Nursing Home Resident Assessment Protocols
Resident Assessment Protocols, or RAPs, flow from the Minimum Data Sets and guide the residents' plans of care. In practice, there are key elements or questions in the MDS that when answered in a specific way "trigger" one of 18 RAPs.
The Resident Assessment
The Nursing Home Reform Act mandates that nursing homes use a clinical assessment tool known as the Resident Assessment Instrument (RAI) to identify residents' strengths, weaknesses, preferences, and needs in key areas of functioning. The RAI is designed to help nursing homes thoroughly evaluate residents and provides each resident with a standardized, comprehensive, and reproducible assessment.
"With consistent application of item definitions, the RAI ensures standardized communication both within the facility and between facilities. Basically, when everyone is speaking the same language, the opportunity for misunderstanding or error is diminished considerably."
The RAI was developed by a research consortium under contract with the the Health Care Financing Administration (HCFA) and consists of three key components: the Minimum Data Set (MDS), Triggers and Resident Assessment Protocols (RAPs), and Utilization Guidelines. Most States required nursing homes to begin implementing the RAI in 1991. It was intended that the RAI be a dynamic tool, and HCFA began developing version 2.0 of the RAI in early 1993 which is now in use. The HCFA is committed to continuous reviews and updates.
The HCFA is committed to continuous reviews and updates.
The RAI is intended to be completed by an interdisciplinary team of nursing home staff who gather facts about the residents' strengths and needs. The interdisciplinary team should ideally include dieticians, speech, physical and occupational therapists, social workers, pharmacists, and nurses. The attending physician is also an important participant. U.S. Department of Health and Human Services, Health Care Financing Administration, Long Term Care Resident Assessment Instrument User's Manual Version 2.0 October, 1995.
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in the RAI process providing valuable input on sections of the MDS and RAPs. Federal regulations require each individual who completes a portion of the RAI to sign, date, and certify its accuracy. Regulations also require a registered nurse sign and certify that the assessment is complete. Upon completion of the assessment, the information guides the team to prepare individualized care plans for each resident.
The Minimum Data Set
The MDS 2.0, a component of the RAI, contains a standardized set of essential clinical and functional status measures. It must be collected on every resident in the nursing home at regular intervals during their nursing home stay regardless of the method of payment. Nursing homes are required to "conduct initially and periodically a comprehensive, accurate, standardized, reproducible assessment of each resident's functional capacity."
All residents must be completely assessed in the first 14 days after admission, promptly after a significant change in their physical or mental condition, and at least once every 12 months. Additionally, all MDS assessments must be reviewed at least every 3 months to assure continued accuracy. The prospective payment system was phased into nursing homes in July of 1998, and all nursing homes were expected to comply with the new system in January of 1999.
Skilled nursing facilities are required to classify residents into one of 44 Resource Utilization Groups (RUGs-III) based on assessment data from the MDS for reimbursement. Since the implementation of the prospective payment system there is a more frequent MDS schedule for those residents reimbursed by Medicare Part A.
Triggers and Resident Assessment Protocols
Specific responses to MDS items alert the nursing home to potential problems for the resident. These "triggers" are associated with specific questions on the MDS. If one or a combination of MDS elements are triggered, the resident is identified as someone who has or may develop specific functional or clinical problems. Triggers identify conditions for additional assessment and review, and cause the nursing home to further evaluate a resident using Resident Assessment Protocols (RAPs). Triggers indicate that specific clinical factors are present that may or may not represent a condition that should be addressed in the plan of care. The MDS responses that define triggers are specified in each RAP.
The Nursing Home Reform Act requires RAPs at the 14 day comprehensive assessment, significant changes, and annually. The RAPs assist in the development of plans of care. There are 18 RAPs in Version 2.0 of the Resident Assessment Instrument. They include items such as cognitive loss/dementia, ADL function/rehabilitation, psychosocial well-
3U.S. Department of Health and Human Services, Health Care Financing Administration, Long Term Care Resident Assessment Instrument User's Manual Version 2.0 October, 1995
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being, nutritional status, dehydration/fluid maintenance, and pressure ulcers.
Plans of Care
Meaningful care planning takes into account the unique traits of each resident which translates into providing good quality of care and quality of life.
The theory behind the RAI is that a strong link between MDS, RAPs and care planning is essential to provide each resident with a solid approach to prevent avoidable decline and build upon current strengths. Meaningful care planning takes into account the unique traits of each resident which translates into providing good quality of care and quality of life. The OBRA '87 requires that each nursing home resident have a comprehensive plan of care. This plan is based on information gathered by the MDS and any further review and assessment. The plans of care must include measurable objectives and timetables to meet the resident's medical, nursing, and mental needs identified in the comprehensive assessment. The services provided under the plan of care are to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The plans of care are to be periodically reviewed and revised when necessary after each assessment.
MDS Coordination
When Medicare reimbursement became linked to resident assessments, MDS coordinator roles became more vital to nursing homes. MDS coordinators are generally registered nurses who oversee the assessments and paperwork in order to guarantee proper completion. The MDS coordinators work with an interdisciplinary staff to produce the written and electronic documents necessary for Medicare reimbursement. The MDS coordinator also assures that each resident's MDS is coded accurately so that the nursing home is financially able to provide all necessary services.
In addition MDS coordinators affect the quality of care of the residents. Completing a thorough and accurate comprehensive assessment enables the nursing home to provide appropriate plans of care for each resident. The MDS coordinators can provide a global picture of each resident and can spot weaknesses in their plans of care.
