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acumen

insight

ideas

attention

reach

expertise

depth

agility

talent

ADLs The Foundation for Building

Healthcare OAHCP Spring Conference

2013

Objectives 1.  Participant will be able to verbalize an

example of how ADLs affect Nursing Home reimbursement.

2.  Participant will verbalize what the abbreviation RUG stands for.

3.  Participant will know what an ADL “aspect” means.

4.  Participant will understand the “difference” between the definition of Limited Assistance and Extensive Assistance.

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Definitions (Webster’s & Medicine Net.com)

ü ADLs refer to a common, everyday tasks, performance of which is required for personal self-care & independent living.

ü Things we normally do in daily living including any daily activity we perform for self-care such as feeding ourselves, bathing, dressing and grooming. o  This ability or inability to perform these ADLs can

be used as a practical measure of ability /disability

Activities of Daily Living

In healthcare ADLs “a term used to refer to daily self-care activities within an individual’s place of residence.”

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ADL measurements are used

1.  Qualify for private insurance policies & or programs v  Often a “trigger” for benefits or payment options

2.  Federal legislation proposed for public insurance plans to do the same.

3.  In some NH helps determine placement within a facility

4.  May help categorize a “disease process”

National & International Surveys

Measuring the ability of elderly people to perform their ADLs and how are they being conducted. Do we get consistent estimates?

Recent studies suggest “NO”

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Studies Studies from the early 1980s and 1990s. Policy makers & insurance want to know:

1.  “How many persons age 65 & older have ADL problems? 2. “How many have ADL problems by each type of activity?” “How many elderly have more than a threshold number of ADL problems?”

Not all surveys use the same list of ADLs

Time Study (STRIVE) ü CMS national NH time study “used to establish

RUG IV model” or PAYMENT ü Began on-site data collection spring 2006

ü Finished in late summer 2007

ü Statistics came from 205 NH

ü 15 states, 12,000 residents

ü Evaluation of STRIVE date ultimately = PPS RUG-IV model for payments (& many states use case-mix payment systems for Medicaid reimbursement.)

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Case Mix System

ü Medicare & Medicaid payment system consists of 3 components: 1.  Staff time measures: Collected time from all

direct care staff 2.  Resident Assessments

3.  Cost calculations of resources

RUG

RUG =

Reimbursement

Utilization

Group

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RUG scores ü ADL index required to qualify for RUG CMI

Example: Pneumonia & Fever

HE1 = $353.07/day (ADL=2-16)

CA1 = $208.81/day (ADL = 0-1)

Difference of: $144.26/day

Resident stays 14 days = $2,019.64

X 5 residents = $10,098.20

Mistake x 1 month = ?

Late loss ADLs

ü People retain their “functional ability” in these 4 areas the longest. 1.  Bed mobility

2.  Transfers 3.  Eating 4.  Toilet use

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Section G of the MDS 3.0

ü 11 ADLs in the assessment (MDS 3.0) 1.  Bed Mobility 7. Dressing

2.  Transfers 8. Eating 3.  Walk in room 9. Toilet use

4.  Walk in corridor 10. Personal hygiene 5.  Locomotion on unit 11. Bathing

6.  Locomotion off unit

ADLs MUST Be Right…..

1.  RUGs = Dollars 2.  Resident changes are identified – potential

Significant Changes 3.  Your Care is Rated

4.  Resident and Family Confidence

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Quality Measures and 5 Star Rating

Developed to help the consumer to understand “quality care in NH”. “A clinical performance measure” or “efficiency of care”

ü Quality Measures

ü 5 Star Rating - how your facility is ranked v Res. showing “significant” declines quarter to

quarter?

ERRORS……..

1.  ADL documentation is completed – how? 2.  Document correctly – how?

3.  Why do we want our residents to be SO good?

4.  Common mistakes?

5.  ADLs always important BUT when most important?

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Reimbursement not the only advantage

ü Quality of Care

Example: “Incontinent Residents should be on a Check-and-Change Program”.

From

:

Ronald Orth

To: LTC Network

Posted:

February 16, 2013 2:11 PM

Subject:

RE: Consolidated Billing and Antiretrovirals

Message:

View Profil

e Add Contact

Blog This Contact

Author

Just make sure 042 diagnosis is on UB when billing Medicare. The 128% increase is automatic. There is no antiretroviral drugs that are unbundled. Ron On Feb 16, 2013, at 11:33 AM, Glenda Hynes wrote: > > This message has been cross posted to the following Discussions: MDS > Connection and LTC Network . > ------------------------------------------- > > Hello, > > Patient being admitted with active HIV AIDS 042 on Med A. > What if any additional coding is required to insure add on reimbursement. > Patient is on antretrovirals - are there any drugs or any circumstances > where the facility can bill for these drugs outside of the PPS bundle? > > Any online resources that you can refer me to? > > Thanks very much! > ------------------------------------------- > Glenda Hynes RN > Westfield MA > ------------------------------------------- > >

Documentation – ADL Tracker ADL Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7

7a-3p Transfers / / / / / / / 3p-11p Transfers / / / / / / / 11p-7a Transfers / / / / / / / 7a-3p Eating / / / / / / / 3p-11p Eating / / / / / / / 11p-7a Eating / / / / / / / 7a-3p Toileting / / / / / / / 3p-11p Toileting / / / / / / / 11p-7a Toileting / / / / / / / 7a-3p Bed Mob / / / / / / / 3p-11p Bed Mob / / / / / / / 11p-7a Bed Mob / / / / / / / etc

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Self Performance Codes

ü 0= Independent: NO TALK, NO TOUCH ü Staff does no assist, instruct, nor cue: resident

does ü All activity ALONE no monitoring, no hands

on assistance. (with your eyes, you watched the resident thru the door)

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ü 1=Supervised: TALK, NO TOUCH ü Staff provides instructions or cueing (verbal),

but does not provide physical (hands on) assistance.

ü Oversight and cueing staff uses mouth/voice only.

ü NO HANDS

ü 2= Limited assistance: TALK and TOUCH ü Staff talks to give instructions or cues and

touches resident to assist: can be as simple as putting hands on resident’s back or holding his/her elbow while walking. Hands used for more than set up, but does not lift any part of the resident. The resident is highly involved, you did some hands on assist but it was NON-WEIGHT BEARING

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ü 3 = Extensive assistance: TALK, TOUCH, and LIFT

ü Staff uses muscle power to lift, move, or “shift” resident. This includes lifting legs into bed, “scooting” buttocks into positioning in bed, lifting arm to assist in self feeding. The resident performed part of the activity, but WEIGHTBEARING ASSIST (someone lifted a part of the body) was required.

ü 4 = Total Dependence: ALL ACTION BY STAFF

ü Resident dose not participate at all in any part of the activity being done for him/her. The resident didn’t lift a finger to help

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ü  (7= the activity occurred only once or twice) (not for CNA training)

ü 8 = the activity didn’t occur during the entire shift.

ü IF THE STAFF MEMBER HAS TOUCHED THE RESIDENT AT ALL, CODE IS AT LEAST LIMITED ASSIST.

Staff Performance

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ü 0 = No staff performance required, zip, zero, nada.

ü 1= set up help only, maybe you undid a cover, set the wheelchair at bedside or set out grooming items

 

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ü 2= ONE person. Physically assisted by one person

ü 3 = 2 or more physically assisted.

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ü 8= Activity didn’t occur during the whole shift.

ADL Aspects or Components

“Components of an ADL activity. These are listed next to the activity in the item set on the MDS. For example, the components of G0110H (Eating) are eating, drinking, and intake of nourishment or hydration by other means, including tube feeding, total parenteral nutrition and IV fluids for hydration.”

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Components or Aspects of an ADL

Example: EATING Eating

Drinking

Intake of Nourishment or Hydration by other means:

v  Tube feeding v  Parenteral nutrition v  IV fluids for hydration

Components or Aspects of an ADL

Example: Bed Mobility v Moving to & from a lying position

v Turns side to side

v Positions body while in bed or alternate sleep furniture

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Components or Aspects of an ADL Example Transfers v How the resident moves between surfaces

v To or from: 1.  Bed 2.  Chair

3.  Wheelchair 4.  Standing position (excluding to/from bath or toilet)

Components or Aspects of an ADL v Transfers on/off toilet (Toileting) v Cleanses self after elimination

v Changes pad

v Manages ostomy or catheter

v Adjusts clothes

Do NOT include emptying bedpan, urinal commode, catheter bag or ostomy bag

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Components or Aspects of an ADL

Example Toileting v How resident uses the toilet

1.  Room

2.  Commode

3.  Bedpan

4.  Urinal

Toileting Scenario: Conflicting?

ü Performing an “aspect” or “component” of the ADL activity for the resident is = extensive assistance.

ü  Performing a portion of a component is not – (CMS decided that zipping zippers, snapping snaps, buttoning buttons is limited assistance, not extensive assist because this is classified as a portion or a PART of a component.)

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Scenario: 3 ways to get Ext Assist

1.  Provide weight-bearing assistance at least 3 Xs 2.  Perform the “entire” activity for the resident at

least 3 times

3.  Perform an entire component or aspect of the activity for the resident at least 3 times

In the 7 day look-back period!

Toilet Use – Catheter or Ostomy?

Section G: Functional Status: (1) Q: How do you code G0110I Toilet Use for

residents with a catheter or ostomy?

A: Be sure you are assessing both methods of elimination….BOWEL AND BLADDER

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Catheter or Ostomy Care

Resident may require: (1) ü only limited assist with catheter

but

ü extensive assist transferring on/off the toilet

ü Just emptying the catheter or ostomy bag does not count,

ü but perineal /skin care does count

Teaching

ü Rule of Three

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Rule of Three (*)

ü RAI Manual says: “When an activity occurs three times at any one given level THEN code that level

ü When an activity occurs three times at multiple levels THEN code the most “dependent” level

Example: Resident requires assistance at an extensive level of assistance 3 times and at a “limited assistance” 3 times then code it as extensive assistance.

Activity occurs “More than 1 level”?(*)

ü But Not Three Times at any ONE level v Episodes of full staff performance are considered to

be weight bearing assistance when EVERY episode is full staff performance=Total Dependence (4)

v When there are 3 or more episodes of a “combination” of full staff performance & weight-bearing assistance=Extensive Assistance (3)

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Rule of Three

ü Exceptions 1.  Total dependence: activity MUST require full

assistance EVERY TIME 2.  Activity did not occur: activity must NOT

have occurred at all or family and/or non-facility staff provided care 100% of the time for the activity over the entire 7-day period.

Rule of Three Scenario: 3 ways to get Ext Assist

1.  Provide weight-bearing assistance at least 3 Xs 2.  Perform the “entire” activity for the resident at least

3 times

3.  Perform an entire component or aspect of the activity for the resident at least 3 times

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Teaching (2)

ü What does each task or “component” of each ADL “mean”.

TASK: Ask 5 different CNAs on different shifts what the definition of toilet use means.

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Teaching Task: Ask your CNAs or LPNs how would you code toileting if you had to empty Mr M’s urinal? ü RAI Manual says: Do Not Include Emptying of :

1.  Bedpan 2.  Urinal 3.  Bedside commode

4.  Catheter bag 5.  Ostomy

Teaching

ü Documentation Tools

Task: Ask 3 different CNAs what does it mean for a resident to be in their 7 day “look-back period or window ”.

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Teaching

ü Documentation

Task: Tell a CNA or an LPN: I want you to document the most dependent level so I can use the “Rule of Three”.

Teaching- Are These Probing Questions? ü How the resident uses the toilet room? Or

commode? Or bedpan? Or urinal? ü How the resident transfers on/off the toilet

ü How the resident cleans themselves after elimination

ü How the resident changes their pad

ü How the resident manages their ostomy or catheter

ü How the resident adjusts their clothing before elimination & after elimination

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Scenario: MEAL

Q: Resident completed all of his/her meal independently except the last few bites the CNA fed the resident. How should this ADL be coded for this meal?

Scenario: MEAL

A: Extensive Assist of one person: 3/2 3 = Extensive Assistance

2 = one staff person was required to assist

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How would you code?

ü Example: a resident who can pull up their pants but need assistance buttoning or zipping their pants?

ü Example: a resident who might be able to partially cleanse themselves but not fully cleanse themselves?

How would you code?

Example: Resident uses a bedpan and when the pan is placed by one CNA the resident helps lift their hips onto the bedpan?

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How would you code?

Example: Mr. P. uses the bathroom but staff assist Mr. P. to zip his pants, hand him a washcloth, and remind him to wash his hands after using the toilet daily. This occurred multiple times each day during the 7-day look-back period.

How would you code?

Example: One staff person is cueing four Dementia residents at a table to eat. They all start out independently eating although “cueing” is frequently needed with two (Resident A & B) and occasionally with the other two (Residents C & D). At one point the staff person uses “hand over hand” to “encourage Resident C to pick up the fork, put food on the fork and put the fork into their mouth. What is the coding for: Resident A, B, C and D?

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Guided Maneuvering versus Weight-Bearing Assistance

ü How do we know? ü Guided Maneuvering: if the resident can “lift”

the fork but staff assistance is just guiding the resident’s hand.

ü Weight-Bearing Assistance: if the staff member supports “some” of the weight of the resident’s hand while helping the resident to move the fork from the plate to the mouth=ext. assist.

How would you code?

ü Example: During bed mobility the staff person hands the resident the trapeze bar so the resident can reposition themselves in bed.

ü Example: During transfer from the bed to the resident’s recliner the CNA hands the resident her walker.

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How would you code? Example: The resident is from Islamabad. She is in the last stage of her Dementia and is loosing weight. Her daughter, Amina, is with her most of the time. Amina prepares special meals for her mom bringing it to her three times each day and spending a great deal of time encouraging her mom to eat for her. The resident does take small quantities of the food some of the time.

How would you code this?

How would you code?

Example: Mr. T. is in a physically debilitated state due to surgery. Two staff members must physically lift and transfer him to a reclining chair daily using a mechanical lift. Mr. T. is unable to assist or participate in any way during the 7 day look-back period. How would you code?

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How would you code? Example: Mrs. S required Supervision 5 times in the “look back period”, while Limited Assistance occurred twice, and Extensive Assistance & Total Assistance each occurred twice.

Correct Code: G01101 would be “1” (Supervision) because there were not 3 or more instances of a single higher level May 2013 RAI update clarification

Think about that…..

Supervision? In the Look Back Period you may find:

1.  Limited assist two times 2.  Extensive assist two times

3.  Total assist two times

BUT Supervision anything 3 or higher it would be coded as SUPERVISION. This meets the Rule of three.

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Responsibilities of ?

ü Monitor ALL ADL documentation to ensure accuracy including: v Asking probing questions to ensure components of

tasks were considered and the findings in the documentation are identical to the documentation

v Look-back period – inaccuracies? v Group education v One to one education

Probing questions? Examples:

MDS: How is Mrs. Cole doing since her stroke? Are you having to dress her?

CNA: She is doing so well. She is back to her old self again.

MDS: Wow! You’re kidding. She just had her stroke 1 month ago.

CNA: I know but she has been trying so hard and has done so well.

MDS: That’s wonderful! Thank you!

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Probing Questions

ü Think about what probing questions should sound like?

ü What are you trying to find out?

ü If you are having a difficult time communicating with certain staff members, ask them to “show” you.

Are your ADLs correct in your facility?

ü What do you need to initiate in your facility? ü Do your staff understand “components” or “aspects”?

ü How do ADLs affect your facility?

ü What else?

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Questions???

Thank You! Carol Smith, RN, BSN, RAC-CT

918-584-2900

csmith@bkd.com