with his arms draped leisurely over his rolling walker.  The rolling walker sports two tennis balls on the bottom two rear walker legs to enhance friction when in movement to prevent "runaway walker".  He waves down his favorite OT, and requests "a boost" to change position from sit to stand (an element of transfers).  The OT readily complies with his request providing him with minimal assistance (25% weight bearing support) sit to stand by grabbing his belt at the lower back of his trousers.  Mr. Jones stands up, smiles, and walks down the hallway without any additional support, cues, or guidance.  In fact, Mr. Jones requires no further assistance over the next few days.  However, during the 7 days within the MDS assessment period, Mr. Jones requests this assistance two more times, totaling 3 instances of minimal assistance from the OT. No other caregiver rendered any form of support for Mr. Jones to transfer during this time frame. 

Now, let's go back to the original questions. 

How would you code on the MDS?

Both of these scenarios result in the exact same coding of transfers on the MDS:

Extensive Assistance (3,2) 

For those MDS Coordinators reading, this is obvious.  For the non MDS Coordinators, this may be somewhat shocking.  These two scenarios depict a very different level and amount of resources provided by the facility level staff.

Did the patient improve?

Yes, the patient improved! In fact, he improved brilliantly....however, if you relied on the MDS to demonstrate the functional improvement of the patient over the course of his or her Medicare stay, this scenario would not demonstrate an improvement. 

So, where do we go from here?  This discussion is to emphasize the importance of an objective, inter-rater reliable measurement tool that eloquently depicts if the patient's functional performance changed during his or her Medicare stay.