The Resident Assessment Instrument (RAI): promise and pitfalls

Use of a mobile device by nursing home residents for long-term care comprehensive geriatric self-assessment: a feasibility study

Long-term-care comprehensive geriatric assessments, such as the Minimum Data Set 3.0, are used to evaluate the clinical, psychological, and personal status of residents in long-term-care nursing facilities. Nursing staff conducts assessment interviews, thereby increasing the workload of nurses and the cost of patient care. This study explored the ability of nursing home residents to use two different mobile devices for a geriatric self-assessment. Study participants were residents of long-term-care nursing homes. A modified Minimum Data Set 3.0 was converted to a format for use with a 6-inch mobile pad and a 3.7-inch mobile smartphone. The survey completion rate and the response time were measured. A Technology Assessment Model questionnaire analyzed the participants' experience. All participants were able to use a 6-inch pad, with an average completion rate of 92.9% and an average time for completion of 21 minutes. Only 20% of the participants could complete the assessment with the 3.7-inch smartphone. The participants found the 6-inch pad easier to use than the 3.7-inch smartphone. This exploratory study suggests that nursing home residents are able to use a mobile device to perform a geriatric self-assessment and delineates the importance of the ergonomics of the device.

[Resident assessment instrument. Application options and relevance for Germany]

The Resident Assessment Instrument (RAI) is a structured and standardized instrument to improve the quality of long-term care. It is based on the Minimum Data Set (MDS) 3.0 to generate clinical data for nursing planning. Further practical applications are calculation of the costs of nursing care (using a classification of residents), measurement and transparency of nursing home quality (using quality indicators) and epidemiological surveys (using uniform data from assessments). The RAI is used nationwide in the USA, to some extent in other countries and in Germany predominantly in the context of research. The paper briefly describes the historical development of the different RAI variations (particularly with respect to the MDS), presents the central utilization options and ends with a critical discussion of possibilities and limits of the RAI.

Finding Gertrude: The resident's voice in Minimum Data Set 3.0

PURPOSE

The new Minimum Data Set 3.0 was designed to improve the assessment process by requiring nursing home (NH) staff to attempt to interview residents with scripted questions to assess subjective states such as pain, mood, and cognitive functioning. Although the case has been made that resident self-report is important, it is unknown whether facilities are doing so in practice. We examined the frequency of attempts to interview residents to elucidate the types of residents able to be interviewed about their clinical conditions and facility characteristics related to the likelihood of attempt.

DESIGN AND METHODS

Data come from Minimum Data Set 3.0 annual assessments for 757,044 residents in 15,030 NHs during 2011-2012 and the 2011 Online Survey, Certification, and Reporting database. Hierarchical generalized linear models were conducted to test the association between resident and facility characteristics and the attempt rate of resident interview for 3 clinical domains (cognition, mood, and pain).

RESULTS

Over 83% of long-stay residents attempted all 3 self-report clinical items. The rates of attempt for mood, cognition, and pain were 88%, 89%, and 92%, respectively. Results from hierarchical generalized linear models suggest that certain resident characteristics are related to the likelihood of participating in interviews, in particular neither having a diagnosis of dementia nor cognitive impairment, not exhibiting signs of delirium, nor a documented prognosis of 6 months or less to live. Residents in smaller, chain-affiliated nursing homes with fewer Medicare residents and fewer assessments per administrative nurse and registered nurse were more likely to attempt the resident interview items.

IMPLICATIONS

This article documents the high rate of NH residents' participation in interviews about their clinical states. Furthermore, we identify types of residents for whom additional investigation into ways to achieve higher rates of participation is required and facility resources that are related to the likelihood of high rates of attempt.

Making the investment count: revision of the Minimum Data Set for nursing homes, MDS 3.0

BACKGROUND

The Minimum Data Set (MDS) is a potentially powerful tool for implementing standardized assessment in nursing homes (NHs). Its content has implications for residents, families, providers, researchers, and policymakers, all of whom have expressed concerns about the reliability, validity, and relevance of MDS 2.0. Some argue that because MDS 2.0 fails to include items that rely on direct resident interview, it fails to obtain critical information and effectively disenfranchises many residents from the assessment process.

PURPOSE

Design a major revision of the MDS, MDS 3.0, and evaluate whether the revision improves reliability, validity, resident input, clinical utility, and decreases collection burden.

DESIGN AND METHODS

In the form design phase, we gathered information from a wide range of experts, synthesized existing literature, worked with a national consortium of VA researchers to revise and test eight sections, pilot tested a draft MDS 3.0 and revised the draft based on results from the pilot. In the national validation and evaluation phase, we tested MDS 3.0 in 71 community NHs and 19 VHA NHs, regionally distributed throughout the United States. The sample was selected based on scheduled MDS 2.0 assessments. Comatose residents were excluded. A total 3822 residents of community NHs in eight states were included. The evaluation was designed to test and analyze inter-rater agreement (reliability) between research nurses and between facility staff and research nurses, validity of key sections, response rates for interview items, anonymous feedback on changes from participating nurses, and time to complete the MDS assessment.

RESULTS

The reliability for research nurse to research nurse and for research nurse to facility staff was good or excellent for most items. Response rates for the resident interview sections were high: 90% for cognitive, 86% for mood, 85% for preferences, and 87% for pain. Staff survey responses showed increased satisfaction with clinical relevance, validity and clarity compared with MDS 2.0. The test version of the MDS 3.0 took 45% less time for facilities to complete.

IMPLICATIONS

Improving the reliability, accuracy, and usefulness of the MDS has profound implications for NH care and public policy. Enhanced accuracy supports the primary legislative intent that MDS be a tool to improve clinical assessment and supports the credibility of programs that rely on MDS.

Identifying failure to thrive in the long term care setting

INTRODUCTION AND RATIONALE

Geriatric failure to thrive (GFTT) is commonly encountered in the long term care (LTC) setting. This syndrome of unexplained functional decline can be approached in a methodical manner. The updated Minimum Data Set (MDS) 3.0, now implemented in almost all skilled nursing facilities, includes pertinent clinical information that could be used to identify residents who manifest GFTT. A screening tool using data from the MDS 3.0 could be used by LTC providers to evaluate LTC residents.

METHODS

A literature review was completed to identify articles focused on (1) GFTT in the LTC setting and (2) tools to identify GFTT. Common components of GFTT were matched with items collected as part of the MDS 3.0 with a goal to determine its utility as a screening tool to identify GFTT in the LTC setting.

OUTCOMES AND DISCUSSION

The MDS 3.0 includes assessment of numerous components commonly observed in patients with GFTT. By using clinically validated tools, the MDS 3.0 may assist in the recognition of LTC residents with or at risk for GFTT. Once GFTT is recognized, the LTC interdisciplinary team can then identify potentially reversible causes, set goals of care, and develop a comprehensive care plan that may include diagnostic measures, curative interventions, and/or palliative measures individualized to the resident.

Temporal and Geographic variation in the validity and internal consistency of the Nursing Home Resident Assessment Minimum Data Set 2.0

Background

The Minimum Data Set (MDS) for nursing home resident assessment has been required in all U.S. nursing homes since 1990 and has been universally computerized since 1998. Initially intended to structure clinical care planning, uses of the MDS expanded to include policy applications such as case-mix reimbursement, quality monitoring and research. The purpose of this paper is to summarize a series of analyses examining the internal consistency and predictive validity of the MDS data as used in the "real world" in all U.S. nursing homes between 1999 and 2007.

Methods

We used person level linked MDS and Medicare denominator and all institutional claim files including inpatient (hospital and skilled nursing facilities) for all Medicare fee-for-service beneficiaries entering U.S. nursing homes during the period 1999 to 2007. We calculated the sensitivity and positive predictive value (PPV) of diagnoses taken from Medicare hospital claims and from the MDS among all new admissions from hospitals to nursing homes and the internal consistency (alpha reliability) of pairs of items within the MDS that logically should be related. We also tested the internal consistency of commonly used MDS based multi-item scales and examined the predictive validity of an MDS based severity measure viz. one year survival. Finally, we examined the correspondence of the MDS discharge record to hospitalizations and deaths seen in Medicare claims, and the completeness of MDS assessments upon skilled nursing facility (SNF) admission.

Results

Each year there were some 800,000 new admissions directly from hospital to US nursing homes and some 900,000 uninterrupted SNF stays. Comparing Medicare enrollment records and claims with MDS records revealed reasonably good correspondence that improved over time (by 2006 only 3% of deaths had no MDS discharge record, only 5% of SNF stays had no MDS, but over 20% of MDS discharges indicating hospitalization had no associated Medicare claim). The PPV and sensitivity levels of Medicare hospital diagnoses and MDS based diagnoses were between .6 and .7 for major diagnoses like CHF, hypertension, diabetes. Internal consistency, as measured by PPV, of the MDS ADL items with other MDS items measuring impairments and symptoms exceeded .9. The Activities of Daily Living (ADL) long form summary scale achieved an alpha inter-consistency level exceeding .85 and multi-item scale alpha levels of .65 were achieved for well being and mood, and .55 for behavior, levels that were sustained even after stratification by ADL and cognition. The Changes in Health, End-stage disease and Symptoms and Signs (CHESS) index, a summary measure of frailty was highly predictive of one year survival.

Conclusion

The MDS demonstrates a reasonable level of consistency both in terms of how well MDS diagnoses correspond to hospital discharge diagnoses and in terms of the internal consistency of functioning and behavioral items. The level of alpha reliability and validity demonstrated by the scales suggest that the data can be useful for research and policy analysis. However, while improving, the MDS discharge tracking record should still not be used to indicate Medicare hospitalizations or mortality. It will be important to monitor the performance of the MDS 3.0 with respect to consistency, reliability and validity now that it has replaced version 2.0, using these results as a baseline that should be exceeded.

The basis for improving and reforming long-term care. Part 3: essential elements for quality care

There is a pervasive effort to reform nursing homes and improve the care they provide. Many people are trying to educate and inform nursing homes and their staff, practitioners, and management about what to do and not do, and how to do it. But only some of that advice is sound. After more than 3 decades of such efforts, and despite evidence of improvement in many facets of care, there are still many issues. Despite improvements, the overall public, political, and health professional perception of nursing homes is often still negative. To date, no tactic or approach has succeeded nationwide in consistently facilitating good performance or correcting poor performance. Only some of the current efforts to try to improve nursing home quality and to measure it are on target. Many of the measures used to assess the quality of performance have limited value in guiding overall quality improvement. Before we can reform nursing homes, we must understand what needs to be reformed. This series of articles has focused on what is needed for safe, effective, efficient, and person-centered care. Ultimately, all efforts to improve nursing home care quality must be matched against the critical elements needed to provide desirable care. Based on the discussions in the previous 2 articles, this third article in this 4-part series considers 5 key elements of care processes and practices that can help attain multiple desirable quality objectives.

Improving the quality of residential care using goal attainment scaling

OBJECTIVE

To illustrate the potential of goal attainment scaling (GAS) as a means to improve the quality of care provided by residential care facilities to frail older adults.

DESIGN

A pre-test/post-test single-group design.

SETTINGS/PARTICIPANTS

Twenty facilities providing inadequate care to at least one resident. These facilities were identified with a case-finding questionnaire followed by a thorough investigation of the quality of care delivered to a sample of frail older adults.

INTERVENTION

The 6-month intervention was conducted by three interdisciplinary teams of health professionals experienced in caring for frail older adults. The intervention was tailored to the main quality problems identified at baseline in the facility. The first task of the intervention team was to set weighted priority goals in conjunction with the facility manager. Subsequent monthly on-site visits, interspersed with frequent telephone calls, were devoted to assisting the manager and staff implement permanent changes in the areas of care targeted for improvement.

MEASUREMENTS

Pre- and post-intervention GAS scores.

RESULTS

Two facilities were lost to follow-up. A total of 81 facility goals were established at the onset of the study. Goals per facility ranged from 2 to 9 (mean = 4.5, SD = 2.04). GAS scores increased significantly between pre- and post-intervention (P < .001). Goal achievement varied with the manager's own rating of the quality of care provided in the facility (P = .008), his/her education level (P = .037), and the intervention team (P = .049).

CONCLUSIONS

This study shows that quality improvement objectives established with the manager following a thorough evaluation of the quality of care provided in the facility can, on average, be attained with the help of experienced health professionals. It also provides some insight into the types of facilities where preset objectives are more likely to be achieved.

Improving the quality of residential care using goal attainment scaling

OBJECTIVE

To illustrate the potential of goal attainment scaling (GAS) as a means to improve the quality of care provided by residential care facilities to frail older adults.

DESIGN

A pre-test/post-test single-group design.

SETTINGS/PARTICIPANTS

Twenty facilities providing inadequate care to at least one resident. These facilities were identified with a case-finding questionnaire followed by a thorough investigation of the quality of care delivered to a sample of frail older adults.

INTERVENTION

The 6-month intervention was conducted by three interdisciplinary teams of health professionals experienced in caring for frail older adults. The intervention was tailored to the main quality problems identified at baseline in the facility. The first task of the intervention team was to set weighted priority goals in conjunction with the facility manager. Subsequent monthly on-site visits, interspersed with frequent telephone calls, were devoted to assisting the manager and staff implement permanent changes in the areas of care targeted for improvement.

MEASUREMENTS

Pre- and post-intervention GAS scores.

RESULTS

Two facilities were lost to follow-up. A total of 81 facility goals were established at the onset of the study. Goals per facility ranged from 2 to 9 (mean = 4.5, SD = 2.04). GAS scores increased significantly between pre- and post-intervention (P < .001). Goal achievement varied with the manager's own rating of the quality of care provided in the facility (P = .008), his/her education level (P = .037), and the intervention team (P = .049).

CONCLUSIONS

This study shows that quality improvement objectives established with the manager following a thorough evaluation of the quality of care provided in the facility can, on average, be attained with the help of experienced health professionals. It also provides some insight into the types of facilities where preset objectives are more likely to be achieved.

Use of a Content Analysis Procedure for the Development of a Falls Management Audit Tool

The Falls Management Audit Tool (FMAT) was developed to assess the documentation of the falls management process in nursing homes. The multistep content analysis procedure was used to guide tool development and obtain reliability and validity of the FMAT. Established fall guidelines and national experts were used for item development. Trained gerontological nurse practitioners conducted chart audits in nursing home residents with a fall history. Adequate content validity (content validity index > .88) and interrater and intrarater reliability were established (kappas > .78) in the final version of the 57-item FMAT and pilot testing demonstrated feasibility. This study provided evidence that the FMAT is a reliable and valid tool, which can be used to assess the documentation of the falls management process and for measuring the effect of research or quality improvement interventions.

Use of proxy respondents and accuracy of minimum data set assessments of activities of daily living

BACKGROUND

Although the Minimum Data Set (MDS) presents a wide range of opportunities for policy makers and practitioners interested in outcomes of nursing home care for frail elderly persons, researchers have debated the validity and reliability of measurements in the MDS from the outset. To investigate this issue, the authors studied the accuracy of functional assessments by comparing the MDS and interview data collected in two evaluation studies.

METHODS

Activities of daily living (ADL) assessment data from 3385 nursing home residents were collected from interviews with nursing home residents (n = 1200), family members (n = 1070), and nursing home staff (n = 1115). The MDS data for these nursing home residents were obtained and matched with the interview data. The agreement in ADL assessments between interview data and the MDS was assessed using Kappa statistics and multinomial logit regression for each of the three data sources.

RESULTS

The agreement on ADL assessments between MDS and interview data was low to moderate (Kappa = 0.25 to 0.52), regardless of the sources of data. Interview data from staff and family proxies agreed to a greater degree with the MDS than did data collected from nursing home residents. The MDS reported fewer ADL difficulties than did staff proxies and more ADL difficulties than did nursing home residents. These findings held even after adjustment for other confounding factors using multinomial logit regression.

CONCLUSIONS

The substantial discrepancy between MDS and interview data can be attributed to both bias and error. The ADL assessments based on residents' and family or staff reports differ, but the size of these differences depends on the proxy type and the method of data collection.

Quality Indicators for the Management of Medical Conditions in Nursing Home Residents

PURPOSE

The purpose of this study was to develop a set of specific care processes associated with better outcomes for general medical conditions identified as quality improvement targets for institutionalized vulnerable elders.

METHODS

A national panel of nursing home experts used a modified-Delphi process to rate the validity (process linked to improved outcomes) and feasibility (of implementation and measurement) of candidate measures for depression, diabetes, hearing impairment, heart failure, hypertension, ischemic heart disease, osteoarthritis, osteoporosis, pneumonia, stroke, and vision impairment. Each quality indicator was written as an "if" statement, describing persons to whom the quality indicator applied followed by a "then" statement identifying the care process to be provided. A separate clinical committee reviewed the resulting set of indicators.

RESULTS

One hundred fourteen quality indicators were identified across the 11 medical conditions. The quality indicators capture a broad range of medical care addressing assessment, management, and follow up. Fifty-five indicators (48%) were identical to quality measures for community-dwelling vulnerable elders. A limited number were rated as questionably feasible to implement or measure (6 and 2, respectively). Thirty-eight (33%) would not be applied to measures of care quality for persons with advanced dementia or poor prognosis.

CONCLUSIONS

Explicit care processes linked to improved nursing home outcomes for general medical conditions can be identified. Most of these care processes can be measured by medical records or interview. Nursing home quality measures for medical conditions must account for exclusions related to poor prognosis and advanced dementia.

A systems framework for evaluating nursing care quality in nursing homes

Given the ongoing concerns about the quality of care in nursing homes, a theoretical framework to guide a systems approach to quality is important. Existing frameworks either do not model causality, or do so in a linear fashion in which the actual linkages between components of quality may not be well specified. Through a review of frameworks for nursing home quality, and empirical studies on the subject, the authors construct a framework for nursing home quality that links contextual components of quality with structure, structure with process, and process with outcomes, focusing on nursing care quality. Intrastructural relationships and feedback mechanisms are also modeled. The framework is matched with a discussion of multilevel structural equation analysis for statistical application. Future research should expand the framework to include non-nursing components of quality.

Nursing care quality in nursing homes: cross-sectional versus longitudinal analysis

This empirical study of the relationship between nursing care adequacy and nursing care quality demonstrates that a positive relationship exists between the process and outcome dimensions of quality of nursing care. The results from the analysis of national data on nursing homes' deficiencies highlight the importance of conducting a longitudinal study of the effect of nurse staffing and nursing care adequacy on the quality of care.

Adherence to pressure ulcer prevention guidelines: implications for nursing home quality

OBJECTIVES

This study aims to assess overall nursing home (NH) implementation of pressure ulcer (PU) prevention guidelines and variation in implementation rates among a geographically diverse sample of NHs.

DESIGN

Review of NH medical records.

SETTING

A geographically diverse sample of 35 Veterans Health Administration NHs.

PARTICIPANTS

A nested random sample of 834 residents free of PU on admission.

MEASUREMENTS

Adherence to explicit quality review criteria based on the Agency for Healthcare Research and Quality Practice Guidelines for PU prevention was measured. Medical record review was used to determine overall and facility-specific adherence rates for 15 PU guideline recommendations and for a subset of six key recommendations judged as most critical.

RESULTS

Six thousand two hundred eighty-three instances were identified in which one of the 15 guideline recommendations was applicable to a study patient based on a specific indication or resident characteristic in the medical record. NH clinicians adhered to the appropriate recommendation in 41% of these instances. For the six key recommendations, clinicians adhered in 50% of instances. NHs varied significantly in adherence to indicated guideline recommendations, ranging from 29% to 51% overall adherence across all 15 recommendations (P <.001) and from 24% to 75% across the six key recommendations (P <.001). Adherence rates for specific indications also varied, ranging from 94% (skin inspection) to 1% (education of residents or families). Standardized assessment of PU risk was identified as one of the most important and measurable recommendations. Clinicians performed this assessment in only 61% of patients for whom it was indicated.

CONCLUSIONS

NHs' overall adherence to PU prevention guidelines is relatively low and is characterized by large variations between homes in adherence to many recommendations. The low level of adherence and high level of variation to many best-care practices for PU prevention indicate a continued need for quality improvement, particularly for some guidelines.

Indicators of the quality of nursing home residential care

OBJECTIVES

To identify quality indicators (QIs) that can be used to measure nursing home (NH) residential care processes.

DESIGN

Modified-delphi panel process to rate potential QIs that were identified through reported interviews with residents and families and through a review of the scientific literature.

SETTING

Meetings of panel of experts.

PARTICIPANTS

A national panel of nine experts in NH care rated potential QIs. A content expert and a clinical oversight committee performed external reviews.

MEASUREMENTS

Panelists' median validity and importance ratings for each QI choice.

RESULTS

The panel considered 64 choices for QI content and rated 28 of these as valid and important for measuring residential care quality. These 28 choices translated into 18 QIs. The external review process resulted in the addition of one QI that was not considered by the NH panel. The 19 indicators address areas identified as important by residents and proxies. Ten of these QIs were rated feasible to implement with current resources in average community NHs, and nine were rated feasible only in better NHs. The panelists identified nine as being measured most reliably by direct observations of care.

CONCLUSION

Experts identified 19 specific care processes as valid and important measures of the quality of NH residential care. Nine of these QIs may be measured best by direct observation of NH care, rather than by interviews or review of existing NH records. Almost half of the QIs were viewed as discriminating between better and average NHs. The panel deemed that only well-staffed nursing homes could consistently implement nine of the QIs.

Pressure ulcer prevalence in long-term nursing home residents since the implementation of OBRA '87. Omnibus Budget Reconciliation Act

OBJECTIVES

To evaluate change in pressure ulcer prevalence in long-term nursing home residents since the implementation of the Omnibus Budget Reconciliation Act of 1987 (OBRA '87).

DESIGN

Cross-sectional comparison of two time periods.

SETTING

Ninety-two nursing homes scheduled for a quality-of-care survey randomly selected from 22 representative states.

PARTICIPANTS

Four thousand six hundred seventy-nine residents who had resided in the facility for at least 100 days were evaluated: 2,336 during 1992-1994 and 2,343 during 1997-1998.

MEASUREMENTS

Trained registered nurses collected data on pressure ulcer prevalence, stage, and risk factors from medical record review during on-site evaluations. Risk-adjusted differences were estimated using logistic regression.

RESULTS

Unadjusted prevalence rates for all stages of pressure ulcers (8.52% vs 8.54%, P =.983) and those rated stage 2 or greater (5.31% vs 5.63%, P =.624) did not differ between the two time periods. After adjustment for urinary incontinence, immobility, poor nutrition, and history of previous pressure ulcers, the relative odds of having a pressure ulcer in 1992/4 versus 1997/8 was 1.06 (95% confidence interval (CI) = 0.84-1.34) for all stages and 1.21 (95% CI = 0.92-1.60) for stages 2 and greater.

CONCLUSIONS

No change in pressure ulcer prevalence was demonstrated since implementation of OBRA '87 in this nationally derived sample of long-term nursing home residents.

Pain assessment and management in cognitively impaired nursing home residents: association of certified nursing assistant pain report, Minimum Data Set pain report, and analgesic medication use

OBJECTIVES

The primary purpose of this preliminary study was to investigate the associations between certified nursing assistant (CNA) report of pain, Minimum Data Set (MDS) report of pain, and analgesic medication use in cognitively impaired nursing home residents.

DESIGN

Correlational study.

SETTING

Three nursing homes in the greater Birmingham, Alabama area.

PARTICIPANTS

Fifty-seven cognitively impaired nursing home residents with a mean Mini-Mental State Examination (MMSE) score of 11.1.

MEASUREMENTS

Pain was assessed using a three-item proxy pain questionnaire (PPQ), developed by the researchers and administered to the residents' primary CNA. MDS and analgesic medication data corresponding with the time of PPQ data collection were gathered from medical records. Cognitive status was measured with the MMSE.

RESULTS

The PPQ elicited substantially higher estimates of pain prevalence than the MDS (48% versus 20%), and the PPQ and the MDS were not well correlated (pain frequency: r=.19, P=.18; pain intensity: r=.22, P=.11). The PPQ was also more strongly associated with analgesic medication use than the MDS. Cognitive status was significantly associated with pain report on the PPQ but not on the MDS. Test-retest reliability coefficients for the three items of the PPQ were excellent, ranging from.84 to.87 (P </=.01).

CONCLUSIONS

The CNA-generated PPQ was a more sensitive measure of pain than the MDS for this sample. Although the MDS represents an important step toward systematic and standardized assessment of pain, more emphasis should be placed on multimodal assessment, including CNAs' perceptions and observations about pain experienced by cognitively impaired nursing home residents.

The validity of the minimum data set in measuring the cognitive impairment of persons admitted to nursing homes

OBJECTIVES

This study examined the construct validity of two cognitive scales from the federally mandated Minimum Data Set (MDS) of the nursing home Resident Assessment Instrument.

DESIGN

A cross-sectional comparisons of the MDS measures, with scales provided by the resident, a proxy person, and nursing staff.

SETTING

Subjects residing in 59 nursing homes (NHs) in Maryland from 1992 to 1995.

PARTICIPANTS

Subjects were 1939 new admissions to NHs, aged 65 and older, with complete MDS information at admission.

MEASUREMENTS

Two MDS scales, the Cognitive Performance Scale (CPS) and the MDS Cognition Scale (MDS-COGS), were compared with the Mini-Mental State Examination (MMSE) and the staff rating on the Psychogeriatric Dependency Rating Scale (PGDRS) Orientation scale, as well as measures of functioning and functional decline.

RESULTS

The CPS and the MDS-COGS were highly correlated (r = 0.92). Both correlated moderately well with the MMSE (r = -0.65 and -0.68) and with staff's rating on the PGDRS Orientation scale (r = 0.63 and r = 0.66). Correlations with the MMSE (r < 0.70) are lower than previously reported (r > or = 0.80). The proportion of cognitively impaired residents in this NH admission cohort was higher using the MDS-COGS than the CPS (65% vs 57%), but both MDS scales produced lower proportions than the MMSE (70%) and higher proportions than the PGDRS (47%). The internal consistency of the CPS was better without the comatose item (alpha = 0.80 vs 0.70). The MDS-COGS had higher internal consistency (alpha = 0.85) and was simpler to compute.

CONCLUSIONS

This is the first study to examine the validity of the MDS in a large sample of residents and NHs in situations where the MDS was not completed by research-trained staff. Compared with other instruments, the MDS-COGS and the CPS had moderate and similar validity for assessing cognitive impairment. Differences in the scales could provide different estimates of impairment among persons admitted to nursing homes.

Stability of performance of activities of daily living using the MDS

The Minimum Data Set (MDS) requires assessment of performance of activities of daily living (ADLs) by newly admitted nursing home residents over all shifts for a 7-day period, for a total of 21 assessments. This study evaluated within-subject equivalence of multiple assessments of 42 residents' admission MDS ADL performance. Friedman two-way analysis of variance for ranks documented no significant within-subject differences among repeated measurements for all 13 MDS ADL variables. Thus, fewer than 21 assessments may accurately assess ADL performance.

Assessing medication appropriateness in the elderly: a review of available measures

The disproportionate use of medications, combined with age-related pharmacokinetic and pharmacodynamic changes, places older adults at high risk for medication related problems (MRPs). MRPs demonstrate significant morbidity, mortality and economic impact among healthcare systems. The negative outcomes associated with MRPs emphasise the need for more careful and thorough assessments of drug therapy among older adults. In the 1990s a number of methods and instruments were developed to assist in the assessment of medication appropriateness. These tools may be categorised by criteria as: implicit, explicit or one utilising a combination of implicit and explicit criteria. This article reviews these available tools and outlines the advantages and disadvantages of each. In conclusion, those instruments considered to be comprised of both implicit and explicit criteria offer a more thorough assessment of medication appropriateness.

Improving quality of care in nursing facilities. Gerontological clinical nurse specialist as research nurse consultant

It is becoming increasingly common for nursing facilities to use Quality Indicators (QI) derived from Minimum Data Set (MDS) data for quality improvement initiatives within their facilities. It is not known how much support facilities need to effectively review QI reports, investigate problems areas, and implement practice changes to improve care. In Missouri, the University of Missouri-Columbia MDS and Nursing Home Quality Research Team has undertaken a Quality Improvement Intervention Study using a gerontological clinical nurse specialist (GCNS) to support quality improvement activities in nursing homes. Nursing facilities have responded positively to the availability of a GCNS to assist them in improving nursing facility care quality.

Minimum Data Set and Resident Assessment Instrument. Can using standardized assessment improve clinical practice and outcomes of care?

Regulating and standardizing the assessment of residents was envisioned by the 1986 Committee on Nursing Home Reform to have many advantages for facility management, government regulatory agencies, and clinical staff to evaluate changes in resident status and adjust the care plans accordingly. Standardized assessment data was viewed as a source of management information to be used to track case mix (i.e., acuity) of residents, allocate resources such as staff, and evaluate care quality. The Resident Assessment Instrument is a clinically relevant assessment process that can facilitate effective care planning, interventions, and quality improvement. It is a clinically complex process requiring care delivery systems developed by RNs to support the implementation of individualized care.

Using outcomes to make inferences about nursing home quality

Recent concerns about containing the growth of public expenditures on nursing home care and the development of prospective and casemix reimbursement systems with incentives for cost containment have increased the importance of monitoring quality in nursing homes. The current view is that quality assurance systems should include more outcome measures to improve quality. This article discusses why it is difficult to develop facility-level outcome measures that can be used to evaluate and compare the quality of care of nursing homes. The article places the current interest in outcomes measures in its historical policy context and reviews important conceptual and methodological issues associated with outcome-based quality assessment. The authors discuss the difficulty in isolating the facility effect when studying nursing home outcomes and implications of using different estimation approaches. In conclusion, they discuss the need to integrate research with outcome-based quality assurance systems to allow ongoing evaluation and quality improvement.