Countdown to MDS Section GG: Collaboration Between Nursing ... · 19/07/2016 · American...

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1 Copyright © 2016

Presented in Collaboration with NASL:

Joanne M. Wisely, MA CCC/SLP, VP Legislative AdvocacyGenesis Rehab Services/Respiratory Health Services

Jane Moffett, RNExecutive Vice-President, Casamba

Amy Franklin RN, RAC-MT, DNS-MT, QCP-MTAANAC Curriculum Development Specialist

Countdown to MDS Section GG: Collaboration Between Nursing and Therapy

2 Copyright © 2016

Faculty Disclosure

• I have no financial relationships to disclose

• I have no conflicts of interests to disclose

• I will not promote any commercial products or services

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3 Copyright © 2016

Requirements for Successful Completion

• 1.0 contact hour will be awarded for this continuing nursing education activity

• Criteria for successful completion includes attendance for at least 80% of the entire event. Partial credit may not be awarded.

• Approval of this continuing education activity does not imply endorsement by AANAC or ANCC (American Nurses Credential Center) of any commercial products or services.

American Association of Post-Acute Care Nursing (AAPACN)* is accredited as a provider of continuing nursing education by the

American Nurses Credentialing Center’s Commission on Accreditation.

*AAPACN d/b/a American Association of Nurse Assessment Coordination

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Learning Objectives

• Detail tasks that facility management need to consider in preparation for the October 1 deadline.

• Explain how implementation of the new section GG will impact workflow and IDT team collaboration

• Describe the best practices and considerations around who from the IDT team should complete section GG

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5 Copyright © 2016

Section GGFunctional Abilities

and Goals

Starts 10-1-16

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IMPACT ACT 2014

• Must have a means of comparing, measuring outcomes and a systematic means of data collection of the Medicare Beneficiary across all Post Acute Care (PAC) settings:

– Skilled Nursing Homes

– Inpatient Rehab Facility

– Long-term Care Hospital

– Home Health Care

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Education

Administrator

Integration Software

Rehab

Discharge Planning

• Interdisciplinary Team (IDT)

• Direct Care Staff

• Business Office Manager

• Medical Records

• Point Of Care

• MDS

• Rehab

• Orders

• Screens – not for GG

•Pre-Admit-Rehab/Medical•By Day 3 •Social Work

Task for the Staff

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A2400. Medicare Stay Dates Dictate When To Code Section GG Look-Back Is Three Days

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GG0130 & GG0170 Admission & Discharge Goal or Discharge Performance

Helper Assistance

• Only required because resident's performance is unsafe or of poor quality

• Score according to amount of assistance provided

• Activities may be completed with or without assistive devices

• Does not include: Family, Hospice, Private Duty, Student Nurses/Nurses Aide

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GG0130 & GG0170 Admission & Discharge Goal or Discharge Performance

Usual Performance

• Over the course of three days

• Compare prior function from the current illness or injury or exacerbation• Think about each Self-Care/Mobility item as separate

when completing Admission and Discharge Performance and Discharge Goal

• Established through IDT collaboration

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New: Safety & Quality of Performance Scale


6-Point Rating Scale

• Independent – Resident completes the activity by him/herself with no assistance from a helper.

Code 06

• Setup or Clean-Up Assistance – Helper SETS UP or CLEANS UP; resident completes activity. Helper assists only prior to or following the activity.

Code 05

• Supervision or touching assistance – Helper provides VERBAL CUES or TOUCHING/STEADYING assistance as resident completes activity. Assistance may be provided throughout the activity or intermittently.

Code 04

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6-Point Rating Scale

• Partial/Moderate Assistance – Helper does LESS THAN HALF the effort. Helper lifts, holds, or supports trunk or limbs, but provides less than half the effort

Code 03

• Substantial/Maximal Assistance – Helper does MORE THAN HALF the effort. Helper lifts or holds trunk or limbs and provides more than half the effort.

Code 02

• Dependent – Helper does ALL of the effort. Resident does none of the effort to complete the activity. Or, the assistance of 2 or more helpers is required for the resident to complete the activity.

Code 01


If Activity was not Attempted

• Resident Refused – If the resident refused to complete the activity. Code 07

• Not Applicable – If the resident did not perform this activity prior to the current illness, exacerbation, or injury.

Code 09

• Not attempted due to medical condition or safety concernsCode 88

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Section GG: Functional Abilities, Goals and Discharge Performance

GG0130. Self-Care

GG130.A

Eating

• The ability to use suitable utensils to bring food to the mouth and swallow food

• Once the meal is presented on a table/tray

• Includes modified food consistency

GG130.B

Oral Hygiene

• The ability to use suitable items to clean teeth

• Dentures:

• The ability to remove and replace from and to the mouth

• and manage equipment for soaking and rinsing them.

GG130.C

Toileting Hygiene

• The ability to maintain perineal hygiene,

• Adjust clothes before and after using the toilet, commode, bedpan, or urinal.

• If managing an ostomy, include wiping the opening but not managing equipment



GG0170. Mobility

GG0170.B Sit To Lying

• The ability to move from sitting on side of bed to lying flat on the bed

GG0170.C Lying To Sitting On

Side Of Bed

• The ability to safely move from lying on the back to sitting on the side of the bed

• With feet flat on the floor

• And with no back support

GG0170.D Sit To Stand

• The ability to safely come to a standing position from sitting in a chair

• Or on the side of the bed

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GG0170.E

Chair/Bed-to-Chair Transfer

• The ability to safely transfer to and from a bed to a chair (or wheelchair)

GG0170.F

Toilet Transfer

• The ability to safely get on and off a toilet or commode

GG0170. Mobility



GG0170. J Walk 50 Feet With 2 Turns

• Once standing, the ability to walk at least 50 feet and make two turns

GG0170.K Walk 150 Feet

• Once standing, the ability to walk at least 150 feet in a corridor or similar space

GG0170.R Wheel 50 Feet With 2 Turns

• Once seated in wheelchair/scooter (manual or motorized), can wheel at least 50 feet and make two turns

GG0170.S Wheel 150

Feet

• Once seated in wheelchair/ scooter (manual or motorized), can wheel at least 150 feet in a corridor or similar space

GG0170. Mobility


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Helper Effort

2 Helpers

01. Dependent

Even if the resident participates

Following behind with a w/c while the other helper is holding the gait belt

Less Than Half

03. Partial/

Moderate Assist

Resident performed more than half

May Lift or Hold or Support Trunk or Limbs

More Than Half

04. Substantial/

Maximal Assist

Resident performed less than half

May Lift or Hold or Support Trunk or Limbs


Refusal vs. Medical & or Safety

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THE IDT

MAKING IT HAPPEN


MDS SECTION GG COMPLETION

Does…

• Use of a “Six Point Scale”

• Capture “Usual” performance of the patient

• Use a three day lookback

• Require IDT collaboration

• Including Rehab, as appropriate

Does NOT…

• Use the “Rule of Three”

• Use a “Seven Day Look back”

• Require Rehab evaluation & goals

• Require Rehab “days and minutes”

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SECTION GG COLLABORATION IDT

Nursing All Shifts

• Admission and Discharge Assessments

• 24/3d Routine Observations (Med Pass, Treatments, etc)

Direct Care -All

Shifts

• Overall Mobility

• Bathing, Dressing Eating

Rehab

Eval with Goal(s)

D/C Status

• Mobility

• Self Care

COLLABORATION = USUAL PERFORMANCE

24/3d Baseline @ Admission WITH Goal for Discharge

24/3d Status @ Discharge


SECTION GG COMPLETIONHow Does It Happen?

Team Leader

&/or NAC

Nursing

Direct Care Staff

Rehab

Social Service

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SECTION GG COMPLETIONHow Does It Happen?

CONSIDERATIONS

Efficient & Accurate Processes• How to meet 3 day deadlines?

• Team members always available?

• Team members educated to “Usual” vs. “Rule of Three”?

• Nursing documentation addresses mobility & self-care?

• Evaluation info from Rehab?

OPTIONS

Change or Create….• MDS Information Capture?

• Stand Up Meeting?

• Shift Change?

• Medical Record Documentation?

• Restorative Program Documentation?

• Team Meetings?

• Electronic Communication?

• Data Capture Worksheet?

www.AANAC.org/Section-GG-Resources


All Data Used to SET THE GOAL

Nursing

Assessment Findings

Med Pass Observations

Treatment Observations

Direct Care

Performance in Daily Activities

Mobility Performance

with or without devices

Overall Need for a “Helper”

Rehab

Evaluation of Mobility

Evaluation of Self Care

Therapy Goal(s) for Mobility

and/or Self-Care

Social Service

Discharge Plan

Home Health Care

Community Discharge or

Remain at Facility

http://www.aanac.org/Section-GG-Resources

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SETTING THE GOAL: Scenario

Nursing Overall Observations - Day 1, 2 & 3

• Unable to complete meals without feeder assistance

• Assistance needed to stand and unable to walk

• Needs reminders and cues to follow direction

Direct Care Observations- Day 1, 2 & 3

• Needs one person assistance to transfer from bed to wheelchair

• Needs helper to push wheelchair

• Needs assistance to clean self and adjust clothes when toileting.

www.AANAC.org/Section-GG-Resources


SETTING THE GOAL: Scenarios

PT Evaluation & Treatment on Day 2 & 3

OT & SLP: no eval orders on admission

• PT Evaluation and 1 treatment– Chair to bed transfer & toilet transfer

• “assist of two”

– Sit to stand

• “assist of one”

• PT Goals

– Sit to stand for 60 seconds: Independent

– Chair to bed transfer & toilet transfer: Supervision with verbal cues


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SECTION GG Setting the Goal

Considerations

A. What is reported as the “usual” performance on Day 1? Day 2? Day 3?

B. Is the performance reported on the PT evaluation the same or different from what other caregivers report?

– Do A & B provide an admission baseline for this patient?• Yes = Continue to Item “C”

• No = Review findings and consult with Interdisciplinary Team


SECTION GGSetting the Goal

C. Did the patient state in the social service notes a preference and/or goal for discharge? – Yes/No

D. Is the patient motivated to achieve greater mobility and independence?– Yes/No

E. Does the patient appear to have potential for increased mobility and more independent self care?– Yes/No

What’s the Goal?

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SETTING THE GOAL WITH REHAB

Section GG Goal Chair to Bed Transfer with Supervision

Nursing Assessment Caregiver Observations

NursingDirect Care

Staff

Rehab Goal

Rehab


SETTING THE GOAL WITHOUT REHAB

Section GG Goal Chair to Bed Transfer with Assist of One

Nursing Assessment Caregiver Observations

NursingDirect Care

Staff

Rehab Goal

Rehab

X

X

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SAME PATIENT & DIFFERENT GOALS?

Reality….

• Rehab is not always ordered on admission

• Historically, Nursing Assessments do not set goals

Collaboration and Cooperation Helps…

• Do you have systems in place for rehab admission orders?

• Do you currently have prompt and effective communication with Rehab staff?

• When the Rehab Director is away, is there an designee named?

• Do you have a Restorative Nurse Coordinator who could help establish goals?

• Could you plan to practice setting Discharge Goals with Rehab beforeOctober 1?


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Therapy

Nursing Team

Observ.

Who Contributes?

RNAC completes the section with input From the resident, family, direct care staff and medical record to determine

the ‘Usual’ performance during the 3 day observation period

Patient & Family


Considerations on Collecting GG Rationale

New Observation Period

Different Definition

Goal Setting

New DC Assessment

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Observation Period for GG vs G

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Day 8

Day 1

Day 2

Day 3

Day 4

Day 5

Day 6

Day 7

Day 8

Section G

Section GG


Medicare Day 1

• Nursing & SNF Staff

• Initiate Admissionassessment

• Observe self-care and mobility performance

• Notify rehab of orders

• Rehab

• Eval/Treat

Medicare Day 2



• Rehab

• Eval/Treat

Medicare Day 3



• Rehab

• Eval/Treat

• MDS Coordinator RNAC

• Review and discuss with team to confirm final ‘Usual’ score for each item

• Decide on appropriate Goal(s)

• Complete MDS Section GG

• Document rationale

When Do We Think GG?

Don’t go back and modify this section when

completing other items. It’s expected that this

section will be scored differently than Section G,

after all both the definition and observation period are different!

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Getting from Day 1 to Day 3

Check• Check census to

determine if a resident was admitted or discharged since the last IDT discussion

• It’s even more important now to know if someone had an early planned discharge

Track• Track all

residents during their 3-day assessment period

• First 3 days and last 3 days of Medicare coverage

Observe• Observe and

document the resident’s USUAL self-care and mobility status during the observation period based on

• direct observation

• resident’s self-report

• family report (but not what family did)

• direct care staff

• medical record

Discuss

• Discuss Residents in an observation period for GG daily at stand up or IDT meetings

• Collect information about self-care and mobility during the past 24 hours


These items map back to the definitions

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An explanation of the scoring is displayed

here for quick reference


Remember use these codes instead of dashes• if the resident refused code 07• if the item is not applicable code 09• if the activity was not attempted due

to medical condition or safety concerns code 88

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The definition of each item is here


Beginning on Day 1 of Medicare, collect information on each shift of the ‘Usual’ performance based on • direct observation• resident’s self-report• family report• direct care staff • medical record

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On Day 3, review and decide on each value AND

complete section GG


Last 72 hours

on Medicare A

Team Consults

Which team members

will be able to contribute

during the three day

observation period

(last three days of Medicare)

Last 48 Hours

on Medicare A

Nursing & SNF Staff

- Initiates discharge

assessment

- Review of current status

to determine usual

Rehab

- Reviews end of care status

to prepare for team collaboration

Last 24 hours

on Medicare A

Nursing & SNF Staff

- Completes discharge assessment

Rehab

- Completes Therapy DC documentation

Facility Designees

- Consolidate information found during the

observation period

- Collaborate to determine final content/scores

Discharge from Medicare

MDS Coordinator/RNAC - Completes MDS

Section GG

Section GG – Discharge

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This area is completed during the last 3 days of the Medicare stay


Template Note for Usual Performance

Section GG completed today. Based on chart review, direct observation and discussion with direct care staff, patient and family over the observation period the following are the usual performance for self-care and mobility:

– xxx is the usual performance for Eating– xxx is the usual performance for Oral hygiene– xxx is the usual performance for Sit to lying– xxx is the usual performance for Lying to sitting on the side of bed– xxx is the usual performance for Sit to stand– xxx is the usual performance for Chair/bed-to-chair transfer – xxx is the usual performance for Toilet transfer– xxx is the usual performance for Walk 50 ft with 2 turns– xxx is the usual performance for Walk 150 ft– xxx is the usual performance for Wheel 50 ft with 2 turns– xxx is the usual performance for Wheel 150 ft

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Sample Note

Section GG completed today. Based on chart review, direct observation and discussion with direct care staff, patient and family over the observation period the following are the usual performance for self-care and mobility:

• Partial/moderate assistance for Eating

• Partial/moderate assistance for Oral hygiene

• Substantial/maximal assistance for Sit to lying

• Substantial/maximal assistance for Lying to sitting on the side of bed

• Dependent for Sit to stand

• Dependent for Chair/bed-to-chair transfer

• Dependent for Toilet transfer


No

t A

sses

sed

These items were not assessed because the

patient refused:

These items were not attempted due to medical

or safety reasons:

These items were not assessed because they are

not applicable:

Be sure to address items that you will code with 07, 09 or 88 in your note. Be sure to use these codes instead of dashes.

Charting for Items That are Not Assessed

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Sample Note – Not addressed

Patient is short of breath on exertion with recent discharge from acute setting due to an exacerbation of CHF complicated with diabetes. The following items were not assessed due to unstable medical condition:

• Walk 50 ft with 2 turns

• Walk 150 ft

• Wheel 50 ft with 2 turns

• Wheel 150 ft


• The IDT team has determined that the resident is expected to make gains in function by discharge in the following areas

Expected to Improve

• The IDT team has determined that the medically complex resident is not expected to progress to a higher level of functioning during the SNF Medicare Part A stay

Not Expected to Improve

• The IDT team has determined that skilled services may slow, but not prevent, the decline of function and has set goals appropriately

Expected to Decline

Sample Note for Goal(s)

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Sample Goal Note

The IDT team has determined that the as the CHF stabilizes, the resident is expected to make gains in function by discharge in the following areas:

• Increase to Supervision or touching assistance as the usual performance for Eating

• Increase to Partial/moderate assistance as the usual performance for Sit to stand

• Increase to Partial/moderate assistance as the usual performance for Chair/bed-to-chair transfer

• Increase to Partial/moderate assistance as the usual performance for Toilet transfer


Can My Software Help?

• Helpful provided all of the team uses it

• CNA’s who may be providing most of the support may not be contributors to these assessments

• Family and patient also don’t typically contribute

Software may be capable of adding a

custom charting area or assessment for GG

• Carefully review any items where software ‘averaged’ or calculated values for you

• Assessments are to be done in compliance with facility, Federal, and State requirements and accuracy of items are subject to audit

Software may be capable of ‘averaging’ answers & calculating

the ‘usual’

• Use caution and carefully review any MDS section where any value is inserted from an external source

• In a 72 hour period for a patient with a RUG of V, therapy is involved for 3 ½ hours - 68 ½ hours of the patient’s stay are not represented

Software may be capable of fetching

values from Therapy software

“Don't assume that an automated process or import would have come to the same conclusion as your IDT team.”

“Check everything!”

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Team Meeting to Review the Following

Ask your team:• Who will be the expert coder of GG and who will be the back-up?• Who will help when Rehab is not treating the Patient?• When should we start practicing?• Usual Performance team discussion?

o Not Worst or Besto Compare prior to the event o Which documents do you need?

• Would a Questionnaire be helpful?• When will the software have your new item set available to practice?

Seek your Rehab team for discharge goal setting advice A2400.B equals 10-1-16 Section GG is to be completed

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NOW is the time TRAIN-TEST- TWEAK!

• Data in Data out (software)

– Clinicians MUST Assess, Evaluate & Attest

• Admission Performance with Goal Setting

• Discharge Performance

• Stop & Think

– Does the record reflect Section GG?


Resources

QRP Manual updated April 2016

• https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/Skilled-Nursing-Facility-Quality-Reporting-Program-Quality-Measure-Specifications-for-FY-2016-Notice-of-Proposed-Rule-Making-report.pdf

Draft MDS 3.0 RAI Manual v1.14 May 2016

• https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursinghomeQualityInits/MDS30RAIManual.html

Section GG Tools Link:

• www.AANAC.org/Section-GG-Resources

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/Downloads/Skilled-Nursing-Facility-Quality-Reporting-Program-Quality-Measure-Specifications-for-FY-2016-Notice-of-Proposed-Rule-Making-report.pdf

https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/NursinghomeQualityInits/MDS30RAIManual.html


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Hand Outs

• Section GG Key coding Q&A Tool

• DRAFT: MDS-3.0-SECTIONS-A-AND-GG-DOCUMENT

• Section GG Collection Data Tool

• Time Line


Contact AANAC

American Association of Nurse Assessment Coordination (AANAC)400 S. Colorado Blvd, Ste 600Denver, CO 80246

Phone: 303.758.7647Toll-free: 800.768.1880Fax: 303.758.3588

Email: https://www.aanac.org/Contact

https://www.aanac.org/contact

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Contact NASL

National Association for the Support of Long Term Care (NASL)1050 17th Street, NW, Suite 500Washington, DC 20036-5558

Phone: 202.803.2385

Email: [email protected]


mailto:[email protected]

Countdown to MDS Section GG: Collaboration Between Nursing ... · 19/07/2016 · American...

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