Since last October’s Minimum Data Set (MDS) changes – considered the most significant since 2011 – nursing homes have faced more rigorous regulatory requirements and administrative burdens to implement them. However, these changes can serve as renewed opportunities to improve resident care through an interdisciplinary team approach, which can result in savings.
To draw success, it is also important for operators to understand the Centers for Medicare & Medicaid Services’ (CMS) intent behind collecting an expanded form of MDS data, according to Leigh Ann Frick, president of Care Navigation Consulting, who led a webinar Tuesday hosted by technology solutions company, Simple.
SNFs often focus on the new data and miss the intent, Frick said. Just collecting the data is not enough and operators must integrate it into care planning involving the whole team to achieve better outcomes.
Frick reviewed key MDS data elements – including recent changes and those proposed in the FY2025 SNF PPS Proposed Rule – and how those items drive person-centered care when communicated and integrated effectively.
A big change was elimination of Section G, and shift to Section GG.
“And that was a big change for us. But in addition to that, there was a roll out of several kinds of social determinants of health type questions.”
And it didn’t end there: A long and comprehensive list of items were aimed at improving success with discharges. And so the collection of data on conditions, forces and systems that shape a person can have an impact on rehospitalizations, for example, and shouldn’t be underestimated.
Knowing the intent
CMS’ intention stems from learning about “how we live our daily lives, what we do and how we do it, our access to health care,” Frick said. And so details on ethnicity and race, focus on preferred language, whether or not an interpreter was needed, whether transportation was an issue, needs for successful daily living, health literacy and social isolation, knowledge of high risk medications and an indication for their use,” are all data that sounds overwhelming to collect but very important when considering that it leads to successful discharge, she said.
“It’s important to note that a lot of those changes, a lot of those additions, found their way also to the Medicare Part A PPS discharge assessment,” she said.
With such a long list of data demands, Frick said teams simply cannot work in silos. If social services or nursing teams learn about a resident’s transportation needs but fail to communicate this to therapy, the care plan can be negatively impacted. The same is true for Section Q, or Participation in Assessment and Goal Setting, which is critical for care planning.
And given the enormous shift, not all participants in the webinar during an internal poll considered themselves experts at logging and implementing the Oct. 1 MDS changes properly.
About a third of the attendees rated themselves as “champions” at implementing the MDS changes, a third rated themselves as “runner-ups,” and yet another third said that they “were in the game.”
“[The October MDS change] was a big deal. And so I think the poll is reflective of that,” said Frick.
Frick, who is also a physical therapist, urged skilled nursing facilities (SNFs) to move beyond mere data collection and towards its meaningful integration into daily care practices.
She advised leveraging the data to personalize and optimize care.
“Care planning is key,” she said, “We want the resident to achieve their goals, and we must be a part of that process.”
Frick suggested individualized interventions that support and honor resident preferences and build upon their strengths.
“We want to avoid declines where we can and manage risk wherever possible. Current standards of practice need to be implemented [through] evidence-based practice,” she said. All this means a constant evaluation of treatment.
“What’s working? What are the timetables for the outcomes? Do they make sense within the time? All that’s a constant evaluation that we’re looking at through the care planning process,” she said.
The demand for data represents a shift towards patient-centered care by federal agencies, Frick noted, where MDS data serves as a foundation for tailoring interventions that incorporate resident populations’ preferences, strengths, and clinical needs and social determinants of health.
The expanded MDS requirements can be more successfully met by involving residents and their families in decision-making, SNFs can align care plans more closely with individual goals, thereby enhancing quality of life and care outcomes, she said.
Discharge function scores
One of Frick’s areas of focus was the discharge function scores.
Successful discharge planning begins from day one of admission, she said. By integrating early assessment of factors like medication management, social determinants of health, and functional abilities, SNFs can mitigate risks associated with transitions of care. This proactive approach not only supports smoother transitions but also reduces the likelihood of rehospitalizations and improves overall patient outcomes.
“Transitions of care are hard and risky,” Frick said. “But starting discharge planning early and involving patients and caregivers actively can mitigate these challenges.”
The incorporation of MDS data into discharge planning ensures that post-discharge care plans are tailored to meet the individual needs and circumstances of each resident, from medication management to social support and ongoing health monitoring.
Moreover, she stressed the importance of ongoing evaluation and adaptation of care plans based on real-time feedback and changing resident needs. This continuous improvement loop, driven by data insights, can allow SNFs to refine their care strategies and enhance the effectiveness of interventions over time.
Frick also touched upon the regulatory implications of these changes, emphasizing the need for accurate and complete documentation to support quality assurance and performance improvement initiatives. By utilizing the MDS data and sharing it at Quality Assurance and Performance Improvement (QAPI) meetings, SNFs can systematically review data outcomes, refine processes, and ensure alignment with regulatory expectations.