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BACKGROUND/RATIONALE:
Improving the quality of nursing home care is a high priority for VA. It implemented the Minimum Data Set (MDS) assessment in its nursing homes in order to assist staff in identifying residents' needs. The MDS is a standardized resident assessment tool that aims to screen for functional, mood and sensory problems in order to trigger and stimulate better care planning. It is an important element of VA nursing home health care operations. The VA National Nursing Home Service already mandates that the MDS be collected at regular intervals on all VA nursing home (NH) residents and uses this information to monitor quality and resource allocation. This project provided national VA input and leadership in revising and evaluating, in VA nursing homes, the validity and performance of nine key sections of the national MDS.
OBJECTIVE(S):
The overall project objectives were to provide scientific input to improve the quality of revisions to the national MDS 3.0, and to inform future VA NH care and quality improvement activities related to the MDS.
Specifically targeted MDS sections were: diagnostic coding, pain, delirium, falls, balance, depression, behavior disorders, quality of life, cognitive assessment.
METHODS:
In phase 1, each of four VA regional research teams developed and pilot tested protocols for two to three of the 9 selected conditions. Pilot data were collected on over 600 VA NH residents across the 4 regional sites. In phase 2 the VA pilot data were used to revise MDS 3.0 before completion of a large national VA and CMS test of MDS. The Phase 3 national test of the revised MDS included 19 VA NHs distributed across 4 geographically diverse clusters. The total VA national sample of 758 included an inter-rater reliability sample (n=402) for all MDS 3.0 items, and a validation reliability sample (n=64).
FINDINGS/RESULTS:
In Phase 1, a VA HSR&D funded consortium of VA NH researchers developed and tested significant revisions to items and instructions for 9 key sections of the MDS. This testing revealed that NH staff could reliably conduct performance based cognitive assessments, identify delirium, assess balance and report on the outcomes of falls. In addition, our research showed that NH residents could answer questions about mood and pain using standardized assessment items and that the PHQ-9 could be used in NHs with higher validity that current MDS mood items and the Geriatric Depression scale. Testing also showed that revised behavior labels and new impact items could allow staff to identify behaviors that placed residents at risk. A revised customary and routine section allowed residents to report on the importance of day-to-day care and of daily activities. In Phase 2, VA recommended changes were incorporated into the Center for Medicare & Medicaid Services (CMS) MDS form prior to national testing.
In Phase 3, the VA HSR&D funded NH research consortium tested the revised MDS 3.0 in 19 regionally distributed VA NHs. A concurrent study was funded by CMS in 71 community NHs. The VA study successfully collected data on 758 VA residents. Privacy protocols and subject protections were adhered to throughout the data collection. The VA study showed that VA nurses who independently collected the new items had high levels of agreement with research trained gold-standard nurses (86% of items had excellent kappas and another 10% had very good kappas). Revised items also significantly improved the accurate assessment of cognition and increased detection of depression, balance problems and pain. Residents across cognitive levels were able to complete items asking about mood, pain, and daily and activity preferences and used the full range of response options for these items. A revised form has been submitted for final implementation decisions by CMS and VA leadership.
IMPACT:
VA research led to a proposal for substantial revisions nationally of a primary instrument for NH care planning, quality assessment and resource utilization measures. These revisions increased residents' voices in their own assessments, supporting resident-centered care assessments. The MDS assessment is submitted to VA almost 67,000 times a year and to CMS almost 14 million times a year. VA leadership was highlighted in an open door forum at CMS with an estimated 5,000 participants. Various finding from this research are highlighted in 3 peer-reviewed publications (published or in press), 16 national broadcast or symposium presentations and 20 additional abstracts presented at national meetings. Presentations which included VA findings were awarded 3 separate awards at the 2008 annual meeting of the American Geriatrics Society.
PUBLICATIONS:
None at this time.
DRA:
Health Services and Systems
DRE:
none
Keywords:
Research measure, Research method
MeSH Terms:
none
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