Navigating the Seas of Change: MDS Changes in LTC for FY 2024
Change is the only constant, and in the dynamic landscape of the Long-Term Care (LTC) industry, adaptation is key to providing quality care. As the healthcare industry steps into Fiscal Year 2024, significant updates to the Minimum Data Set (MDS) are poised to make waves in how providers assess, document, and enhance the well-being of residents.
Major changes to the MDS v1.18.11 for FY 2024 impact patient care, documentation, form changes, and payment. Not to mention, there have been multiple and ongoing changes to all the item sets with the sixth version of the MDS item sets released October 20, 2023, i.e., 20 days after the formal implementation. The changes affect many roles beyond the MDS Coordinator and multiple factors that require consideration by the entire organization.
This article delves into the top 10 changes of the MDS for FY 2024, shedding light on what this means to skilled nursing facilities, job roles, and necessary operational refinements.
1. MDS Item Sets Increased
Given the addition of 59.5 new items rendering the most intense changes to the MDS in over 10 years, data collection and MDS completion may require additional labor hours. Hence, providers need to assess hours, systems, and reallocation of resources. While simultaneously providing ongoing education to the MDS Coordinators and Interdisciplinary Team members.
2. Resident’s Voice
The MDS changes for FY 2024 are designed to create a more inclusive and resident-focused care environment. By actively involving residents in the assessment process, incorporating their perspectives, and promoting personalized care plans, these changes empower residents to have a stronger voice in shaping the care they receive in the LTC setting.
- Expanded Resident Interviews and Participation:
- The revised MDS guidelines place a greater emphasis on resident interviews and engagement. By including residents more actively in the assessment process, the updates aim to capture their unique preferences, goals, and concerns directly from the source. This shift ensures that the care plans are not only clinically sound but also aligned with the individual needs and desires of each resident.
- Inclusion of Resident-Reported Outcomes:
- FY 2024 MDS changes incorporate a broader range of resident-reported outcomes. This means that residents have a more prominent role in expressing their experiences and perceptions of their own health and well-being. Including their perspectives in the assessment process not only enhances the accuracy of the data but also fosters a more patient-centered approach to care.
- Focus on Goal Setting and Personalized Care Plans:
- The MDS updates encourage a more detailed approach to goal setting based on resident input. By tailoring care plans to align with residents' individual goals and aspirations, the changes empower residents to actively participate in decisions about their care journey. This personalized approach promotes a sense of agency and autonomy among residents, reinforcing the concept of resident-directed care.
- Enhanced Communication and Collaboration:
- The revised MDS guidelines encourage improved communication between healthcare providers and residents. This includes fostering regular discussions about care preferences, treatment options, and potential changes in health status. By strengthening the communication loop, residents are better informed and have more opportunities to voice their opinions, contributing to a collaborative and transparent care environment.
- Incorporation of Quality-of-Life Indicators:
- FY 2024 MDS changes introduce new quality of life indicators, reflecting a holistic approach to resident well-being. These indicators encompass social, emotional, and cultural aspects of life, allowing residents to express their values and priorities beyond just clinical health. This comprehensive view enables care providers to tailor services that not only address medical needs but also enrich the overall quality of life for residents
3. Triple Check Process
Monthly Triple Check meetings are particularly important with the MDS changes including those in the errata documents. The October 20, 2023, MDS Manual Errata (v2) document is 54 pages and has 21 changes applicable starting October 1, 2023.
The MDS updates and numerous software glitches have caused multiple issues with submitting accurate claims. Changes with items in MDS Sections such as:
- Section D Resident Mood,
- Section K Swallowing/Nutritional Status, and
- Section O - Special Treatments, Procedures, and Programs
require close attention or reimbursement opportunities may be missed.
A separate Triple Check meeting for Medicaid claims is recommended given the complexity of many MDS and billing changes related to using the PDPM Nursing Case Mix Group. A distinct, detailed, and comprehensive review of the Medicaid claims for states that use the additional OSA for reimbursement should also be held given the inverted scales used, the “Rule of 3” versus using usual performance, and the learning curve for new definitions of multiple items.
4. Social Determinants of Health (SDOH)
Social determinants of health (SDOH) play a crucial role in influencing an individual's overall well-being, and their impact is increasingly recognized in the healthcare landscape. The Minimum Data Set (MDS) in the Long-Term Care (LTC) industry serves as a comprehensive assessment tool, and its integration with an understanding of social determinants can significantly enhance the quality of care provided. Here's how social determinants of health relate to MDS in the LTC setting:
- Holistic Assessment of Residents:
- Social determinants, such as socioeconomic status, living conditions, and community resources, can influence an individual's health outcomes. MDS assessments, when designed to consider these social factors, provide a more holistic understanding of a resident's situation. This holistic approach helps in tailoring care plans that address not only medical needs but also social and environmental factors impacting health.
- Identification of Barriers to Care:
- MDS assessments can uncover social determinants that may act as barriers to optimal health. For instance, if a resident lacks access to transportation, it could impact their ability to attend medical appointments. By identifying these barriers, healthcare providers can develop targeted interventions to mitigate the effects of social determinants and improve access to necessary care.
- Customization of Care Plans:
- Social determinants influence an individual's ability to engage in their care. MDS data, when coupled with an understanding of social factors, allows for the customization of care plans that are sensitive to the unique needs and challenges residents face. This ensures that interventions are realistic and achievable within the context of the resident's social environment.
- Enhanced Communication and Collaboration:
- Integrating social determinants into MDS assessments fosters better communication and collaboration among healthcare professionals, social workers, and other members of the care team. Understanding the social context enables a more comprehensive and collaborative approach to care planning, with a focus on addressing both medical and social needs.
- Risk Stratification and Targeted Interventions:
- Social determinants can contribute to health disparities and affect the risk profile of individuals. MDS assessments, when enriched with information about social determinants, enable risk stratification. Identifying residents at higher risk due to social factors allows for targeted interventions and support services that can positively impact health outcomes and prevent avoidable complications.
- Quality Improvement Initiatives:
- Analyzing MDS data in conjunction with social determinants helps identify patterns and trends in health disparities. This information can inform quality improvement initiatives aimed at addressing systemic issues related to social determinants of health within the LTC facility. This proactive approach contributes to better overall resident outcomes.
Recognizing and incorporating social determinants of health into the MDS framework in the Long-Term Care industry is crucial for providing person-centered, comprehensive care. By understanding the social context of residents, healthcare providers can develop interventions that not only address immediate health needs but also work towards creating a supportive and health-promoting environment tailored to each individual's unique circumstances.
5. Standardized Patient Assessment Data Elements (SPADEs)
The SPADE items are in the APU Table which was revised for the QRP Data Submission Threshold. Data collected after January 1, 2024, will affect the QRP Program Year 2026 when the threshold will be 90% instead of 80%.
6. Functional Status: Section G Elimination
The elimination of Section G (Functional Status) from the MDS impacts an array of areas including but not limited to; the Loss of Functional Status Information, an Impact on Care Planning, the source data for Quality Measurement and Benchmarking, Interdisciplinary Communication, Reimbursement Implications, as well as the Adaptation to Changing Standards:
While all are extremely important, it is important to note that Section G impacted five quality measures and both the Quality Measure and the Staffing Components of the Five Star Rating System. The calculations for quality measures will change after a freeze period (starting in April 2024) when four measures will be frozen with three of them remaining frozen until January 2025.
7. Data Transparency
The information available to the public, referral sources, and others is increasing with reporting on Care Compare, the Provider Data Catalog at Data.CMS.gov and elsewhere. These sites include data based on the new MDS items. For instance, the transfer of health data posted to Care Compare in October of 2025 will be based on the pertinent items that are new on MDS 3.0 v.1.18.11.
8. Medicare Part A PPS Discharges Complexity
The Medicare Part A PPS Discharge Assessment (NPE) item set increased from 13 to 23 pages, a 76.9% increase. The timing of interviews that it includes such as the BIMS, PHQ 2-9 Resident Mood Interview, and the Pain Assessment can be confusing, especially if there is an unplanned discharge. These items count towards the provider’s SNF QRP Data completion threshold.
The new requirement in the MDS RAI Manual, chapter 2, page 2-44 changed the guidance about combining a PPS Discharge Assessment with an OBRA discharge assessment so that when the Medicare Part A Stay ends on the same day or the day before the day of discharge from the facility these assessments must be combined. As a result, the timing of multiple interviews including the SDOH items, even with an unplanned discharge, are critical given the SNF QRP data completion threshold.
New NPE items improve discharge planning and will be useful to ensure attainment of the surveyor guidance for F-Tag 660 and F-Tag 661.
The Discharge Function Score for SNFs that will be included in both the SNF QRP, and the Value-Based Purchase Program (VBP) has data collection starting October 1, 2023, and the Performance Year slated to begin October 1, 2024. Currently, this does not impact reimbursemen, but MDS accuracy will make a difference when it does.
9. Resident Mood – PHQ 2-9: Section D
The transition in MDS Section D from the PHQ-9 to the PHQ-2-9 to assess resident’s mood (conducted during the ARD 7-day look-back period) can be a shorter interview with a skip pattern depending on how the first two questions are answered. The PHQ-2-9 and the RAI Manual change regarding when a staff interview can be conducted, may cause a decline in MDS’ with a depression end-split. It does not necessarily change the quality measure and should not impact the need for comprehensive interdisciplinary care planning or looking for any significant changes in the resident’s mood.
Monitoring the PHQ-2-9 scores, providing additional training on the interview process and the PHQ-2-9 assessment, and enhancing the care planning process will assist with providing quality care, survey outcomes, and reimbursement.
10. ICD-10 Coding
The new updates to the ICD-10-CM code system for fiscal year 2024 include 395 new billable codes in areas such as external causes of morbidity, social determinants of health (SDOH), and osteoporosis.
Understanding the ICD-10 Code changes for FY 2024 and the updates to the ICD-10 Mapping File released September 2023 impacts coding of several sections of the MDS. For states that use PDPM for Medicaid reimbursement (in addition to Medicare Part A), the financial impact is much greater.
Documentation must support the MDS coded diagnoses following the RAI Manual guidelines. It is important that physicians understand the full implications of certain ICD-10 Codes and that staff have a streamlined query process for clarification of diagnoses as needed.
11. Training and Clinical Leadership
Updating the facility policies and procedures to properly reflect these MDS changes must be completed and implemented expeditiously. Education with frequent trainings about the revised policies and procedures, the reasons for the changes, combined with information on the MDS changes and their importance is critical. Following up on this to gauge how the clinical team is adjusting to these significant MDS and RAI Manual changes is equally essential.
Success with the above requires aligning operations with the MDS changes and regulatory expectations plus recognizing the key factors of quality, safety, and person-centered care. Education, audits, more education, and a strong QAPI program will make a difference with the new MDS changes.
If you have education and training needs, please contact below
Kris B. Harmony OTR/L, LNHA, MBA