Opportunities for Engaging Long-Term and Post-Acute Care Providers in Health Information Exchange Activities: Exchanging Interoperable Patient Assessment Information. Resident Assessment Instrument/Minimum Data Set

12/01/2011

The RAI, which includes the MDS, is a standardized data collection instrument designed to assess and screen care given to residents in nursing facilities. The RAI is mandated for all residents in Medicare or Medicaid-certified nursing facilities in the United States. The assessment items that make up the core MDS are considered the minimum elements required to provide a comprehensive picture of a resident’s functional status.36 The MDS was designed to standardize assessment data nursing homes were collecting already as part of their routine business.37 While the primary use of data collected through the MDS was to direct and improve clinical care, the MDS has also become the basis for setting payment levels and monitoring quality of care, in addition to directing certain state survey and certification activities for nursing homes.38

Full MDS data must be collected on all nursing home residents within fourteen days of admission and either annually thereafter, or when there is a significant change in condition. Data from the MDS are used to trigger specialized Resident Assessment Protocols (RAPs), through which individual care plans for at-risk patients are developed. A subset of MDS data must be collected on a quarterly basis to assess how well the care plan is working. The MDS, RAPs, and utilization guidelines, instructions on when and how to use the RAI, are the three core components of the RAI. In version 3.0 of the RAI, scheduled for implementation in October 2010, the Care Area Assessment (CAA) process replaces the RAPs.

MDS assessments must be encoded and electronically transmitted from the care facility to the CMS contractor in the state government. This data is then forwarded to CMS. In the FY 2010 proposed rule for SNF PPS published May 12, 2009 [74FR222208], CMS proposed that LTC facilities be required to transmit MDS data directly to the national CMS System, instead of to the states. The transmission file of MDS data must meet the data specification standards set by CMS. CMS makes available free software (RAVEN) that Medicare and Medicaid nursing facilities may use to electronically transmit MDS assessments.39

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