You may have heard that Section G of the Minimum Data Set (MDS) was going away; however, that will not be happening anytime soon. While it is true that Section G may eventually be eliminated, this change has been pushed back due to stakeholder concerns as well as the impact of the Coronavirus. As of now, the release of MDS updates will be delayed until October 1st of the year that is at least two full fiscal years after the end of the COVID-19 PHE. What does this mean for you? It’s important not to grow complacent with ADL coding practices pending the dissolution of section G.  Keep in mind that multiple items from Section G are still being used to inform Quality Measures.

 

What Quality Measures use Section G information?

 

  • Percent of Residents Who Made Improvements in Function (Short Stay). This measure reports the percentage of short-stay residents who were discharged from the nursing home that gained more independence in transfer self-performance (G0110B1), locomotion on unit self-performance (G0110E1), and walking in corridor self-performance (G0110D1) during their episodes of care. As this measure is looking at improvement over time, performance in these Section G items is derived from the “valid discharge assessment” – return not anticipated, and compared to the performance reported for those same items on that resident’s preceding PPS 5-Day or OBRA Admission assessment – whichever is earlier. Those who “trigger” for this measure (numerator) are short-stay residents who have a change in performance score that is negative. Performance is calculated as the sum of G0110B1, G0110E1, and G0110D1, with codes of 7’s (activity occurred only once or twice) and 8’s (activity did not occur) recoded to 4’s (total dependence). Please refer to the MDS 3.0 Quality Measures User’s Manual v14.0 for complete logical specifications including exclusion and covariate considerations.

Remember that this measure is used in the Five-Star Quality Rating System, and triggering for this quality measure is a good thing! The higher the numerator, the greater the number of residents who have improved in function since receiving care in your SNF.

  • Percent of Residents Whose Need for Help with Activities of Daily Living Has Increased (Long Stay). This measure reports the percent of long-stay residents whose need for help with late-loss ADLs has increased when compared to the prior assessment. The four late-loss ADL items are bed mobility self-performance (G0110A1), transfer self-performance (G0110B1), eating self-performance (G0110H1), and toileting self-performance (G0110I1). An increase is defined as an increase in two or more coding points in one late-loss ADL item or a one-point increase in coding points in two or more late-loss ADL items. For calculation purposes, codes of 7’s (activity occurred only once or twice) and 8’s (activity did not occur) are recoded to 4’s (total dependence). Please refer to the MDS 3.0 Quality Measures User’s Manual v14.0 for complete logical specifications including exclusion considerations.

This measure is also used in the Five-Star Quality Rating System, and triggering for this quality measure is not desirable. The higher the numerator, the greater the number of residents who have functionally declined throughout their stay.

 

  • Percent of Residents Whose Ability to Move Independently Worsened (Long Stay). This measure reports the percent of long-stay residents who experienced a decline in independence of locomotion on the unit self-performance (G0110E1) during the target period when comparing the target assessment with the prior assessment. An increase of one or more points at G0110E1 between the target assessment and prior assessment will indicate a decline in ability. Here again, for calculation purposes codes of 7’s (activity occurred only once or twice) and 8’s (activity did not occur) are recoded to 4’s (total dependence). Please refer to the MDS 3.0 Quality Measures User’s Manual v14.0 for complete logical specifications including exclusion and covariate considerations.

This measure is also used in the Five-Star Quality Rating System, and triggering for this quality measure is not desirable. The higher the numerator, the greater the number of residents who have functionally declined throughout their stay.

 

What can we do to monitor accuracy and improve performance in these ADL measures?

 

  • Education and Training: Many facilities rely on nursing assistants to observe and document Section G items. Regardless of who completes Section G documentation in your facility, ongoing education and training is imperative to accuracy and should occur upon hire, annually, and as any gaps in process and/or performance are identified. Education should be based on item and coding definitions provided in the RAI manual. Ideally, training should include coding scenarios, case studies, and real-life observations to promote and evaluate coding competency.
    1. Recognize also that some of these Section G items (e.g., locomotion) are not often included in ADL training as the focus is usually on the late-loss ADLs. Make sure to include all relevant items in education and training activities.
  • Auditing and Monitoring: Each MDS item used in the measure calculation should be reviewed for accuracy. This includes the Section G items used directly in the calculation as well as items used to establish exclusions and covariates, as applicable. It is possible that, while the Section G items are coded correctly, an item that would exclude the resident from the measure is overlooked or miscoded – including the resident in the measure when they would otherwise be excluded.
  • Accuracy reviews beyond the target assessment: Each of these measures uses a comparison of current data to previous data, so when auditing and monitoring for accuracy, it is important to review both assessments for erroneous codes.
  • Codes of 7 or 8: Education and monitoring activities should include a focus on the appropriate use of these codes. As noted above, codes of 7 or 8 are converted to a code of 4 for calculation purposes. This can directly impact the total performance score and in some cases, potentially indicate a decline that may not be indicative of the resident’s true performance. Using Residents Whose Ability to Move Independently Worsened as an example, if the prior assessment reports G0110E1 as 2 (limited assist) and the target assessment reports G0110E1 as 7 (activity only occurred once or twice), the 7 will be converted to a 4 (dependent) which will indicate a 2-point increase and the resident will trigger for this measure.
  • Monitor for and prevent functional declines: Once coding accuracy has been assured, use consistent Quality Measure data and internal monitoring practices to identify potential or actual individual declines in function. Utilize effective Restorative Nursing and/or Functional Maintenance Programs to promote functional ability and slow decline, and implement internal processes for Therapy referrals and screens to engage rehabilitative services where appropriate.

 

Concerned about quality measures? Contact Proactive to learn more about QM enhancement consultation and a 5 Star partner work plan.

 

Blog by Eleisha Wilkes, RN, RAC-CTA, Proactive Medical Review

Click here to learn more about Eleisha and the rest of the Proactive team.