Question

How does Medicare assess the need for long-term care services in a nursing home setting? Your answer must include reference to MDS, RUGS and CAAs.

Answer 1

Ans) Long-term care refers to a comprehensive range of medical, personal, and social services coordinated to meet the physical, social, and emotional needs of people who are chronically ill or disabled.

- A nursing home facility may be the best choice for people who require 24-hour medical care and supervision.

- Nursing homes offer the most extensive care a person can get outside a hospital. Nursing homes offer help with custodial care -- like bathing, getting dressed, and eating -- as well as skilled care. Skilled nursing care is given by a registered nurse and includes medical monitoring and treatments.

- Skilled care also includes services provided by specially trained professionals, such as physical, occupational, and respiratory therapists.

- The services nursing homes offer vary from facility to facility. Services often include:

• Room and board
• Monitoring of medication
• Personal care (including dressing, bathing, and toilet assistance)
• 24-hour emergency care
• Social and recreational activities

- The MDS 3.0 is a core set of elements, including common definitions and coding categories, which form the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. The screening, clinical, and functional status items in the MDS 3.0 standardize communication about resident problems and conditions. The MDS 3.0 contains items that reflect the acuteness of the resident’s condition, including diagnoses, treatments, and functional status. MDS 3.0 assessment data is personal information SNFs must collect and keep confidential by Federal law.

- The MDS 3.0 is one of three components of the Resident Assessment Instrument (RAI). The other two components are:

- Care Area Assessment (CAA) Process, which assists with systematic interpretations of the completed MDS 3.0
- RAI Utilization Guidelines, which provide guidance on when and how to use the RAI
The complete RAI yields information about a resident’s functional status, strengths, weaknesses, and preferences, and it offers guidance on further assessment once you identify problems.

- The MDS 3.0 classifies residents into a Resource Utilization Group Version IV (RUG-IV) based on the average resources needed to care for someone with similar care needs. RUG-IV classifications help Medicare determine the Part A SNF PPS payment.

- The RUG-IV classification system includes eight major classification categories:

• Rehabilitation Plus Extensive Services
• Rehabilitation
• Extensive Services
• Special Care High
• Special Care Low
• Clinically Complex
• Behavioral Symptoms and Cognitive Performance Problems
• Reduced Physical Function