MDS Changes for Nursing Homes: Key Definitions of Quality Measures

Nursing homes and skilled nursing facilities (SNFs) adjusting to most recent minimum data set (MDS) changes

Minimum Data Set (MDS) changes for nursing homes have been extensive, and promise to continue. And while much is being discussed and debated, one thing is sure: New rules that require changes to the way facilities are reimbursed for Medicare or Medicaid through the Patient-Driven Payment Model (PDPM), Medicaid case mix, quality reporting, and care plan development are and will touch on the way reporting is done through the SNF Quality Reporting Program, Quality Measures, and Five-Star rating system.

These are some of the biggest changes employees and administrators will have seen in their careers. Because of the impact this will have on all areas of care and reporting in an SNF, it’s essential to consider every aspect of the new ways MDS will be evaluated. Even terms and processes used daily in SNFs will be altered, and we want MDS coordinators to have the tools to be prepared for these updates.

Below are key definitions used in Quality Measures and how they are impacted by these changes.

MDS Quality Measures: Numerators and Denominators

Here’s a quick refresher course on quality measures definitions: the numerator is the number of residents that triggered a quality measure during a reporting period. The definition lays out the criteria to determine if the patient can be counted in the numerator. The denominator is the population for the measure —the number of nursing home residents who have the necessary records to trigger that quality measure. Exclusions are omitted from both the numerator and denominator for specific conditions or missing data, such as being in hospice, having an end-stage disease, or being dependent on an ADL.

MDS Quality Measures: Covariates

Some quality measures are risk-adjusted, and covariates are used to weight facility performance based on resident conditions. Taking covariates into account decreases errors in the model because it can eliminate some residents from the calculation. Covariates are weighted as 1 if the condition is present and 0 if it is not.[1] Factors such as having a catheter would be used to risk-adjust quality measures to account for nuances in the clinical picture of the residents. Including these residents would not give an accurate representation of the care because of a condition that is not the purpose of the measure.

In the new MDS changes for nursing homes, a covariate is being impacted by the removal of Section G Short Stay Improvement in Function and being replaced with the Discharge Function Score.[2] The long stay ADL measure and the long stay worsening mobility measure are both impacted by this change as well as a shift away from Functional Status to Functional Abilities and Goals. Each of these changes impacts the numerator because they look specifically at activities of daily living. As we will see, these changes also affect Five Star ratings.

For long-stay patients with pressure ulcers, there’s also an impact on the denominator because part of the MDS assessment was to determine residents who are at high risk for developing pressure ulcers, and that included some ADL self-performance. This measure has transitioned to the percentage of all long-stay residents with pressure ulcers. Incontinence is the flip side of that. The incontinence measure would trigger only for residents who were in the low-risk population, which includes some mobility items. This measure changes to long-stay patients with new or worsened bowel or bladder incontinence.[3]

Essentially, none of these quality measures can be calculated anymore in their current form because Section G is no longer available to serve as the method for collecting that data. The newer, worse, and more pressure ulcer short stay is what’s called an incidence-based quality measure. So, the current MDS is compared to the one prior to it to determine if the resident triggers it. This means that while Section G is no longer in practice, the knowledge used to collect this data is still an essential job function and will impact reporting on the new Section GG.

There is also an impact on claims-based quality measures because they use MDS assessments to make risk adjustments and collect some of the data that is used in covariates. Using claims makes it easy to include or exclude large numbers of patients and data sets. So, Section G is used as covariates in the claims-based re-hospitalization, short-stay ED visits, long-stay hospitalizations, and long-stay ED visits measures. The downside to this covariate is that it has about a three-quarter time lag because of the claims process. This makes it more difficult for providers to notice the trigger and adjust the data to reflect it.

MDS Changes: OBRA Admissions

Another change is that Section GG is now required on all OBRA admissions, assessments, quarterlies, annual, and significant change assessments. While it mostly impacts long-term residents in the facility, anybody who has been in a skilled nursing facility for more than 14 days needs to have at least one OBRA assessment completed. Section GG is now required nationally for OBRA assessments. It will be used for payment classification and quality measures and can result in a deduction of reimbursement if incorrectly collected or documented.

It’s a huge challenge to a facility’s assessment processes if they are just now being implemented. Some facilities have been doing this for years to adjust to the new measures. Everyone from MDS administrators to those delivering direct care will need to be aware and trained on new Section GG requirements. Now, items have been added to collect data on social determinants of health (SDOH), which includes race and ethnicity.

That section of the MDS has been greatly expanded, including potential transportation barriers that the resident experiences in the community and health literacy, and the CMS is beginning to collect this data on the challenges that many residents have or may have in transitioning to the community. New items about personal hygiene, oral hygiene, transferring into and out of the shower, and other mobility indicators have also been added.[4]

MDS Changes: Section D

There’s also a change to the way teams code and collect information on mood intervention in Section D. The PHQ -9 is now the PHQ -2 to 9. Some of the items have been renumbered, and a new item has been added measuring social isolation, so take care when coding information in the new format. MDS assessors are not being asked to make a determination about the diagnosis of depression; they just need to note the absence or presence of symptoms.

There is also new logic that leads care providers through the questionnaire and determines if all of the questions need to be asked. The result will give a score of the severity of depression symptoms and suggestions for future care plans.

This new procedure could potentially screen out some residents who would otherwise trigger mood issues. This is not going to substantially affect the outcome of the depression quality measure, but it is a big change in the process and may impact reimbursement under PDPM.

MDS Changes: Section N

MDS changes for nursing homes include Section N, and they got a significant revamp with a lot more specific information on high-risk drug classes. However, this is a relabeling of questions and data sets, not a complete overhaul, meaning that the data essentially remains the same. MDS assessment and coding will need to be updated.

There are now two columns to complete in Section N—one if the patient has taken any high-risk drug classification medications during the past seven days and another if the reason for taking the medication is indicated by a physician. It is essential that there is strong rationale for giving these high-risk drugs to patients.

Two new classifications have been added to this assessment. Nursing homes now also need to indicate if patients are taking antiplatelet or hypoglycemic drugs, including insulin.

MDS Changes: Section K and Section O

Section K, nutritional interventions, and Section O, special treatments and procedures, were both updated with more specificity. New time frames have been added to Section K about the method a patient is using for feeding at different time periods. MDS coordinators will now need to document a resident’s feeding method at the time of admission, while not a resident, while a resident, and at the time of discharge.[5]

In Section O, assessors are now asked to code treatments both received and performed, meaning that this also includes things patients can perform themselves. Tracking for these procedures and treatments extends to “on admission” and “at discharge.” Remember to be detailed in this section to include the types of treatment, for example, the route for oxygen, what type of IV access, and more. This section also includes documentation about offering influenza vaccines and how to document an interrupted stay.

MDS Changes: Five-Star Rating Calculations

Changes to Five-Star Ratings in the new MDS include both the Quality Measure Rating and the Staffing Rating. The RUG-IV 66 grouper is no longer used to calculate staffing levels. Instead, a new calculation has been developed that takes into account the daily distribution of patients by PDPM. To accommodate this adjustment, staffing measures will freeze from April to July 2024.

Section G, which provided guidance for short-stay Quality Measures, has been eliminated. SNFs need to transition to Section GG and the new Five Star Quality Measures within. Important changes have been made to one short-stay and three long-stay Quality Measures:

• The short-stay Residents Who Made Improvements in Functions will be replaced with Discharge Function Score in October 2024.
• Residents Whose Need for Help with ADLs Has Increased QM will still be tracked. It will be carried over in a similar measure in Section GG
• Residents Whose Ability to Move Independently Worsened QM will also be transferred to Section GG.
• The pressure ulcer QM is redefined to include any resident with a pressure ulcer and eliminate the high-risk language from the measurement.

The details for each section will be essential competencies for MDS coordinators as well as administrators, managers, and care providers. With 60 changes, both large and small, the transition from Section G to Section GG will require attention to detail and dedicated time with each patient. Many changes took effect in October of 2023, but the changes will continue to come into effect through 2025. During the transition period, coordinators should be vigilant that anyone touching MDS assessments understands and complies with the new regulations to avoid the risk of decreased reimbursement.

In the end, MDS changes for nursing homes are designed to provide better, higher-quality care to patients in nursing homes. The additional information will better help SNFs provide the exact care patients need. Ratings such as Five Star will reflect a facility’s ability to assess all areas of a patient’s well-being and respond appropriately.

SOURCES

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• [1] https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/downloads/nhqiqmusersmanual.pdf
• [2] https://www.cms.gov/medicare/quality/nursing-home-improvement/quality-measures
• [3] https://www.cms.gov/files/document/mds-30-qm-users-manual-v160pdf.pdf
• [4] https://www.linkedin.com/pulse/dissecting-section-gg-changes-10123-dolores/
• [5] https://dietitiansondemand.com/updated-2023-mds-documentation/