With ‘Significant Dollars’ at Stake, Nursing Home Operators Prep for MDS Mood Interview Changes

As nursing home operators enter the final stretch before Minimum Data Set (MDS) changes take effect on Oct. 1, they are focusing particular attention on items related to capturing resident depression.

With a substantial amount of reimbursement being at stake, the effect of the change from the PHQ-9 to the PHQ-2 to 9 is the “million-dollar question” facing operators, Alicia Cantinieri, vice president of MDS policy and education for Zimmet Healthcare Services Group, said at the firm’s recent “Roaring Reimbursement” conference in Connecticut.

While the exact consequences of the PHQ switch remain to be seen, the new interview parameters are going to “change things pretty drastically,” Ignite Medical Resorts VP of Clinical Reimbursement Shawna Rainey told Skilled Nursing News at the Zimmet conference.

Instilling strong interview techniques is therefore a crucial element for operators’ preparation process for the MDS, as they enter this crucial phase leading up to Oct. 1. But while the PHQ changes are a cause for some concern, Rainey and other operational leaders expressed that they are generally confident that their teams are in a good position to make the MDS transition.

Significant dollars at stake

To gain a better understanding of how the switch to PHQ-2 to 9 could affect skilled nursing facilities, analysts with Zimmet and partner SimpleLTC reviewed 2 million MDS assessments. They determined that if the forthcoming system had been in place, the number of assessments resulting in a depression end-split would have fallen by 18%.

This is alarming news from a financial perspective for SNFs, given that the depression end-split triggers a reimbursement increase under Medicare Part A.

The issue lies in the new directives for how to conduct the resident mood interview. The interview currently consists of nine questions meant to gauge the level of distress and frequency of related symptoms over the previous 14-day period. Under the changes taking effect this fall, a resident’s answers to the first two interview questions determine whether the subsequent questions will be asked, or whether the mood interview will immediately end.

The first question pertains to whether the individual has had “little interest or pleasure in doing things” and the second question relates to whether the individual has been “feeling down, depressed, or hopeless” during the previous two weeks. If the frequency for these items falls in the 0-6 day range, the mood interview will immediately end.

This new approach has some troubling implications from a care planning perspective, in Cantinieri’s view, considering that even if a resident has been experiencing mood-related distress for up to 42% of the previous 14 days, the assessment will no longer glean further information about matters such as sleep quality, poor appetite, or even whether a resident has had thoughts of hurting themselves or being “better off dead.”

From a financial perspective, a score of 10 or higher on the mood interview currently triggers the depression end-split payment, translating to about a $40 per day increase to the nursing component under PDPM, which for Medicare Part A is in 28% of available nursing case mix groups. On a state-by-state basis, reimbursement could be affected as case mix groups are affected under RUGS, Cantinieri noted.

“You get my point here — there’s significant dollars per day for signs and symptoms of depression in residents who score more than a 10 on that severity scale,” she said.

Interview skills more crucial

The PHQ changes place a premium on the skills of the interviewer, particularly given the sensitivity of the questions related to mood.

“There’s always been a stigma around depression or feeling down or hopeless,” Ignite’s Rainey told SNN.

Because of that stigma, a resident might not acknowledge feeling down, depressed or hopeless, affecting their answers to those first two “gateway” questions in the mood interview process. Given this risk, Ignite is training interviewers in techniques to put residents more at ease and encourage them to be candid.

“We have to take time to lay a foundation, make sure that the resident … is comfortable with who they’re talking to,” said Rainey.

Doing so requires that interviewers slow down and establish a relationship with the resident during the interview, which can be difficult, given the time pressures affecting all nursing home staff. As Rainey said, “We’re all busy.”

Another key element of the interview will be explaining to the resident that the questions about mood pertain specifically to the previous 14 days. Quite often, this is a time period when a resident would have been going through situations that would affect mood.

“A lot of that [time] is leading into their hospital stay — they probably had a traumatic event that led them there,” Rainey said.

Confidence in preparations

While the mood interview changes demonstrate the importance of careful preparation for the MDS switch, and the potential for a reimbursement hit if operators botch the transition, Rainey and other operational leaders said they are confident that their teams will be ready come October.

There are plentiful resources to draw from in training staff on the PHQ changes and the overall MDS transition, Rainey said. She and her colleagues have “attended conferences all summer long” to educate themselves and now are ready to begin more intensive training throughout Ignite, including “breakout sessions with individual disciplines.”

Focused Post Acute Care Partners already has done a “high-level, overview training with everybody” and is following up with “major, two-day trainings by region,” Vice President of Clinical Reimbursement Kristal Prather told SNN. The company’s portfolio, which consists of 30 facilities across Texas, is divided into four regions.

“The main goal for me was to just calm everybody down, because people are leaving the industry left and right,” Prather said. “So, just to calm everybody down, [and say] that we’ve got this, we’re going to be fine, just like we are every time they have changes in health care.”

A lot of the anxiety is due to the fact that so many people joined the nursing home industry during the Covid-19 Public Health Emergency and have not gone through an MDS update before, said Jolene Johnson, VP of clinical reimbursement with The Springs of Arkansas, which operates about 20 facilities across that state.

The Springs recently held a two-day training with MDS coordinators, and before addressing the coming MDS changes, a major focus was reviewing standard Medicare rules and regs, given that many of them have been working under the PHE waiver for their entire career in nursing homes up to this point.

Some big questions remain, including how the deletion of Section G will affect certain quality measures that affect Five Star ratings, as well as how certain states will handle the deletion of Section G — among the markets that Ignite serves, Missouri is the “outlier” that is not a PDPM state and has yet to announce a new system.

These issues notwithstanding, Rainey credits industry associations and Ignite’s partners — including vendors and software providers — with doing “a great job of preparing us.”

Prather and Johnson echoed Rainey’s comments.

“I feel very confident with the MDS changes,” Prather said. “I think we’re ready. We’ve got everything we need.”