Coding the RAI MDS 2.0 for Experienced Assessors ... 2014-2015 i Coding the RAI-MDS 2.0 for...
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Coding the RAI-MDS 2.0
for Experienced Assessors - Cognitive and Mental Health
and Quality of Life
Participant Workbook
Revised: November 2014
CIHI 2014-2015 2
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in part and by any means, solely for non-commercial purposes, provided that
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Canadian Institute for Health Information
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Phone: 613-241-7860
Fax: 613-241-8120
www.cihi.ca
© 2014 Canadian Institute for Health Information
Based upon the Resident Assessment Instrument (RAI) RAI-MDS 2.0 User’s Manual, Canadian
Version, 2012. The RAI-MDS 2.0 is interRAI Corporation, Washington, D.C., 1997, 1999. Modified with
permission for Canadian use under licence to the Canadian Institute for Health Information. Canadianized
items and their descriptions are protected by copyright: 2002, Canadian Institute for Health Information.
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Coding the RAI-MDS 2.0 for Experienced Assessors: Cognitive and Mental Health and Quality of Life
Table of Contents
About CIHI ................................................................................................................................. 4
Acknowledgements .................................................................................................................... 4
Objectives .................................................................................................................................. 5
Materials Needed ....................................................................................................................... 5
Coding and Interpreting .............................................................................................................. 6
RAI-MDS 2.0 Guidelines ........................................................................................................ 6
RAI CODE Critical-Thinking Strategy...................................................................................... 7
Pre-Work Activity .................................................................................................................... 8
Activity 1 – Interpret Coding .................................................................................................... 9
Activity 2 – Coding and Interpreting .......................................................................................17
Data Quality ..............................................................................................................................31
Ensuring Quality Data for Quality Care ..................................................................................31
Activity 3 - Data Quality .........................................................................................................33
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About CIHI The Canadian Institute for Health Information (CIHI) collects and analyzes information on health
and health care in Canada and makes it publicly available. Canada’s federal, provincial and
territorial governments created CIHI as a not-for-profit, independent organization dedicated
to forging a common approach to Canadian health information. CIHI’s goal: to provide timely,
accurate and comparable information. CIHI’s data and reports inform health policies, support
the effective delivery of health services and raise awareness among Canadians of the factors
that contribute to good health.
Acknowledgements CIHI wishes to acknowledge and thank interRAI and staff at participating organizations across
Canada who provided expertise and support and who volunteered to pilot the Coding the
RAI-MDS 2.0 for Experienced Assessors: Cognitive and Mental Health and Quality of Life
training. Their generous contribution has allowed us to provide you with this education material.
We would like to thank the residents/clients, staff and volunteers at the Élisabeth Bruyère
Residence, Extendicare Starwood, Bethany Care Society and Champlain Community Care
Access Centre for giving CIHI permission to use their pictures, including those of their families
and homes.
All names and stories used in this training are fictitious.
Symbols
Important Note
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Objectives The web conference Coding the RAI-MDS 2.0 for Experienced Assessors: Cognitive and
Mental Health and Quality of Life is a two and a half hour activity-based training session. This
session covers the following sections of the RAI-MDS 2.0 assessment:
Section B: Cognitive Patterns
Section E: Mood and Behaviour Patterns
Section F: Psychosocial Well-Being
Section N: Activity Pursuit Patterns
In this training, you will
Use the RAI-MDS 2.0 User’s Manual to interpret and apply coding standards in the areas
of Cognitive and Mental Health and Quality of Life;
Document Cognitive and Mental Health and Quality of Life assessment findings using the
RAI CODE critical-thinking strategy; and
Identify ways to improve data quality in your facility.
The primary intent is for you to engage in peer discussion and sharing. In this session, you will
draw on each other’s clinical judgment and expertise to code vignettes where the interpretation
of the coding standards for documenting items becomes challenging. You will also explore the
consequences of incorrect coding for clinical and organizational decision-supporting your
facility.
Materials Needed The following materials are required for this web conference:
Resident Assessment Instrument (RAI) RAI-MDS 2.0 User’s Manual
Coding the RAI-MDS 2.0 for Experienced Assessors: Cognitive and Mental Health and
Quality of Life Participant Workbook
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Coding and Interpreting
RAI-MDS 2.0 Guidelines As described in the RAI-MDS 2.0 Manual, there are several integral concepts used to assist
clinicians in documenting assessment findings. These include:
The resident is a person with strengths, preferences and needs
Clinical Assessment Protocols identify persons with potential to improve and those at risk of
decline
An interdisciplinary approach to resident care is vital – both in assessment and in
developing the resident’s care plan
Good clinical practice requires sound assessment skills
Using the RAI-MDS 2.0 Guidelines in the assessment process
Minimum data set (MDS)
Observation period is the seven days prior to the assessment reference date, unless a
longer time frame is specified
Information is obtained from multiple sources
Clinical judgment is key—it is not a questionnaire
Coding standards guide the assessment process
Coding reflects resident’s functioning
Regardless of the assumed cause
With assistive/adaptive aids in place
All sections work together to give a holistic view of the resident
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RAI CODE Critical-Thinking Strategy This mnemonic helps guide the critical-thinking process that often occurs intuitively as part of
your assessment process. It is a tool for reflective problem-solving and decision-making.
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Pre-Work Activity
In This Activity You Will
Prior to the web conference:
Read the vignettes for Activity One and Activity Two
Activity #1 – Vignettes 1 and 2
Activity #2 – Vignettes 1 and 2
Note: The documentation of your findings and rationale will be completed during the web
conference.
Approximate time to complete: 10 minutes
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Activity 1 – Interpret Coding
In This Activity You Will
Review each vignette and associated coding
You will use the following resources:
- Participant workbook: Activity One—vignettes 1 and 2
- RAI-MDS 2.0 guidelines found on page 6
- RAI CODE critical-thinking strategy found on page 7
- Example – Average Time Involved in Activities (N2) on page 13
- RAI-MDS 2.0 User’s Manual
As a group, document your rationale for the coding of each vignette
Present your findings and participate in discussions
Time allotted: 15 minutes
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Vignette 1: Mr. T—F1, F2 and F3
Mr. T has been a widower for 20 years. He worked as a landscape architect before he retired.
He was admitted to Rainbow LTC home two years ago following a CVA resulting in
right-sided paralysis. Mr. T shares a semi-private room with Mr. B, a younger resident with a
brain injury.
Mr. T spends most of his time in his room working on his laptop. He has stated to staff that he
would like to finish writing his book before he dies. He has asked to be moved to a private room
when one becomes available. Communication between him and his roommate is challenging;
he says he has no quiet time as his roommate has frequent visitors and is noisy at night. Mr. T’s
son has tried to communicate with him using Skype, but Mr. T refused, saying he is upset that
his son sold the family home and moved to South America with his family rather than caring for
him at home.
He is an experienced gardener and had enjoyed volunteering at the local chapter of the
Horticultural Society prior to admission. He has not done any gardening this summer. He says
it’s not the same without Frank, who was a volunteer at the facility. Mr. T had developed a
friendship with Frank, and when Frank moved to Edmonton with his daughter four months ago,
Mr. T stopped going to the garden. He says he misses Frank very, very much. This was the only
group activity he attended and enjoyed.
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Review the responses and document your rationale for coding of the items in F1, F2 and F3 for
Mr. T.
Rationale:
Rationale:
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Rationale:
In the Index of Social Engagement (ISE), all items from Section F1 (Sense of
initiative/involvement) are used in the calculation of this outcome scale.
Rationale:
Important Note
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Example—N2
Average Time Involved in Activity Pursuits (N2)
The past 7 days, Mrs. B woke up around 7 a.m. She listened to the news on TV until the PSW
came in to assist her with morning care. Once in her wheelchair, she pushed herself to the
dining room for breakfast. At 9 a.m. she went to the activity room and participated in group
exercise led by the recreation therapy assistant. At 10 a.m. the nurse gave Mrs. B her
medications, followed by a dressing change to her right foot. By 11 a.m., Mrs. B sat in
her recliner chair and knitted.
After lunch, she took a one-hour nap. She had the volunteer wake her up for the 2 p.m. activity
(cooking and music sessions). Mrs. B spent her afternoons in the lounge chatting with other
residents or sitting outside on the patio feeding birds.
After supper, Mrs. B napped as usual and got up when her husband arrived. Just before he left
at 10 p.m., he helped her with undressing and getting her in bed. On his way out, he notified the
nurse so Mrs. B’s HS medications could be administered.
Code 0 (Most—more than 2/3 of the time)
Rationale: Mrs. B was actually involved in activity pursuits more than two-thirds of the available
free time she had in the last seven days.
She was asleep approximately 11 out of 24 hours.
She received nursing care/treatments or was engaged in ADL activities approximately 6
out of 24 hours.
This left her approximately 7 out of 24 hours to pursue various activities.
She used most of these 7 hours participating in group activities (exercise, music and cooking
sessions) and being involved in one-on-one activities (watching TV, knitting, reading and feeding
birds). She was also involved in chatting with other residents in the afternoons and visiting with her
husband in the evening
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Vignette 2: Mr. D—N1, N2, N3, N4 and N5
Mr. D is a 58-year-old man who has Down’s Syndrome with dementia. He was recently
admitted to Harmony Nursing Home after his mother, who was his primary caregiver, suddenly
passed away.
He wakes up at 7:00 a.m. every morning and tends to be lethargic. He takes a half hour nap
every morning and afternoon because he sleeps poorly at night. He is most active in the middle
of the afternoon. Mr. D enjoys walking outside on the grounds every day with a volunteer and
enjoys their conversations. Most afternoons, Mr. D meets the horticultural therapist and
together they water the plants, weed the garden and feed the birds. He also enjoys sitting in the
gazebo and listening to his music. Mr. D has a congenital heart defect and requires frequent
rest periods; he is found watching TV or looking at magazines in his room later in the afternoons
and early in the evenings. He is usually in bed by 11 p.m. Having vision and hearing deficits
makes it more difficult for him to participate in group activities. So far, he has not participated in
group activities with other residents; he is very shy and prefers one-on-one interaction with
others or time alone.
On admission, his brother George shared with the staff that Mr. D has always been a loner and
has never socialized much. George reinforced with the staff the importance of a structured
environment for Mr. D. He has always had difficulty transitioning to new activities and schedule
changes. His brother added that Mr. D might like to go to the church service on Friday morning
if someone accompanied him.
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Review the responses and document your rationale, on the next page, for coding of the items in
N1, N2, N3, N4 and N5 for Mr. D
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Rationale:
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Activity 2 – Coding and Interpreting
In This Activity You Will
Review each vignette
You will use the following resources:
– Participant workbook: Activity Two—vignettes 1 and 2 including tracking forms
– RAI-MDS 2.0 guidelines found on page 6
– RAI CODE critical-thinking strategy found on page 7
– RAI-MDS 2.0 User’s Manual
As a group, document your findings for each vignette and identify any other areas on the
assessment where you would capture this information. What items impact the outcome
scale scores in Section B (Cognitive Patterns) and Section E (Mood and Behaviour
Patterns)?
Present your findings and participate in discussions
Time allotted: 20 to 25 minutes
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Vignette 1: Miss J—Sections B2, B3, B4, B5 and B6
ARD: Thursday, September 25, 2014
Miss J has been at the New Star LTC home for three months now. She was admitted for
rehabilitation following a stroke, and she is hoping to return to her group home soon. Miss J has
schizophrenia which is being closely monitored and has been reported as stable since her
admission. She has adapted well to her temporary placement.
In the past week, staff reported that she was having trouble remembering what she ate for lunch
when questioned five minutes after she finished her meal as she was walking back to her room
independently. However, she was able to recall her birthday. Normally, she is able to recall
what season it is and able to recognize staff members by name. When asked where she lives,
she indicated that she is in a home for old people until she gets better and can go back to her
group home where her friends live.
Since admission, Miss J was usually able to choose her clothes for the day and know when to
walk to the dining room for meals. However, since Tuesday (September 23), staff have
reported that Miss J has been unable to find her assigned table in the dining room. She didn’t
seem to realize that she kept sitting at different tables and she did not ask staff or volunteers for
assistance. Yesterday (September 24), she arrived for breakfast in her pajamas and her winter
jacket and she had her roommate’s shoes on. The health care aide offered to help her change
her clothes and she accepted willingly.
In the evenings during HS care, staff noted that Miss J was having difficulty removing her
clothes and, when handed the toothpaste, she didn’t know what to do with it. Before she
finished brushing her teeth, she started to brush her hair. She went on about a movie she saw
last month as if it had happened yesterday, then in the middle of a sentence she started to hum
a song. The day staff did not report this behaviour.
The staff have also observed that Miss J is continuously picking at her clothes, trying to
remove lint when none is apparent. However, that is not new for her; she’s been doing this for
months now.
This morning (September 25) Miss J would not get up for
breakfast. She was difficult to rouse and speech was incoherent.
Lori immediately reported her findings to the nurse practitioner,
who ordered blood work.
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Document your findings and rationale using the completed tracking form (where applicable) for
Sections B2, B3, B4, B5 and B6 for Miss J.
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1. In reviewing Miss J’s story, identify other areas on the assessment where you would capture
this information (if applicable)?
2. What items in Section B (Cognitive Patterns) impact the outcome scale scores?
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Vignette 2: Mr S. — Sections E1, E2, E3, E4 and E5
ARD: Thursday, October 30, 2014
Mr. S has been at the Cross Roads Manor for more than four years. He is pleasant and very
jovial, enjoys social activities and is always the first one to initiate gatherings. He plays his
harmonica for people when there are get-togethers in the lounge.
Four months ago, he fell getting out of his son’s car and suffered a hip fracture. Following
surgery, he returned to the home and was started on an intensive physiotherapy program. In the
first six weeks, he was compliant with the program and was determined to get back on his feet.
In the last month, when he realized his improvement was much slower than he expected, the
staff have observed changes in Mr. S’s mood. He has been looking sad and discouraged. He
started to find all kinds of reasons for not going to the gym or doing his exercises with the rehab
assistant. He has been declining pain medication and staying in bed most of the day, saying he
really needs to rest. He has not wanted to be with others, and when going for meals he has
been keeping to himself and quickly returning to his room right after eating.
Two weeks ago, when staff noticed a small pressure ulcer on his left buttock (stage 2), he told
them he had no more energy to fight anything. He has repeated similar statements to other staff
at least three times last week and again twice this week, according to the tracking sheet. He told
the recreation therapist last week that he was no good anymore and that he was not going to
play his harmonica anymore. No one else heard him saying this.
Daily, since October 27, staff have reported incidents where Mr. S has thrown his clothes on the
floor and shoved his wheelchair against the wall after transferring to his bed. Francis, the dietary
aide, said he noticed Mr. S moving his wheelchair back and forth and appearing agitated twice
last week. He has been impatient with people coming into his room—pointing at the door and
refusing assistance with dressing and personal hygiene. It was reported that Mr. S cursed at
staff while they were providing HS care. Staff let him have his space during these outbursts
and he calmed himself within a few minutes. They understand that he has lost so much
independence over the past few months and they are willing to tolerate the fact that he is
disagreeable at times. Mr. S was started on an antidepressant 14 days ago.
This morning (October 30), Mr. S told Mia, the health care aide,
that watching mass on television was OK but he was looking
forward to returning to the chapel to attend mass with the priest.
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Document your findings and rationale using the completed tracking forms for Sections, E1, E2, E3, E4 and E5 for Mr. S.
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1. In reviewing Mr. S’s story, identify other areas on the assessment where you would capture
this information (if applicable)?
2. What items in Section E (Mood and Behaviour Patterns) impact the outcome scale scores?
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Data Quality
Ensuring Quality Data for Quality Care Use of information, often referred to as data, is the most direct route to data quality; it
encourages people to take a closer look.
Part of being an informed assessor is understanding not only the information you are
collecting but also how it can be used to provide care for your residents.
Everyone who touches information has an impact on its quality.
As front-line assessors, how you code affects the information that is used for the resident,
the organization, the ministry and researchers.
How Continuing Care Data Flows
Data flows in a cyclical process. It starts with clinicians assessing residents based on
knowledge and best practices. This information is then used to support decisions and drive
continuous improvement, which cycles back and is reflected in resident care.
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Cognitive and Mental Health and Quality of Life Outputs
Sections B, E, F and N impact the following clinical and organizational outputs:
Section B (Cognitive Patterns) Section E (Mood and Behaviour Patterns)
CAPs
ADL, Physical Restraints, Cognitive
Loss, Delirium, Communication, Mood,
Behaviour, Activities, Social
Relationship, Dehydration, Feeding
Tube, Urinary Incontinence, Bowel
Conditions
CAPs
Cognitive Loss, Mood, Behaviour, Activities
Outcome Scales
CPS, CHESS
Outcome Scales
DRS, ABS
Resource Utilization Groups (RUGs) Resource Utilization Groups (RUGs)
Quality Indicators Quality Indicators
Section F (Psychosocial Well-Being) Section N (Acitivity Pursuit Patterns)
CAPs
Activities, Social Relationship
CAPs
Activities
Outcome Scales
ISE
Resource Utilization Groups (RUGs)
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Activity 3 - Data Quality The Activities CAP and CPS are generated directly from information coded in the Cognitive and
Mental Health and Quality of Life domain. If the sections are coded incorrectly, what could
happen at an aggregate level that may affect both the resident and the facility?
Response: