Providing residents with post-hospital and long-term care is complex and challenging work

Development of effective individualized care plans requires staff in all disciplines to demonstrate clinical competence, skilled observations, effective interviewing, and critical thinking. To do this, the Centers for Medicare & Medicaid Services (CMS), responsible for establishing quality of care standards and conditions of participation for the Medicare and Medicaid programs, designed an assessment tool, the Resident Assessment Instrument (RAI), consisting of three elements:

The Minimum Data Set is a core set of screening, clinical, and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid.

The Care Area Assessment Process assists the assessor in systematically interpreting the information recorded on the MDS and helps the clinician to focus on key issues so that decisions as to whether and how to intervene can be explored with the resident.

The Utilization Guidelines provide instructions for when and how to use the RAI.

Be prepared for Federal and State surveyors

More than 4,000 Federal and State surveyors conduct onsite reviews of every nursing home about once a year. By implementing the MDS 3.0 module of American Health Care Software’s Clinical Care Suite, not only will your institution be prepared for surveyors, you will have the tool to gather definitive information to develop individualized care plans, track changes in residents’ status, and maintain residents’ highest practical level of well being.

Built into AHC’s MDS 3.0 are all of the content and structural revisions made by the RAND Corporation and Harvard University on MDS 2.0 as well as the features that expand the uses for the MDS. Medicare and many state reimbursement systems use data collected from MDS. They also monitor the quality of care provided to nursing home residents through required assessments. AHC’s MDS 3.0 has also been adapted for the hospital swing bed program to obtain reimbursement under the Skilled Nursing Facility Prospective Payment System.

The tabbed interface keeps you oriented and organized

You select a resident, start an assessment, and move through the assessment section by section. American has retained the section and item numbering scheme on the printed MDS 3.0 form.

American prefills information for you

As you display the various sections of the RAI, you will notice that American has prefilled many of the items with values taken from the Clinical Care Suite database. This feature drastically cuts down the data entry you must do and turns a tedious task, such as entering all the required identification information, into a simple review of the data displayed.

You can compare previous assessments side by side

Displayed for each resident are the results of any previous assessments. .You can track changes in the resident’s physical and mental health, treatments, medications, and communication.

CMS’ RAI Version 3.0 Manual is built in

Built into AHC’s MDS 3.0 is a help system that incorporates the item-by-item coding instructions for all required sections and items in the comprehensive MDS Version 3.0 item set included in CMS’ RAI documentation. A glossary and robust index and search feature gives you the information you need as you complete the assessment—without interrupting your work or leaving the screen to get it.

For more information visit: www.ahconline.com/clinical