MDS 3.0 Sections B and C

Alright, we're going to talk about Section B this morning. As Jennifer said,
there's not a lot of changes in Section B, but this is a critically important
section because it really sort of sets up your sense of who the resident is, and
their ability to see and to hear and to communicate is fundamental to their life
in the facility. So, this is a really important section to get right even if
it's not a section that's changed a whole lot.
So, what are we going to try to do this morning? Talk about the intent of the
section; identify the communication skills that need to be assessed; and then
summarize coding requirements for some of the few modified items. If you'll
notice, we moved some of these sensory items before the cognitive section
because, again, it's really important to know about someone's ability to see and
to hear and to communicate before you start assessing their cognitive abilities.
So, you're going to be looking at hearing; ability to understand and communicate
with others; and visual limitations in this section.
The first item in this section is very familiar to you at this time. It's B0100
Comatose, and it's just basically to determine if the resident is comatose or in
a persistent vegetative state. That item is unchanged from the past. I think the
main thing to note with this item is that it requires a diagnosis of being
comatose or in a persistent vegetative state in the medical record by either the
physician, nurse practitioner, or clinical nurse specialist as allowed by state
law. So, I think that's the most important thing to underscore about this
unchanged item.
The next item is B0200 Hearing, and this asks about the ability to hear with a
hearing aid or appliance if normally used. And the choices that you have are:
"Adequate - no difficulty in normal conversation, social interactions, or
listening to television"; "Minimal difficulty - difficulty in some
environments." That is like when a person speaks softly or the setting is noisy.
"Moderate difficulty - the speaker has to increase their volume and speak
distinctly" for the individual to understand them, or "Highly impaired - the
absence of useful hearing."
So, how do you go about assessing this item? Well, the first thing you want to
do before doing this is make sure you understand whether or not the resident
uses a hearing aid or other appliance before you start the assessment. Always
attempt to talk to the resident to make a determination. Observe the resident in
various situations -- when they're sitting in social activities, when they're
watching television, when they're interacting with family and friends -- and
consult with family, significant others and staff. Look for indications of a
hearing problem. What's your resident interview? Asking them if they have
trouble hearing in certain situations.
That item should be assessed with what they normally would use. So, ask them if
they have a hearing aid [or] if the hearing aid is with them in the facility,
because oftentimes it's not. We had one patient whose family refused to leave
their hearing aid in the nursing home because they were afraid it would get
lost. So, they would bring it the one day a week they visited and that was the
only time anyone could communicate with the patient. So, find out if they have
it in the facility, check and make sure batteries are working and that it's
operational for them.
The Hearing Aid: indicate whether the resident used a hearing appliance during
the seven-day hearing assessment. So, this is a little bit different than the
old item. It's not asking do they have a hearing aid/ do they own a hearing aid.
It's really asking, was a hearing aid used when you scored the item above. When
you scored B0200, was there a hearing aid involved in how you assessed their
hearing? Code 0 if there was not. Code 1 if "yes", and it can be a hearing aid
or other hearing assistive device that that resident normally uses. B0600 -- let
me just say one more thing about the hearing aid section. The reason this is
important is because if they have limited hearing with their hearing appliance
in place, then we should be asking ourselves is the hearing appliance
functioning properly? Does the hearing appliance need to be reassessed? If they
don't have a hearing assistive device in place, then we should be asking
ourselves: Would they potentially benefit from that appliance?
Speech Clarity: Select the best description of your speech pattern. Zero is
"Clear speech - distinct intelligible words"; 1 is "Unclear speech, slurred or
mumbled words"; and 2 is "No speech - absence of spoken words. That has not
significantly changed from the 2.0.
"B0700 - Makes Self Understood", is the ability to express ideas and wants, and
it's important to understand, with this item, that it considers both verbal and
nonverbal communication. So 0 is "Understood", 1 is "Usually understood". In
other words, they have difficulty communicating some words or finishing some
thoughts, but they're able, if you prompt, or give them time, to communicate.
"Sometimes understood" means that their "ability is limited to making concrete
requests" and 3 would be the code for "Rarely or never understood". The "Makes
Self Understood" item - one of the changes in this version of the manual is that
it explicitly allows sign language and recognizes that as a form of
communication. It explicitly does that. Many of you have been counting that;
others haven't. It also underscores that it's in the language of their choice.
So, it's not that they speak Spanish, you speak English and, therefore, they
can't make themselves understood. The question is in their language of their
choice, can they make themselves understood.
The "Ability to Understand Others" is understanding verbal content, however
able, of course with their hearing assistive device, if used. Zero is
"Understands - clear comprehension; 1, "Usually understands", misses some or
part of the intent of a message, but they can comprehend most conversations; 2
is "Sometimes understands - responds adequately to simple direct communication
only"; and 3 is "Rarely/never understands". Again, if the person relies on
signage to communicate, that should be taken into account. That is if they can
communicate with signage, then that is an ability to understand others.
Likewise, it's in the language of their choice.
The vision items: B1000 and B1200. B1000 looks at the ability to see in adequate
light, and if you look at this, it's primarily focusing on the ability to do
reading or close-up types of visual tasks. Adequate is "Sees fine detail,
including regular print in newspapers and books"; 1 is "Impaired - sees large
print, but not regular print in newspapers or books"; 2 is Moderately impaired -
limited vision, not able to see newspaper headlines but can identify objects";
and 4 is "Severely impaired - no vision or sees only light colors, shapes, eyes
do not appear to follow objects." And this, again, is not significantly changed
from 2.0 and, like in 2.0, the instruction is to try showing them a newspaper
and looking at the regular print in the newspaper versus, say, the title lines
in the newspaper and their ability to read those.
If someone can't read, if they're illiterate, you can show them objects in order
to determine their or numbers, you can start with numbers, if they can do that,
or objects. Illiteracy is not uncommon, and it's something to think about when
testing visual ability using the newspaper. You know, I had this patient that I
kept -- every time she came to my clinic, I'd write out her med list for her,
and every time she came back, her meds were a mess. She would bring back this
bag of medication that didn't match anything I had written down. Finally, took
me a while, I realized that she couldn't read these lists that I was very
carefully making out for her. So, it does happen, and it's something that we
need to think about before we label someone as having limitation. The reason to
look for this item is obviously we can do things to help people with low vision.
Sometimes it's as simple as improving the lighting on their work area or work
space. Sometimes it's providing extra reading materials that are in a larger
print. Sometimes it's books on tape.
And, for B1000, how do you go about determining it? First, again, make sure if
they use corrective devices that they have them in place. You can also consult
with family or other folks that know them well, and the staff, about if they've
noticed any difficulties with vision, and ask the resident and then verify with
the reading test, as I said. This item has changed slightly - the corrective
lenses item. It's now anchored to what you based your assessment on in the item
above. So, if you were saying above that they had some impairment, did you say
that with them using a corrective lens or without using a corrective lens? And
that's 0 -- would be they didn't use a corrective lens, a magnifying glass or
other visual aids, and yes would be they did. So, that's pretty straightforward.
Jennifer, I think we'll show the video. Now, what we have in the VIVE video, and
the VIVE video is available here at the meeting -- Tom brought, or actually, I
think you can order them at the desk. Jenifer's made that announcement several
times. You can also download it on the Picker Institute website or order it from
-- the Pioneer Network has agreed to distribute it for us.
Can I help you turn the chair around? All right. Mrs. White? Mrs. White? Yes?
Thank you for agreeing to come to your room to talk with me. As I said in the
rec room a few minutes ago, my name is April, and I'm one of the nursing staff
here at Eastern Home Who? My name is April, and I'm a nurse here at Eastern
Home. Okay, April. Is it all right if I take a few minutes to talk with you?
Yes. Great. Okay. Should I sit here? Can you see me and hear me? Oh. Could you
come a little closer? Sure. Of course. Now, I need to understand that you can
hear me. Have you ever worn a hearing aid? Oh, yes. Years ago, but I could never
work it. Well, some people have some trouble hearing me. That's why I always
bring this hearing amplifier. This is often helpful for people who can't
understand me in this tone, so I don't have to shout. It's a headphone and
microphone connected together. Let me show you how it works first, and if you
like, you can try it and see if it might work. Okay. You put the headphones over
your ears, and this connects to here. This is the microphone I'll be speaking
into. Do you think you might like to try it? Oh, sure. Great. And you can adjust
them so they fit comfortably over your ears. And I'll turn this on. Is that
better? Oh, yes. Yes. That's very good. Terrific. Terrific You want me to hold
it? If you would do that for me, that would be great. I hear you fine.
Wonderful. Now, have you ever worn glasses? Oh, yes. I think they're in the
drawer over there Okay. Can I get them for you to wear? Yes, please. Here you
go. I'll help you with these. Thank you. Well, it's wonderful to have you here
with us. I understand you came to us from another facility. How has your stay
been with us so far? Well, everybody's been very nice. But you know what, it's
cold in here. Cold Can I get you something to wear, something warm? How about --
how about your lovely sweater? Oh, yes, that would be very good. Great. How is
that? That's nice. Much better. Great. Now, what I'd like to do today is ask you
some questions about concentration, about your mood and how you've been feeling
over the past couple of weeks. I'd also like to ask you some questions about
your routine here at the nursing home, and I'd like to ask you some questions
about physical pain. Does that sound okay? Oh, yes, very good. Great.
[end of VIVE video clip]
Deb Thank you, Jennifer. So, this video I showed now instead of interviewing
techniques. We'll talk about some of the techniques that April used during the
"Interview Technique" section, but it wants to sort of underscore this idea that
part of what we're doing when we go in to talk with our patients is making sure
they can hear us, they can see us and that we're sitting in a place that's
comfortable to them. There's actually a neat little study in a family practice
journal where one group of providers went in the room and stood around the
bedside and sort of did their thing, and someone went back later and asked the
patient how much time that provider had spent with them. And another group of
providers went in to a patient's room and sat down in a chair and spent exactly
the same amount of time in the room. But, they went back later and asked how
much time the provider had spent with them, and the patients almost always said
that the provider who sat down spent more time with them even though it was
exactly the same amount of time. Now, you know it wasn't the most rigorous study
in the world, but it was actually, I think, very telling for how giving that
patient that sense that you're taking the time and the space to be with them
really can sort of make a difference in getting things set up. But, the main
point about this is that this is one source of information for assessing their
hearing and then starting to get ready to assess their vision.
So, we're going to move on to Section C: Cognitive Patterns, or the Brief
Interview for Mental Status. We're going to talk about the intent of the
section, why we are switching to a performance-based assessment to determine the
resident's cognitive status; list the steps in doing the assessment; define what
a category cue is; explain a little bit about conducting the BIMS; and code some
BIMS interview questions correctly. We're also going to show part of the video,
an example scenario of the Brief Interview for Mental Status.
The intent of Section C is pretty straightforward. It's to determine the
resident's attention, orientation and ability to register and recall new
information, and we'll talk a little bit more about those as we go through the
specific items. Why is this important? You guys all know this. It's crucial in
your care planning decisions that you're going to make as an interdisciplinary
team with your residents. Misdiagnosis may result in appropriate communication
activities and failing to offer appropriate therapies for the individual. It's
important to note that a cognitively intact resident may appear to be
cognitively impaired because they're very frail. So, sometimes we're just
eyeballing people and trying to figure out their cognitive abilities. We tend to
have -- there's a systematic bias where older people get rated with poor
cognitive ability whether or not they have poor, because they just look impaired
to us. Hearing impairment, lack of interaction -- the residents may appear more
-- there are some residents that we all know. Some of our family members, who
really do a great job of covering up their cognitive impairment. And, so,
without sitting down and really doing a very structured assessment, it can be
difficult to uncover that they're gaming.
The hearing impairment is an interesting story. On the video, what we won't show
you, is one of the gold standards nurse's testimony. That when she went into a
facility and was pointed towards the room of a severely cognitively impaired
patient, long-stay patient, who had been in the nursing home for over a year.
She went in, and they put the hearing assistive device on the resident. She sort
of perked up, but then she went pretty flat, and they tried a couple of
questions and then left the room. But, on their way out the door, they put the
headset back on to just test the volume and see where things were and realized
that the batteries were dead. They went back out to the nurse's station,
borrowed some batteries, put them in the hearing assistive device and said,
"What the heck? Deb said it will work. We don't think it will work, but we'll go
back in and try." So, they put the headset on the patient. She sat up in the
chair. She started talking to them. She pointed to items on the cue card,
indicating that she was understanding the answers that she was giving and
responding to them. She still had cognitive impairment. She wasn't totally
cognitively intact, but this woman had been unable to communicate basically with
her providers for a very long period of time. Not because of her cognitive
impairment, but because of her hearing problem. And this was when we did our
data collection in 2007. This is not a story pre-RAI. So, this is just one
example, but it was, again, in a fairly limited sample that we unearthed this
one patient.
Performance-based assessment: It decreases the chance of incorrectly labeling
someone's cognitive ability. The other thing that this helps with is improving
your detection of delirium. When Ann talks to you about delirium, I'm sure
she'll make this point: it's not whether or not they get the questions right on
the structured cognitive assessment, it's observing their patterns of response
when you're asking them these very concrete, specific questions that gives you
some insights into whether or not they may have delirium. You're looking for
change over time in that structured assessment and that also may clue you in
that there may be an underlying delirium or some other significant change that's
taken place with that resident. Think about delirium or depression, if you
notice a worsening in your cognitive assessment.
So the brief -- the MDS assessment for cognition now is the Brief Interview for
Mental Status. It lets you observe signs and symptoms. It can be completed and
attempted for most residents. If you remember on the slides that I presented
yesterday, 90% of residents were able to complete the Brief Interview for Mental
Status. Some of them scored zero, some of them scored 15. So, some scored the
lowest possible and some scored the maximum, but 90% were able to participate.
If they cannot be interviewed, then you will do the staff assessment as an
alternative, and that's basically just the old 2.0 items that you guys are
familiar with and Ann will be covering those with you later. You do not have --
you do not conduct an interview and staff assessment. If they complete the BIMS
by the scoring rules, you're done. You don't have to go through the seven pages
of medical records to look at everything that's in there or not in there, as the
case may be, and go interview all the staff across all shifts and go interview.
When they complete the Brief Interview for Mental Status, you're done. It's more
accurate and reliable than observation alone. We've compared it. Others have
compared it. It's just better to sit down and do these few limited items. It
prevents mislabeling based on appearance and diagnosis. It helps to identify
needed supports, and we'll talk about that when we get to some of the items in
the delirium that I've talked about.
The first item in this section, C0100, is basically just asking if that skip
pattern that I talked about yesterday, should this interview be conducted. And
it's just sort of to help you remember who it is that you conduct the interview
with and to help you with skip patterns, because we know that those are harder
to follow. Those of you, some of your vendors will sort of take care of this for
you with your data collection instruments, but this item is C0100: "Should the
Brief Interview for Mental Status be conducted". And you should be attempting to
conduct the interview with all residents who are capable of making themselves
understood at least some of the time. "No", you would answer "no", you're not
going to conduct the interview, if the resident is rarely or never understood
and, in which case, it tells you to skip and answer C0700 to C1000 Staff
Assessment for Mental Status.
If they are able to make themselves understood some of the time, you go straight
to C0200, Repetition of Three Words. Attempt the interview if the resident can
be understood at least some of the time. Make every effort to provide an
interpreter, if needed, for this section. So, you should never do a cognitive --
if someone's preferred language is Korean -- you should never do a cognitive
assessment in English if their preferred language is something other than
English. So, you do need to try to find an interpreter to do this assessment.
If, we realize, okay, let's see, and let's see if there's anything else here.
So, this just refers you back to the little item that you're looking at to think
about the language issue, C1100, and it's whether or not the resident needs or
wants an interpreter to communicate with a doctor or healthcare staff. That
language is basically the language that NCQA has recommended for determining
language needs for all patients, and "No" is they don't need an interpreter.
"Yes" is they do, and you write the language below. Or you're unable to
determine. So then, basically, you're going to code whether or not the cognitive
interview should be attempted with a resident. So, on to the items.
So, basically the Brief Interview for Mental Status. This is not a comprehensive
cognitive assessment. We didn't have room for it. The form's long enough. We
didn't put everything that you could possibly assess for cognition. Some
facilities are already doing the MMSE. If you're doing that, great. You still
need to fill in these items on the MDS. It doesn't replace. It doesn't cover all
the domains that MMSE is going to cover. It's highly correlated with MMSE, but
doesn't replace it. Most facilities aren't doing the MMSE and, so, these items
will halt. C0200 Repetition of Three Words, C0300 is Temporal Orientation, and
C0400 is Recall. And, then, at the end, they're compiled into a summary score
which, again, is very highly correlated with some of the longer cognitive
assessments that are out there, including the MMSE.
So, to conduct the interview, as you saw April do, you're going to establish a
comfortable environment; make sure the resident can hear you; address their
concerns; and then you're going to, for the Brief Interview for Mental Status,
this is the one interview that is very important you complete it in one sitting
with the resident. Don't interrupt it. Don't get up and go away and come back.
This is the one interview that needs to be completed. It's very short and quick.
So you won't have, you know - the need to interrupt it should be pretty minimal.
Ask each item in the order they appear on the MDS item set. If a resident
refuses to answer an item, okay. Accept it and move on. Stop the interview if
you need to. Now, there is an opportunity to stop the interview because they're
giving you too many responses and it's going to be considered non-responsive
answers and it's going to be considered an incomplete interview. I think we'll
get to that actually later. So, I'm not going to dwell on it right now. I'll do
it when we get to that set of slides. Assess for cognitive patterns. No, wait.
We don't get to it later. Hold on a second. Yes, we do. Okay. So, I'm going to
skip that one, too. Sorry.
Repetition of Three Words - Here we're following the first item in the BIMS:
Repetition of Three Words. So, you're going to ask the resident to repeat three
words, and you're going to basically say, "I'm going to say three words for you
to remember. Please repeat the words after I have said all three. The words are
sock, blue and bed. Now, tell me the three words." And you will then Ö in this,
again, what you're looking for in this item. The reason it's a fundamental item
that's in a lot of cognitive assessments, the other is that it could tell you,
one: if they can't tell it back to you if they have a hearing impairment. The
other is possibly a language barrier. Another is inattention. So, they're, you
know, like my teenager. They're looking off in space while you're talking to
them, but that can be a sign of delirium that you're sort of looking for and
watching for attention. And it can also be a sign of organic cognitive
impairment.
Ask the question as written and immediately prompt for a response. If the
resident repeats all three words correctly on the first attempt, then you will
be reinforcing. Everybody gets the reinforcement with the category cues. This is
because, later on, you're going to be asking them to recall the item, and you
may be giving them category cues to help them with their recall. It also helps
encode that information a little bit better that you're giving them the category
cues.And you'll code their response before moving on to the next interview
question.
So what's a category cue? It's basically a phrase. Prompt is another word for
this. It's a phrase that puts a word in context. It helps prompt your recall
ability, stimulates learning and fosters memory even among residents that are
able to repeat the word immediately. So, the cues for this item are: a sock is
something to wear; blue is a color; and, bed a piece of furniture. You can
provide these category cues to them verbally, or if their preferred method of
communication is writing, you can provide them in writing. That's the one, you
can do it in writing, not for your convenience, not because you have an
inability to speak clearly, but because they prefer to communicate in writing,
then you can give these category cues in writing and that's in the manual.
So you'll say to them if they get them right, you'll say, "Yes, that's correct.
The three items were sock, a piece of clothing; blue, a color; bed, a piece of
furniture." Okay? And you will write down in that little coding box a "3". If
they recalled two or fewer words on the first attempt, you're going to make a
second attempt; and, the second time that you try to get them to encode those
words, you're going to give them the category cues. But, what you're going to
write in that box on C0200 is how many items they got right the first time you
asked. You're not writing down the number of times you had to repeat. You're not
writing down how many they got right the second time or the third time, because
you're looking for that first effort to repeat back the item to you, But, you're
going to keep trying to give them this information so they can encode it so that
they have an opportunity later on to recall. If they don't recall on the second
attempt, you're going to make a third attempt, and you're going to repeat the
words again and use the cues. If they don't get all three words after three
tries, make sure that they can hear you - that that's not the problem. But if
they can hear you, then you're going to move on to the next question. Obviously
if they can't hear, you need to figure out if there's any way to optimize their
hearing before proceeding.
The way that you score this is it doesn't matter what order they recall the
words. If they recall blue before sock or sock before bed, it doesn't matter as
long as they give you the three words, and the words can be recalled in any
context. So, they can make up a little mnemonic right on the spot, like I
sometimes do to remember things. That sentence that contains the three words
that they feed back to you. That's okay. As long as the three words are in
there, they've given you back the words. Score the number of words repeated on
the first attempt, as I said on the item. If the interviewer cannot say the
words clearly, then you need to just have another staff member conduct the
interview with the resident. So, some providers have very thick accents and it
can be difficult, sometimes, for them to say those three words clearly. The best
course for the facility is to have a provider who can speak clearly, and without
an accent, conduct the interview with the resident for this specific
performance-based assessment. The limited circumstances where the BIMS can be
conducted in writing, I've already talked about and that's if the resident's
preferred form is in writing. And there's language about these two things in
Chapter 3 of the manual.
Coding instructions: Again, you're going to record the maximum number of words
that were repeated on the first attempt - whether they got zero, none of the
words, one of the words, two of the words, three of the words. And, gee, the
numbers match. So, that's good.
So here's an example: The interviewer says, "The words are sock, blue and bed.
Now please tell me the three words." The resident says, "Bed, sock and blue" and
the interviewer will then say, "That's right. The words are sock, something to
wear; blue, a color, and, bed, a piece of furniture." So, basically that
interviewer will code this item as "3" because the resident repeated all three
items on the first attempt.
Now, one of the things that we do in the manual is give you just some suggested
language to sort of introduce the section - which I forgot to talk about at the
beginning - and that is to just say - and you'll see it in the scenarios - "I'm
going to ask you some questions. We ask these of everyone to help us plan their
care better. Some of these questions may seem easy. Some may seem hard. Is it
okay if we start?" And, you know, most residents, again, want to tell you and to
help you help them, and they want to answer your questions. If you get someone
that says, "No, go away, I don't want to talk to you," that's important to know
that this person is not wanting to communicate and talk to their providers. But,
you're not going to force the situation. You can ask, you know, "Would it be
okay if I come back at another time or if someone else comes back," but if they
say no, they don't want to, then you don't force the situation.
Scenario 2: The interviewer says, "The words are sock, blue and bed. Now please
tell me the three words" and the resident goes, "What were those three words?"
The interviewer goes ahead and repeats the three words and the category cue, but
they're going to code this item as 0, none, because on the first attempt the
resident was unable to repeat any of the words.
So, practice items: The interviewer says, "The words are sock, blue and bed.
Now, please tell me the three words" and the resident says back, "Sock, bed and
black." The interviewer repeats the three words, plus the category cues: "Let me
say the three words again. They are sock, something to wear; blue, a color; and
bed, a piece of furniture. Now tell me the three words." And the resident says,
"Oh, yeah. Yeah, that's right. Sock, blue and bed."
So how should this be coded? From the Audience: 2 So, most people said 2, and
the correct code is 2 because the resident repeated two of the three words on
the first attempt. Again, it's scored based on the first attempt only.
So, second practice item. "The words are sock, blue and bed. Now, please tell me
the three words and the resident says, "The blue socks belong on the dresser."
The interviewer repeats the three words plus the category cues. How should this
one be coded? From the Audience: 2 So, hearing and seeing a lot of 2s, all
right, which is correct. The correct answer is 2. The resident repeated two of
the three words: blue and sock. They put them in a sentence, but that's okay
that they were able to use a mnemonic.
Now, you may want to make a note of that, you know, that your resident uses
mnemonics to remember things. I mean, to yourself. CMS doesn't need to know
that, but you can make a note of that for your care planning team, or whoever is
completing the Brief Interview for Mental Status, because that's an important
thing to sort of know about this person's cognitive patterns and how they learn.
"The words are sock, blue and bed. Now please tell me three words." The
interviewer repeats the words and the resident says, "I'm sorry, "Shoe, bed,
red." The interviewer repeats the three words, plus the category cues, and the
resident says, "Oh, I thought you said, 'Red bed and shoe.'" From the Audience:
1 1. Exactly correct. The correct code is one because the resident repeated one
of the three words on the first attempt.
"The words are sock, blue and bed. Now please tell me the three words." "My
husband always left his socks under the bed." The interviewer repeats the three
words plus the category cues, how should this be coded? From the Audience: 2 I
hear a lot of 2s. You're right. The correct code is 2. The resident repeated two
of the three words: bed and sock. The resident put them in a sentence, but
that's okay and it led to them repeating two words.
So, on to C0300: Temporal Orientation. You're going to ask the three questions
in this section, one at a time. Again, temporal orientation is common to a lot
of cognitive items that, a lot of cognitive assessments that are out there, the
MMSE, the 3 MS. A lot of the different longer assessments used temporal
orientation. We modified this a bit because we know residents in nursing homes
or in any institutions, hospitals, may not be exactly oriented to time. So, we
give partial credit for being close because something about the institutional
setting may set you off a bit. After you ask each item, you're going give them
up to 30 seconds to sort of think about it and respond. You do not give them
clues, even if they try to get them out of you; and, if they do, you just tell
them you need to know if they can answer without any help from you. So, the
first item, C0300A, is the year. You're assessing their ability to report the
correct year. "Please tell me what year it is now." And you're going to record
-- let me see. Yeah. I'm sorry, let me go back. So, if they miss it by more than
five years or don't give you an answer, then you record it as a 0. If they miss
by 2 to 5 years, then you'll record it as a 1. If it's missed by one year, as a
2, and if they got it correct, they get a 3. They, again, get partial credit for
being close and the closer the better. So let's say, for example, the date of
the interview was May 5, 2010, and the resident states, "It's twenty-ten (2010)"
or two thousand and ten (2010). Then, you code that as "3, correct."
Moving on to month: Assessing the ability to -- this item just assesses their
ability to report the month. They get partial credit for being close. If they
miss it by more than a month, then they get no answer. If they miss it by six
days to one month, they get a 1. If they're within five days of the month, then
they get a 2. We'll show you some examples.
The date of the interview was June 25th, 2010 and the resident says it's June.
So, obviously, they're accurate within five days of the month, and they would be
coded as a 2. Now, we'll get to some examples of the other more complicated ways
of coding in just a minute. Assessing the resident's ability to report the
correct day of the week in C0300 C, what day of the week is it today, and here
they just either got it right or they didn't. Zero is incorrect and 1 is
correct. So, here's a coding example. It's Monday, June 25th, 2010, the resident
says, "It's Monday." They got it right. They got a 1.
So, here's some practice activities that will clarify some of these partial
scoring approaches. We know it makes it a little more complicated to do, than
just completely right or completely wrong, but it gives you a more nuanced and
fairer picture of where that resident's cognitive status is. So, it's worth
learning the slightly more complicated scoring rules.
The date of the interview is June 16, 2010, and the resident responds to your
statement when you say, "Please tell me what year it is right now." They say,
"It's 2007." From the Audience: 1 So, the question is do you code it 0, 1, 2 or
3, and I heard a lot of 1s, which is right. So the correct code is 1. They
missed it by two to five years, 2007. If you had a hard night last night, I'll
tell you it's within two to five years of 2010. Laughter
For the date of the interview now is, again, January 10, 2010. The resident,
when you're asked to tell you what year it is right now, they say, "It's 1910."
So: 0, 1 or 2 or 3 and, obviously, the correct code is 0. They missed it on more
than five years or no answer. Even though 10 is part of the year, it really ..
it's 1910, and they got it wrong.
Date of interview is April 1, 2010. The resident responds to the statement,
"Please tell me what year it is right now,' and they say, "Ten." And the
interviewer asks, "Can you tell me the full year?" The resident says, "Ten." The
interviewer can state one more time, "Can you please tell me the full year? For
example, 1982." And the resident says, "It's 2010." Now, here what do you think
you would code that? D - 3. Correct. So, basically, even though 10 was partially
correct, you can't give them credit for it, obviously, because they can think
it's 1910 or 1810. So, you need to give them an opportunity to tell you back
that it's 2010. And they did.
The date is June 28, 2010 and you ask them, "What month are we in right now?"
and they say, "It's July." So is that a 0, a 1 or a 2 coding? I'm hearing
different answers. I'm hearing 1s and 2. The correct answer is 2. It's accurate
within five days. So, now here's a clue. If you're not sure, write it down and
go back and check the calendar when you're through. Laughter But, basically,
"Thirty days hath September, April, June and November." Right? So, June, 27, 28,
29, 30, 31. Right? So, July is within five days of the evaluation. Okay?
Everybody okay?
On the date of the interview is June 30, 2010. The resident responded to the
question, "What month are we in right now?" says, "It's August." So, do we code
it a 0, 1 or a 2? Hearing some slightly different answers on this one. It's 0
because they missed it by more than one month or they didn't answer.
June 2, 2010 is the correct date, and when you ask what month we're in right now
the resident says, "May." So, did they miss it by more than one month, by six
days to a month or were they accurate within five days? Yes, 2. A lot of people
said 2. Accurate within five days. So, June 2 minus five days is May 29th. You
know? So, May has 31 days, but when you count back five days you count June 2 as
the first, and you count back five days, that gets you to May the 29th. The
resident is stating the month within five days.
Ok. The date of the interview is Monday June 25, 2010, and the resident responds
by saying, when you ask what day of the week it is, they say, "Tuesday." Zero.
The correct answer is 0 - incorrect or no answer. They incorrectly stated date
of the week.
The day of the interview was Monday, June 25, 2010, and when you ask what day of
the week it is, they say, "Well, today's a good day." Laughter So, the code is 0
- incorrect or no answer.
So, let's move on to 400: Recall. So, you're going to ask the resident to repeat
the words from the earlier question, and the language you're going to use is
right there on the form: "Let's go back to an earlier question" and "What were
those three words that I asked you to repeat?" And you're going to allow, give
them up to five seconds to recall the items. If they recall the word, great.
You're going to score that as 2- Yes. No cue required. But if they don't, you're
going to give them that category cue that we initially taught them up above.
We're going to give it to them now and say, "One word was a color," and give
them a chance to say, "Oh, yeah. Blue." And then, if they get it with that, then
they get a 1.
If they can't recall it, even with the cue or the prompt, then you code it as a
0. You give them a chance to answer first before you give them the cues to
answer. Each word is coded separately: C0400A is for sock; C0400B is for blue;
and C0400C is for bed. It's considered a recall without cueing if they recall
the items. They can recall them in any order, and they can recall them as again
part of the sentence or mnemonic. It's just as long as they recall the words
without a cue. The interviewer recalled the cueing. You gave them the cue, and
again, they can recall them in any order or in a sentence. If they could not
recall the word, even after you cued them, then the item is coded as a 0, or if
they refuse to answer. If they do recall it after you've given them the category
cue or prompt, then you code it a 1. If they were able to do it without cueing,
just right off the bat, then you code that as a 2.
So, here's an example. The resident says, "Socks, shoes and bed," and the
interviewer says, "One word was a color." And the resident goes, "Oh, the shoes
were blue." So, here's how you would code this one: They got socks without the
cue. So, they got a 2 for sock. They got blue after they got a category cue. So,
they get a 1 for that item, and they got bed without a cue. They got it right
initially. So, they get a 2 for that.
All right, so, some practice items: You ask them to recall the three words, and
they say, "You know, I'm so tired. I just don't want to do this anymore." So,
how are you going to code the items in C0400? Zero - Could not recall. Choosing
not to answer a question often in this population indicates an inability to
answer. They don't want to say, "I don't know." They'll say, "I don't feel like
it." "I'm tired." "You're asking too many questions." And, for cognitive
testing, we take that as an indication that they, in all likelihood, don't know
the answer to the question. The most accurate way to score cognitive function,
even though we know sometimes it can just be that the resident really was tired
or cranky, this interview takes about two, maybe three minutes to complete. So,
they're not going to be too tired, and so, again, the standard way of coding
cognitive assessments for refusals is to code it as incorrect.
The resident is asked to recall the three words. They say, "I don't remember."
You say, "One word was something to wear," and they say, "Clothes." The
interviewer says, "Okay, one word was a color," and they say, "Blue." And then
they say, "Okay, the last word was a piece of furniture" and the resident says,
"Couch." Now, this one -- I laughed yesterday about the SAT. This was like SAT
answers. Okay, so, A: All terms are coded "0. - No, could not recall" because
the resident initially stated she couldn't remember. B option is: All terms are
coded 1 because the resident required cueing to attempt recall for all of the
items. C: All terms are coded 1, yes, after cueing because the resident
remembered at least one term after cueing, or D: Code sock and bed as 0 - no,
could not recall" and code blue as 1 - yes after cueing." [The answer is] D. All
right. So, you would code A and C as no, because they were not able to recall.
But you would code -- excuse me, B correct. Blue, because they did recall it
after they got the cue.
Practice. All right. So, we're going to watch the video of a Brief Interview for
Mental Status. Now, one of the things that I thought was in here, but -- is the
idea of nonsensical answers. So, I'm just going to review nonsensical answers
really quickly. So, what nonsensical means is not that they got it wrong. What
nonsensical means is that the answer has absolutely nothing to do with the
question that you've asked. It's totally off track. So, I have a patient in the
nursing home who is the sweetest guy, but every time you ask him a question, he
looks at you and says, "Where is Sylvia?" So, when I ask him an item like what
year is it, and he tells me, "Where's Sylvia", that's a nonsensical answer. It's
not at all related to this. If he had told me it was 1820, that's clearly wrong,
but it's related to the question of year. Now, in the BIMS, a nonsensical answer
is still coded as wrong. Okay? It's coded as a 0, because they didn't get it
right, obviously, but it will be part of the stop rules for you to remember how
many nonsensical answers you got because if they give you too many nonsensical
answers, we're going to tell you that that that's not considered a completed
interview, and you need to go to another form of assessment to the staff
assessment because there is the possibility that they could have some kind of
expressive aphasia and still be cognitively intact. And so, you don't want to be
miscoding. So, if someone had an inability to answer the questions because
they're giving you, you know, totally unrelated items, then you're going to need
to go ahead and do your staff assessment. Likewise, if someone is not able to
communicate, you can't just assume they're cognitively impaired just because
they can't communicate. And so, your staff assessment needs to be done with the
assumption that they may have intact, or at least partially intact, cognitive
ability w hen you enter into doing that staff assessment. Alright, Jennifer, can
we start? So, the date of the interview is November 23, 2009 on this and just
try to keep track as she's asking her the questions.
The purpose of the first interview section in MDS 3.0 is to assess the
resident's cognitive patterns. The Brief Interview for Mental Status
sufficiently provides insight into the resident's current condition and helps to
identify needed supports. Most residents are able to attempt this Brief
Interview for Mental Status. Without an attempt at structured cognitive
interview, a resident may be mislabeled based on his or her appearance or
assumed diagnosis. Now, we will demonstrate an interview. Score the interview as
you watch. To do this, you will need to know that it is Monday, November 23,
2009. Before watching and scoring the interview, review the coding instructions
in the manual.
Ms. Jones? Ms Jones? Ms. Jones, I'd like to ask you those questions now. We ask
these questions of everyone and we do it so we can better plan your care. Some
of the questions may seem easy, others more difficult. Are you ready? Okay. I'm
going to say three words for you to remember. Please repeat the words after I
have said all three. The words are: sock, blue and bed. Now, tell me the three
words. Bed. Blue. Blue is my favorite color. Okay. Yes, two of the words are
bed, a piece of furniture, and blue, a color. The third, sock, is something that
you wear. Now, tell me the three words. The blue socks are on the bed. Okay, now
can you tell me what year it is right now? Don't you know? We ask these
questions so that we can better plan your care. Please tell me the year we're
in. 1999, the Millennium. And what month is it? November. My grandchildren made
that turkey for me. Oh, very creative. And what day of the week is it? Monday.
Monday, we play Bingo. It's Monday. You play Bingo on Monday? It's Monday.
Wonderful! Now, let's get back to the earlier question. What were those three
words I asked you to repeat? Blue. Okay, and something that you wear? Dress.
Okay, and the piece of furniture? Bed. Okay, now I'd like to ask you some
questions about your mood. Would that be all right with you?
Okay, so, Kathy is actually one of the nurses, the MDS Coordinator in one of the
facilities that I work in. So, let's go through how that was scored.
C0200? 2. She remembered two of the words initially. Bed and - repeated, I'm
sorry, two of the words initially: bed and blue. C0300A? Zero. 1999 is more than
five years away from 2010. What month are we in right now? Two. She was accurate
within five days. Now, I think that was an important point. She used the turkey.
That's okay. That's one of the reasons that, you know, we say, "Well maybe
people are going to know." Some people say, "Nursing home residents: how will
they know what month it is?" There's always something going on in the
facilities. It's Valentine's Day; it's Thanksgiving; it's Christmas; or other
holidays going on where there are decorations and parties and things going on.
So, there's actually more opportunity for orientation than or, you know, it's
their birthday month or whatever. So using an environmental cue is okay. Now,
it's not okay for them to get you to walk across the room, get the calendar out
of their desk drawer, and start looking at it. But, you know, if they're using
environmental prompts and cues, that's okay to score it. So she got a 2 for that
one. What day of the week is it today? One. She was correct. Again she used a
cue, the fact that it was Bingo Day, to do that. How about "C0400A - Recall of
sock"? Zero. No. How about "C0400B - Able to recall blue?" Two. She got that
right, just without any kind of prompting. And how about, "Able to recall bed -
C0400C"? One. So C is coded a 1. She needed the cue, but she did give it back to
you after a cue.
So, did I go backwards? What did I do here? So, next is a summary score. So,
we'll sum her score in just a second. I just want to talk about why that's
important. It allows you to compare future and past performance. So you can just
look at that score, and see if it's changing over time. It decreases the chance
of incorrectly labeling cognition; improves the detection of delirium because
you're looking for that change; provides a more reliable estimate and allows the
staff to interact based on the resident's ability. So, I'm sorry, one of the
things I didn't bring up was the recall item. Again, you're coding here that she
needed a prompt, and that's really important for you for care planning. So, this
item is not just an MDS item to make CMS happy. It actually can help you with
your care planning. Here's a patient that you know is helped by prompts. So make
a note of that, whoever is doing the interviews interviewing them, and bring it
back to the care planning team - that this is a particularly important tool to
help this resident in being oriented or in remembering things.
So, okay. You're going to conduct the assessment, and then you just add up the
values for the BIMS assessment. You want to fill in both of those two boxes.
There are two boxes there. So if they got 0, you write 00. If they got a 9,
you'd write 09. If they got a 15, you write 1 and 5. Don't add up the score
while you're with the resident. Wait until you've left the room, and focus your
full attention on the interview. Then, you can just honestly say if they ask how
they did you can say, "You did fine. I'll add it up later," and just move on.
Apply the guidelines to determine if the interview is complete or incomplete,
and we'll go over those in a second. So, now the total score reflects cognitive
status, but it's not diagnostic of cognitive status. You're not being asked to
make a diagnosis. The total score is highly correlated with MMSE, but, again,
there are other reasons somebody might be getting these wrong, and it's really
up to the primary care provider or the neurologist or neuropsychological staff
to be sort of coming up with whether or not it meets criteria for dementia or
other cognitive impairment. But the correlation is such that 13 to 15 correlates
highly with someone who is cognitively intact. A total score of 0 Ö 8 to 12 is
moderate impairment and 0 to 7 is severe impairment. Again, we talked about the
two digit. Be sure you use a leading 0 if it's less than 10. If they were unable
to complete the interview, then you code 99, and it says that right there on the
form so that you don't have to remember that. And a 0 does not mean the
interview was incomplete. It just means they got them wrong. And this one just
shows you basically the whole point of this example was just that you add two
plus two plus one plus two plus one and you come up with eight. So, if we add
her interview items, we get the first item was two, the next was two, one, two
and one. So we've got four, five plus three. Eight. Everybody with me on that?
So, you just write down a 0 and an 8 in C0500 for that interview that you just
observed.
All right, so, this gets back to what I was talking about logical and illogical.
So, basically for us to say that this section was completed, they need to have
answered at least four of the items from C0200 through C0400. They don't have to
have gotten them right, but they need to have not refused and not given you
illogical answers for at least four of the items. They can get them wrong, but
if they refused or they gave you completely, "Where is Sylvia" for all of them,
for four of the items, then you will consider that an incomplete interview. To
be relevant, a response only has to be related to the question or logical. The
responses do not have to be correct to be counted as an answer. A score of 0
does not mean that it's incomplete. What constitutes an incomplete interview: if
they can communicate but they choose not to participate. Belmont principles -
you have the right to refuse anything we try to do to you. Minority of residents
are unable or unwilling to participate in the brief interview. When we presented
it to folks scheduled for their MDS assessments, 90 % completed this. If the
resident gives nonsensical responses to four or more items in C0200 through
C0400, again that same idea, incorrect is not illogical or nonsensical. So,
conduct C0200 and 300 with all residents who attempt the interview. If by the
time you get through with C0300 they haven't answered any items or they've given
you nonsensical responses to all of the items up to the end of C0300, they've
now failed the four rule, and you don't have to continue on with the assessment.
You can - and that's basically what this next bullet says. So, they need to have
provided relevant responses to at least four items in C0200 hundred to C0400 for
you to be able to enter a score instead of a 99 in box C0500, Section C0500. If
you stopped it after C0300, because they either refused to answer everything
through the end of C0300 or they've given you nonsensical answers through the
end of C0300, then you're going to have coded the ones you've tried as a 0. And
then you'll code the items in C0400 with a dash, and then under the summary
score for C0500, you'll enter a 99 because you didn't complete it. And dash
means you didn't try it. Same convention for the dashes, you have in other parts
of the form. And if you code it as a 99, that means you do the one and do the
staff assessment for mental status. If you get through to the end of the
interview, you get through the end of C0400, it could still be incomplete
because they still did not answer, give you relevant answers to four or more
items in that section. And, again, you would code 99 and C0500 and indicate that
it was an incomplete interview. So the item in C0600 again is just to help you
with the prompting in here, and it's basically asking you should the staff
assessment be conducted, C0600 and the answer for that one would be basically if
you entered something other than 99 in that C0500 box, then you would enter "0 -
No, the resident was unable to complete the interview" and you would move on to
doing the delirium items. If they were unable to complete the interview, if you
either entered a 0 in C0100 or you entered a 99 in C0500, so there are two ways
they could not have completed the interview: One is you never attempted because
they were unable to make themselves understood even some of the time or you
tried the interview and it was incomplete, then you would put a 1 in box C0600.
And actually I told you something wrong. I apologize. Let me back up. So the
only time you'd be entering a 1 because of the skip pattern you had in C100, it
skips you straight through to C0700. So you would never end up -- if you had
said at the beginning they were rarely or never understood, you would have
skipped C0600. You would not be in C0600. Sorry, we changed that after the
national study. So basically if you entered a 0 in C0100, you would just be
going straight to C0700. So you would be entering a 1 in this box that, yes, the
resident was unable to complete the interview if you had entered a 99 in box
C0500. Now, again some of your vendors may take care of this for you in your
software programs, but this is just to help those people that are doing it paper
and pencil and entering it into their software, and, let's see, again, you know,
still need to assess people for this. It's really important. Even though they
couldn't complete the interview, it's important to do a staff assessment,
because there are reasons other than severe cognitive impairment that they might
not have been able to complete the interview, and you're going to be observing
their behaviors. And you're going to -- this is just what we talked about.
You're going to look at the answer to C0500 to see whether or not it was
completed, and then, we talked about this already, you'll code 0 if you did
finish the interview, a 0 goes in that box for C0600, and if you entered a 99 in
that box and then a 1 goes in that item. So, basically, that's the Brief
Interview for Mental Status. If you'll notice, this is the one section that we
don't use cue cards because unless .. again, the only way that resident
communicates normally is in writing then we will write things out, but
otherwiseÖ you'll rely on interaction with the resident.