Coding the RAI MDS 2.0 for Experienced Assessors ... 2014-2015 i Coding the RAI-MDS 2.0 for Experienced Assessors: Cognitive and Mental Health and Quality of Life Table of Contents

Coding the RAI-MDS 2.0

for Experienced Assessors - Cognitive and Mental Health

and Quality of Life

Participant Workbook

Revised: November 2014

CIHI 2014-2015 2

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The contents of this publication may be reproduced unaltered, in whole or

in part and by any means, solely for non-commercial purposes, provided that

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For permission or information, please contact CIHI:

Canadian Institute for Health Information

495 Richmond Road, Suite 600

Ottawa, Ontario K2A 4H6

Phone: 613-241-7860

Fax: 613-241-8120

www.cihi.ca

[email protected]

© 2014 Canadian Institute for Health Information

Based upon the Resident Assessment Instrument (RAI) RAI-MDS 2.0 User’s Manual, Canadian

Version, 2012. The RAI-MDS 2.0 is interRAI Corporation, Washington, D.C., 1997, 1999. Modified with

permission for Canadian use under licence to the Canadian Institute for Health Information. Canadianized

items and their descriptions are protected by copyright: 2002, Canadian Institute for Health Information.

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Coding the RAI-MDS 2.0 for Experienced Assessors: Cognitive and Mental Health and Quality of Life

Table of Contents

About CIHI ................................................................................................................................. 4

Acknowledgements .................................................................................................................... 4

Objectives .................................................................................................................................. 5

Materials Needed ....................................................................................................................... 5

Coding and Interpreting .............................................................................................................. 6

RAI-MDS 2.0 Guidelines ........................................................................................................ 6

RAI CODE Critical-Thinking Strategy...................................................................................... 7

Pre-Work Activity .................................................................................................................... 8

Activity 1 – Interpret Coding .................................................................................................... 9

Activity 2 – Coding and Interpreting .......................................................................................17

Data Quality ..............................................................................................................................31

Ensuring Quality Data for Quality Care ..................................................................................31

Activity 3 - Data Quality .........................................................................................................33

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About CIHI The Canadian Institute for Health Information (CIHI) collects and analyzes information on health

and health care in Canada and makes it publicly available. Canada’s federal, provincial and

territorial governments created CIHI as a not-for-profit, independent organization dedicated

to forging a common approach to Canadian health information. CIHI’s goal: to provide timely,

accurate and comparable information. CIHI’s data and reports inform health policies, support

the effective delivery of health services and raise awareness among Canadians of the factors

that contribute to good health.

Acknowledgements CIHI wishes to acknowledge and thank interRAI and staff at participating organizations across

Canada who provided expertise and support and who volunteered to pilot the Coding the

RAI-MDS 2.0 for Experienced Assessors: Cognitive and Mental Health and Quality of Life

training. Their generous contribution has allowed us to provide you with this education material.

We would like to thank the residents/clients, staff and volunteers at the Élisabeth Bruyère

Residence, Extendicare Starwood, Bethany Care Society and Champlain Community Care

Access Centre for giving CIHI permission to use their pictures, including those of their families

and homes.

All names and stories used in this training are fictitious.

Symbols

Important Note

Coding RAI-MDS 2.0 Experienced Assessors – Cognitive and Mental Health and Quality of Life

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Objectives The web conference Coding the RAI-MDS 2.0 for Experienced Assessors: Cognitive and

Mental Health and Quality of Life is a two and a half hour activity-based training session. This

session covers the following sections of the RAI-MDS 2.0 assessment:

Section B: Cognitive Patterns

Section E: Mood and Behaviour Patterns

Section F: Psychosocial Well-Being

Section N: Activity Pursuit Patterns

In this training, you will

Use the RAI-MDS 2.0 User’s Manual to interpret and apply coding standards in the areas

of Cognitive and Mental Health and Quality of Life;

Document Cognitive and Mental Health and Quality of Life assessment findings using the

RAI CODE critical-thinking strategy; and

Identify ways to improve data quality in your facility.

The primary intent is for you to engage in peer discussion and sharing. In this session, you will

draw on each other’s clinical judgment and expertise to code vignettes where the interpretation

of the coding standards for documenting items becomes challenging. You will also explore the

consequences of incorrect coding for clinical and organizational decision-supporting your

facility.

Materials Needed The following materials are required for this web conference:

Resident Assessment Instrument (RAI) RAI-MDS 2.0 User’s Manual

Coding the RAI-MDS 2.0 for Experienced Assessors: Cognitive and Mental Health and

Quality of Life Participant Workbook


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Coding and Interpreting

RAI-MDS 2.0 Guidelines As described in the RAI-MDS 2.0 Manual, there are several integral concepts used to assist

clinicians in documenting assessment findings. These include:

The resident is a person with strengths, preferences and needs

Clinical Assessment Protocols identify persons with potential to improve and those at risk of

decline

An interdisciplinary approach to resident care is vital – both in assessment and in

developing the resident’s care plan

Good clinical practice requires sound assessment skills

Using the RAI-MDS 2.0 Guidelines in the assessment process

Minimum data set (MDS)

Observation period is the seven days prior to the assessment reference date, unless a

longer time frame is specified

Information is obtained from multiple sources

Clinical judgment is key—it is not a questionnaire

Coding standards guide the assessment process

Coding reflects resident’s functioning

Regardless of the assumed cause

With assistive/adaptive aids in place

All sections work together to give a holistic view of the resident


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RAI CODE Critical-Thinking Strategy This mnemonic helps guide the critical-thinking process that often occurs intuitively as part of

your assessment process. It is a tool for reflective problem-solving and decision-making.


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Pre-Work Activity

In This Activity You Will

Prior to the web conference:

Read the vignettes for Activity One and Activity Two

Activity #1 – Vignettes 1 and 2

Activity #2 – Vignettes 1 and 2

Note: The documentation of your findings and rationale will be completed during the web

conference.

Approximate time to complete: 10 minutes


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Activity 1 – Interpret Coding


Review each vignette and associated coding

You will use the following resources:

- Participant workbook: Activity One—vignettes 1 and 2

- RAI-MDS 2.0 guidelines found on page 6

- RAI CODE critical-thinking strategy found on page 7

- Example – Average Time Involved in Activities (N2) on page 13

- RAI-MDS 2.0 User’s Manual

As a group, document your rationale for the coding of each vignette

Present your findings and participate in discussions

Time allotted: 15 minutes


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Vignette 1: Mr. T—F1, F2 and F3

Mr. T has been a widower for 20 years. He worked as a landscape architect before he retired.

He was admitted to Rainbow LTC home two years ago following a CVA resulting in

right-sided paralysis. Mr. T shares a semi-private room with Mr. B, a younger resident with a

brain injury.

Mr. T spends most of his time in his room working on his laptop. He has stated to staff that he

would like to finish writing his book before he dies. He has asked to be moved to a private room

when one becomes available. Communication between him and his roommate is challenging;

he says he has no quiet time as his roommate has frequent visitors and is noisy at night. Mr. T’s

son has tried to communicate with him using Skype, but Mr. T refused, saying he is upset that

his son sold the family home and moved to South America with his family rather than caring for

him at home.

He is an experienced gardener and had enjoyed volunteering at the local chapter of the

Horticultural Society prior to admission. He has not done any gardening this summer. He says

it’s not the same without Frank, who was a volunteer at the facility. Mr. T had developed a

friendship with Frank, and when Frank moved to Edmonton with his daughter four months ago,

Mr. T stopped going to the garden. He says he misses Frank very, very much. This was the only

group activity he attended and enjoyed.


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Review the responses and document your rationale for coding of the items in F1, F2 and F3 for

Mr. T.

Rationale:

Rationale:


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Rationale:

In the Index of Social Engagement (ISE), all items from Section F1 (Sense of

initiative/involvement) are used in the calculation of this outcome scale.

Rationale:

Important Note


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Example—N2

Average Time Involved in Activity Pursuits (N2)

The past 7 days, Mrs. B woke up around 7 a.m. She listened to the news on TV until the PSW

came in to assist her with morning care. Once in her wheelchair, she pushed herself to the

dining room for breakfast. At 9 a.m. she went to the activity room and participated in group

exercise led by the recreation therapy assistant. At 10 a.m. the nurse gave Mrs. B her

medications, followed by a dressing change to her right foot. By 11 a.m., Mrs. B sat in

her recliner chair and knitted.

After lunch, she took a one-hour nap. She had the volunteer wake her up for the 2 p.m. activity

(cooking and music sessions). Mrs. B spent her afternoons in the lounge chatting with other

residents or sitting outside on the patio feeding birds.

After supper, Mrs. B napped as usual and got up when her husband arrived. Just before he left

at 10 p.m., he helped her with undressing and getting her in bed. On his way out, he notified the

nurse so Mrs. B’s HS medications could be administered.

Code 0 (Most—more than 2/3 of the time)

Rationale: Mrs. B was actually involved in activity pursuits more than two-thirds of the available

free time she had in the last seven days.

She was asleep approximately 11 out of 24 hours.

She received nursing care/treatments or was engaged in ADL activities approximately 6

out of 24 hours.

This left her approximately 7 out of 24 hours to pursue various activities.

She used most of these 7 hours participating in group activities (exercise, music and cooking

sessions) and being involved in one-on-one activities (watching TV, knitting, reading and feeding

birds). She was also involved in chatting with other residents in the afternoons and visiting with her

husband in the evening


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Vignette 2: Mr. D—N1, N2, N3, N4 and N5

Mr. D is a 58-year-old man who has Down’s Syndrome with dementia. He was recently

admitted to Harmony Nursing Home after his mother, who was his primary caregiver, suddenly

passed away.

He wakes up at 7:00 a.m. every morning and tends to be lethargic. He takes a half hour nap

every morning and afternoon because he sleeps poorly at night. He is most active in the middle

of the afternoon. Mr. D enjoys walking outside on the grounds every day with a volunteer and

enjoys their conversations. Most afternoons, Mr. D meets the horticultural therapist and

together they water the plants, weed the garden and feed the birds. He also enjoys sitting in the

gazebo and listening to his music. Mr. D has a congenital heart defect and requires frequent

rest periods; he is found watching TV or looking at magazines in his room later in the afternoons

and early in the evenings. He is usually in bed by 11 p.m. Having vision and hearing deficits

makes it more difficult for him to participate in group activities. So far, he has not participated in

group activities with other residents; he is very shy and prefers one-on-one interaction with

others or time alone.

On admission, his brother George shared with the staff that Mr. D has always been a loner and

has never socialized much. George reinforced with the staff the importance of a structured

environment for Mr. D. He has always had difficulty transitioning to new activities and schedule

changes. His brother added that Mr. D might like to go to the church service on Friday morning

if someone accompanied him.


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Review the responses and document your rationale, on the next page, for coding of the items in

N1, N2, N3, N4 and N5 for Mr. D


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Rationale:


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Activity 2 – Coding and Interpreting


Review each vignette

You will use the following resources:

– Participant workbook: Activity Two—vignettes 1 and 2 including tracking forms

– RAI-MDS 2.0 guidelines found on page 6

– RAI CODE critical-thinking strategy found on page 7

– RAI-MDS 2.0 User’s Manual

As a group, document your findings for each vignette and identify any other areas on the

assessment where you would capture this information. What items impact the outcome

scale scores in Section B (Cognitive Patterns) and Section E (Mood and Behaviour

Patterns)?

Present your findings and participate in discussions

Time allotted: 20 to 25 minutes


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Vignette 1: Miss J—Sections B2, B3, B4, B5 and B6

ARD: Thursday, September 25, 2014

Miss J has been at the New Star LTC home for three months now. She was admitted for

rehabilitation following a stroke, and she is hoping to return to her group home soon. Miss J has

schizophrenia which is being closely monitored and has been reported as stable since her

admission. She has adapted well to her temporary placement.

In the past week, staff reported that she was having trouble remembering what she ate for lunch

when questioned five minutes after she finished her meal as she was walking back to her room

independently. However, she was able to recall her birthday. Normally, she is able to recall

what season it is and able to recognize staff members by name. When asked where she lives,

she indicated that she is in a home for old people until she gets better and can go back to her

group home where her friends live.

Since admission, Miss J was usually able to choose her clothes for the day and know when to

walk to the dining room for meals. However, since Tuesday (September 23), staff have

reported that Miss J has been unable to find her assigned table in the dining room. She didn’t

seem to realize that she kept sitting at different tables and she did not ask staff or volunteers for

assistance. Yesterday (September 24), she arrived for breakfast in her pajamas and her winter

jacket and she had her roommate’s shoes on. The health care aide offered to help her change

her clothes and she accepted willingly.

In the evenings during HS care, staff noted that Miss J was having difficulty removing her

clothes and, when handed the toothpaste, she didn’t know what to do with it. Before she

finished brushing her teeth, she started to brush her hair. She went on about a movie she saw

last month as if it had happened yesterday, then in the middle of a sentence she started to hum

a song. The day staff did not report this behaviour.

The staff have also observed that Miss J is continuously picking at her clothes, trying to

remove lint when none is apparent. However, that is not new for her; she’s been doing this for

months now.

This morning (September 25) Miss J would not get up for

breakfast. She was difficult to rouse and speech was incoherent.

Lori immediately reported her findings to the nurse practitioner,

who ordered blood work.


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Document your findings and rationale using the completed tracking form (where applicable) for

Sections B2, B3, B4, B5 and B6 for Miss J.


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1. In reviewing Miss J’s story, identify other areas on the assessment where you would capture

this information (if applicable)?

2. What items in Section B (Cognitive Patterns) impact the outcome scale scores?


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Vignette 2: Mr S. — Sections E1, E2, E3, E4 and E5

ARD: Thursday, October 30, 2014

Mr. S has been at the Cross Roads Manor for more than four years. He is pleasant and very

jovial, enjoys social activities and is always the first one to initiate gatherings. He plays his

harmonica for people when there are get-togethers in the lounge.

Four months ago, he fell getting out of his son’s car and suffered a hip fracture. Following

surgery, he returned to the home and was started on an intensive physiotherapy program. In the

first six weeks, he was compliant with the program and was determined to get back on his feet.

In the last month, when he realized his improvement was much slower than he expected, the

staff have observed changes in Mr. S’s mood. He has been looking sad and discouraged. He

started to find all kinds of reasons for not going to the gym or doing his exercises with the rehab

assistant. He has been declining pain medication and staying in bed most of the day, saying he

really needs to rest. He has not wanted to be with others, and when going for meals he has

been keeping to himself and quickly returning to his room right after eating.

Two weeks ago, when staff noticed a small pressure ulcer on his left buttock (stage 2), he told

them he had no more energy to fight anything. He has repeated similar statements to other staff

at least three times last week and again twice this week, according to the tracking sheet. He told

the recreation therapist last week that he was no good anymore and that he was not going to

play his harmonica anymore. No one else heard him saying this.

Daily, since October 27, staff have reported incidents where Mr. S has thrown his clothes on the

floor and shoved his wheelchair against the wall after transferring to his bed. Francis, the dietary

aide, said he noticed Mr. S moving his wheelchair back and forth and appearing agitated twice

last week. He has been impatient with people coming into his room—pointing at the door and

refusing assistance with dressing and personal hygiene. It was reported that Mr. S cursed at

staff while they were providing HS care. Staff let him have his space during these outbursts

and he calmed himself within a few minutes. They understand that he has lost so much

independence over the past few months and they are willing to tolerate the fact that he is

disagreeable at times. Mr. S was started on an antidepressant 14 days ago.

This morning (October 30), Mr. S told Mia, the health care aide,

that watching mass on television was OK but he was looking

forward to returning to the chapel to attend mass with the priest.


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Document your findings and rationale using the completed tracking forms for Sections, E1, E2, E3, E4 and E5 for Mr. S.


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1. In reviewing Mr. S’s story, identify other areas on the assessment where you would capture

this information (if applicable)?

2. What items in Section E (Mood and Behaviour Patterns) impact the outcome scale scores?


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Data Quality

Ensuring Quality Data for Quality Care Use of information, often referred to as data, is the most direct route to data quality; it

encourages people to take a closer look.

Part of being an informed assessor is understanding not only the information you are

collecting but also how it can be used to provide care for your residents.

Everyone who touches information has an impact on its quality.

As front-line assessors, how you code affects the information that is used for the resident,

the organization, the ministry and researchers.

How Continuing Care Data Flows

Data flows in a cyclical process. It starts with clinicians assessing residents based on

knowledge and best practices. This information is then used to support decisions and drive

continuous improvement, which cycles back and is reflected in resident care.


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Cognitive and Mental Health and Quality of Life Outputs

Sections B, E, F and N impact the following clinical and organizational outputs:

Section B (Cognitive Patterns) Section E (Mood and Behaviour Patterns)

CAPs

ADL, Physical Restraints, Cognitive

Loss, Delirium, Communication, Mood,

Behaviour, Activities, Social

Relationship, Dehydration, Feeding

Tube, Urinary Incontinence, Bowel

Conditions

CAPs

Cognitive Loss, Mood, Behaviour, Activities

Outcome Scales

CPS, CHESS

Outcome Scales

DRS, ABS

Resource Utilization Groups (RUGs) Resource Utilization Groups (RUGs)

Quality Indicators Quality Indicators

Section F (Psychosocial Well-Being) Section N (Acitivity Pursuit Patterns)

CAPs

Activities, Social Relationship

CAPs

Activities

Outcome Scales

ISE

Resource Utilization Groups (RUGs)


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Activity 3 - Data Quality The Activities CAP and CPS are generated directly from information coded in the Cognitive and

Mental Health and Quality of Life domain. If the sections are coded incorrectly, what could

happen at an aggregate level that may affect both the resident and the facility?

Response:

Documents

Coding the RAI MDS 2.0 for Experienced Assessors ... 2014-2015 i Coding the RAI-MDS 2.0 for Experienced Assessors: Cognitive and Mental Health and Quality of Life Table of Contents