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Giving “Voice” to Nursing Home Residents: A Revolution in Quality Assessment

by Debra Saliba

October 9, 2012

As the population ages, Americans increasingly face the challenge of providing care for elderly family members. Some elders need help for a short time to recover from acute illness or injury while other elders need supportive care for months or years. In many cases, the best available care option is a nursing home. Whatever the reason that Mom or Dad, Uncle Bill or Aunt Mandy are in a care facility, their families want to know if their needs are being met.

Thanks to a quiet revolution that took place in 2010 in nursing homes across America, loved ones can answer the question directly. It seems obvious to ask nursing home residents about their own health. But until the implementation of the Minimum Data Set (MDS) 3.0, it didn't work that way.

To learn what the MDS 3.0 is, why it is revolutionary, and what it means for elderly patients, RAND talked with Debra Saliba, a geriatrician and RAND staff member who designed and tested the new MDS.

RAND: What exactly is the Minimum Data Set?

Debra Saliba: It's an assessment that all Medicare-certified nursing homes use to evaluate residents' health and inform the plan for each resident's care. Residents, whether or not their care is paid for by Medicare, must be assessed when they first enter the nursing home and at regular intervals thereafter. There are about 16 million MDS forms submitted to Medicare every year so the MDS affects care for millions of patients.

RAND: Why did the MDS need revision?

DS: We wanted to improve the MDS's clinical accuracy—for example, include better measures of a condition. We also wanted to decrease the amount of time required to complete the assessment—in national tests we succeeded in cutting the time nearly in half. And we wanted the make the MDS more user-friendly—for example, we used larger fonts, fewer questions per page, and better layout. But the biggest change was including questions that ask residents directly how they feel and what their preferences are.

RAND: That seems a pretty obvious thing to do if you are assessing residents' care. So why was it so revolutionary?

DS: It was always the case that nursing home staff members were supposed to talk to residents when they conducted the assessment. But that wasn't happening. Nursing homes were just transferring data from residents' charts into the form. Residents were being excluded from the process. So facilities were spending a lot of time filling out the MDS form, but they weren't getting accurate information that could actually help them care for patients.

RAND: Why is it so important to ask residents questions directly?

DS: Because sometimes that's the best way to get the information you need. Information like pain, mood, and patient preferences often isn't in the medical record. Because the new MDS asks residents directly about such things, it provides accurate information efficiently. If patients can't answer questions directly, then the nurses do an alternative observational assessment.

RAND: Give us some examples of the kinds of questions you ask residents.

DS: The questions range pretty broadly, but they include things like: Have you had any pain or hurting in the last five days? Does pain make it hard for you to sleep at night? Have you been bothered by little interest or pleasure in doing things? How important is it to you to be around animals such as pets? How important is it to you to participate in religious services or practices? How important is it to you to have your family or close friend involved in discussions about your care?

RAND: That does sound pretty revolutionary. How did nurses react to the new form?

DS: Our team talked to a lot of providers while we were developing the new MDS. One of the biggest surprises for me was how little experience nursing home staff had in using tested and reliable questions to find out about patient needs directly from patients. At first nurses had a lot of reservations about the interviews. They said “I can't ask these questions,” and “No way my residents can answer that.” But after only a few attempted interviews, their attitudes shifted dramatically. One of them wrote to us, “It was amazing. Residents didn't mind being asked and you learn so much from asking.”

In this video, two nurses who participated in the MDS 3.0 national test tell the Centers for Medicare & Medicaid Services about their experiences interviewing nursing home residents:

The MDS 3.0 is a tool to improve care for nursing home residents, but other experts in the field highlight its very broad importance. In a recent editorial, Dr. Eric Tangalos, Professor of Medicine at the Mayo Clinic, calls it a remarkable piece of work that “harmoniously makes an attempt to be all things to all people…It is a document to record care needs, identify diagnoses, and marshal resources when there is a change in conditions. It provides survey oversight and opportunities for quality improvement. It serves as a mechanism for reimbursement in many states. It does all of these things using 'the patient's own voice'.”

Dr. Tangalos personally told RAND: “Developing MDS 3.0 was a long, drawn out process. Everyone has their own opinions about what should and should not be included. Everyone agreed that the survey should be shorter, but no one wanted to shorten the section that reflected their particular interests.”

He added: “The success of this new survey has broad implications. The focus on providing patient-centered care really just emerged in the last 10 years. What Dr. Saliba did was prove that patients can describe their physical and mental status much more accurately than anyone assumed. She proved that you can trust what the patient says.”

A recent article by Dr. Saliba and her team gives more detail about development of the MDS 3.0.

Mary E. Vaiana


Debra Saliba is a geriatrician and a staff member at the RAND Corporation. She is also Director of the UCLA/JH Borun Center for Gerontological Research and a physician in the Geriatric Research Education and Clinical Centers in the Veterans Health Administration.