The MDS medical abbreviation stands for Minimum Data Set and is a required assessment for all residents of nursing homes and skilled nursing facilities (SNFs) in the United States. This important assessment standardizes how patients are evaluated, and treatment plans are established. Any healthcare provider in a nursing or skilled care facility must be familiar with the MDS assessment process and how the results impact billing, treatment, and quality reports available to the public.
The MDS impacts every position in a Medicare- or Medicaid-supported facility, as it is the basis for all clinical documentation for each patient. Regardless of when a patient is in residence, an MDS assessment will be required periodically. Since it is a federally mandated program, it is essential that all healthcare workers, whether they provide direct care to patients or supervise those who do so, understand the Minimum Data Set and how it impacts the patients, facility, and their daily tasks.
What Is MDS Medical Abbreviation?
The Minimum Data Set was introduced in 1990 by the Department of Health and Human Services as a federally-mandated assessment for patients in Medicare or Medicaid licensed nursing or rehabilitation centers. In 1995, the MDS assessment was updated to version two, which included more than 600 assessment items across 23 areas of concern.
In 2010, the federal government implemented version three. This time, direct interviews with residents were included in the assessment to increase accuracy and include screening for cognitive concerns like depression. More significant changes were made to MDS starting in 2023 and rolling throughout 2024, aimed at improving patient care and data reliability.
The Minimum Data set evaluates each facility resident to determine their capabilities and help healthcare providers identify issues. The Centers for Medicaid and Medicare Services and the Department of Veterans Affairs use this data to track the function and disability of older adults on a large scale. The MDS data is directly used for the following purposes:
- Reimbursement. This data determines a resident’s Patient Driven Payment Model (PDPM) classification and Medicare and Medicaid reimbursements to the facility. The PDPM is adjusted for each major element of the patient’s care, such as physical therapy, occupational therapy, speech-language pathology, and more. Correctly documenting all of the services a patient needs and will receive at the SNF through the Minimum Data Set assessment will ensure accurate reimbursement to the facility.
- Quality Monitoring. Quality of care in the facility is monitored via MDS data sets. There are measures for long-term and short-term patients to measure the quality of the care received. These measures include tracking residents who are re-hospitalized, changes in skin integrity, emergency department visits, infections, vaccinations, and other indicators of the care they receive.
- Care Management. The data in the Minimum Data Set is used to develop treatment plans and goals based on the patient’s diagnoses, mobility, function, and ability to perform daily living activities. The first MDS assessment is performed upon admission to the facility and contributes to the care team’s understanding of the patient’s concerns, strengths, and preferences for treatment.
What Is the MDS Assessment?
The MDS assessment is in-depth, comprehensive, and time intensive. As such, it’s important for those administering and documenting the assessment to be well-trained in evaluating and accurately reflecting a patient’s status. Besides basic demographic information, the MDS includes sections on all of the following.
- Hearing, Speech, and Vision: Questions in this section determine the resident’s ability to hear, understand, and communicate with others with or without assistive devices. It also assesses if they can see their environment. Addressing concerns here will lessen social isolation and improve understanding of and participation in their treatment plans. Addressing hearing, speech, and vision concerns can greatly improve quality of life and can easily be remedied by assistive technology.
- Cognitive Patterns and Mood: This part of the assessment tests a patient’s attention, orientation, and ability to recall new information. Any signs of delirium or depression would be noted here so additional support can be offered. Resident’s mood and social isolation are evaluated based on their answers to questions about feeling depressed, having trouble sleeping, appetite changes, and ability to concentrate. This is especially important if a significant or sudden change is observed.
- Behavior: This section evaluates a resident’s behavior patterns over the past seven days. It includes items that are distressing to the patient, other residents, or the facility’s staff. Items include kitting, kicking, biting, threatening, or making disruptive sounds. These questions are unique because evaluators are asked to determine the frequency of the behavior and the impact it has on their own medical treatment or the safety of others.
- Preferences for Customary Routine Activities: Any resident capable of communicating or having a family member who can relay their preferences should be able to determine how they receive daily care at the facility. Questions in this section will indicate how involved the patient wants to be in decision-making and will assist providers in creating individual treatment plans that consider the patient’s unique voice. Topics include if they prefer baths or showers, when they like to have snacks, if they want access to reading materials, and how much social activity they would choose.
- Functional Status: Functional Status focuses on self-care and mobility and assesses how much assistance a resident requires to complete these activities. When evaluating self-care, the assessor will consider the past three days and how independent the resident was when performing tasks like oral hygiene, dressing, and bathing.
- Active Diagnoses, Health Conditions, Medications, and Treatments: This section should note any treatments, diagnoses, or risks. The goal is a comprehensive and updated picture of the resident’s health and quality of life.
- Swallowing and Oral Health: Since an SNF has a dietary staff, this assessment will ensure that the resident receives the appropriate food and assistance to consume it. It will also track weight loss or gain and include problems with dentures, lost teeth, or bleeding gums.
- Skin Conditions: It’s important to track pressure injuries’ healing or determine whether a patient is at risk for developing them. Also consider sudden changes in skin, like new dryness or increased perspiration.
- Physical Restraints: The use of restraints must be documented and justified, as they have numerous adverse effects, both physically and mentally.
- Participation in Assessment and Goal Setting: Involving the patient, their family, and other support systems in planning for discharge and goal setting is the gold standard for medical care. It will also help in planning for health care and support services once the patient leaves the SNF.
Why Is MDS Important for Nursing Homes?
First and foremost, the MDS assessment is federally mandated. Nearly all residents of nursing homes and skilled nursing facilities in the United States are subject to guidelines that require this assessment periodically during their stay at the facility. The Centers for Medicare and Medicaid Services state that the purpose of MDS is “To provide the facility with ongoing assessment information necessary to develop a care plan, to provide the appropriate care and services for each resident, and to modify the care plan and care/services based on the resident’s status.” As this indicates, every decision made about the care and treatment of residents will be compared to or driven by the assessment and progress tracking found in the MDS.
In addition, the Five-Star Quality Rating System is based on ten Quality Measures documented in the MDS. Factors like mobility declines, the presence of high-risk pressure ulcers, and the use of restraints affect these Quality Measures, hence the Five-Star rating. These ratings are published and help patients, their families, and community healthcare providers decide where to place patients for treatment. The lowest 20% of nursing homes will receive a one-star rating, which interested parties will see when researching the facility on Nursing Home Care Compare.
2024 Updates to MDS
In 2023 and 2024, big changes have taken place in MDS assessment, and providers need to keep pace with these changes to comply with federal law and receive appropriate reimbursement for their services. If you have been an MDS nurse in the past, you’ll need to refamiliarize yourself with new protocols and standards for the most recent changes.
One entire section—Section G—was rewritten as Section GG. In this new section, MDS nurses evaluate the patient’s usual performance level for activities of daily living over three days before the assessment. The patient is ranked on a scale from independent to dependent for each self-care and mobility skill. Several other changes have been made to evaluation time periods, how patients are scored, documentation methods for interrupted stays, and more.
Some measures are frozen for a time while the transition from the older method to the new one takes place. However, it is imperative for nursing homes and skilled nursing facilities to quickly revamp their protocol to meet the demands of new standards.
What Providers Need to Know about MDS
While MDS assessments are federally mandated, it is the responsibility of the nursing home or SNF administration to communicate to front-line workers why it is essential to the care they provide to residents. The integrity of the data is important to tracking progress or flagging areas of concern. It also supports individualized care planning and avoids medical errors. Administrators should train providers thoroughly and motivate MDS nurses and other assessors by transparently using the data in the facility.
MDS assessments are intended to be multi-disciplinary. Because the most recent updates touch nearly every department of an SNF, a team that is not limited to an MDS nurse will be required. Assessments include factors related to medical, mental health, socialization, nutrition, mobility, and occupational therapies. Each provider will need to add information to the MDS assessment for completion. This 360-degree approach will also create better, more comprehensive patient treatment plans.
Providers will also be responsible for ensuring MDS assessments are completed on time. The new legislation requires that assessments be completed at the time of admission, at least every three months, when there is a significant change in condition, and at the time of discharge. The facility will be responsible for tracking the most recent assessment and determining when the next should take place.
Facilities are responsible for transmitting the data to the Centers for Medicare and Medicaid Services via the Internet Quality Improvement Evaluation System (iQIES) within 14 days. Some states have additional requirements for the collection and submission of data that providers need to know and understand. The data is scanned for errors, including improper coding, invalid dates, and missed assessment items upon submission. Facilities have seven days to edit the assessment documents and resubmit.
Technology to Support Nursing Home Staff Data Collection
Health Information Technology (HIT) can support SNF teams while collecting, tracking, and documenting all the data required by the Minimum Data Set. The use of Electronic Health Records is required by US law. Starting with this baseline, additional technology can be added to help teams communicate clearly, better track patient progress, meet deadlines for data submission, and more accurately aggregate information required by MDS. These types of EHRs have been shown to prevent errors, expedite decision-making, increase administration efficiencies, and expand access to health care.
The Impact of the MDS Medical Abbreviation
In the United States, 80-90% of nursing homes accept Medicaid and, therefore, are subject to MDS assessment requirements. These assessments, particularly after the updates in 2024, will affect every care provider at the facility. Because they are intended to be comprehensive, everyone providing services to a patient will be asked to participate and evaluate the prognosis of each resident. It is truly a team effort to complete the assessment, finalize documentation, and ensure accuracy for patient safety and timely reimbursement. A deep understanding of MDS assessment will be essential for any provider working in these settings now and in the future.
