The Interview Process and MDS 3.0
By Chris Ebell and Mary Gennerman
It is October 2010, therefore the new MDS 3.0 is now in use in long-term care.
MDS 3.0 has been designed to improve the accuracy and usefulness of the MDS. Among the changes that stem from MDS 3.0 is the introduction of resident interviews as part of the assessment process, giving the residents more opportunities to voice their needs and desires.
This change appears to coincide with the emerging approach in long-term care to a person-centered one. It recognizes the need for the person's preferences to be identified, honored, and added to the overall care plan.
Interview Includes BIMS
The interview includes the Brief Interview for Mental Status (BIMS), with a resulting score of cognitively intact, moderately impaired, or severe impairment. The interview also includes questions related to the resident's mood. The resident is asked if he/she has been bothered by any of nine problems (e.g., feeling depressed, feeling bad about yourself, trouble concentrating, and moving or speaking so slowly that other people could have noticed). Then the resident is asked to identify on how many days the person has experienced these problems over the past two weeks. The resident is given a card with frequency choices such as two to six days or seven to 11 days.
In addition, the interview includes a section that asks the resident about daily and activity preferences. Some of the daily preference questions include, how important is it to you to choose your own clothing or have a place to lock your things to keep them safe? There are eight specific activity questions that ask the resident how important is it for you to do such things as, listen to music, be around pets, or keep up with the news.
It is great to see the shift to recognizing the importance of respecting the person's individuality through interview of the person, and then incorporating these findings into the plan of care for the individual. However, these interviews do require that the resident is able to understand the question, have a good sense of the calendar and the passing of time, provide answers that are reliable, and have a realistic understanding of his/her abilities/deficits.
As many studies suggest, the majority of persons residing in long-term facilities have some form of dementia. The prevalence of persons with dementia in long-term care facilities has been measured at 75 to 90% of the residents. As these residents age in place, the prevalence and degree of dementia increases; therefore some facilities may have a majority of residents whose cognitive skills and/or verbal skills are not adequate for successfully and accurately completing this interview.
Level Low 4
Persons with dementia performing at Allen Cognitive Level Low 4 often have good verbal skills. However, their ability to recognize their cognitive deficits is very poor. Therefore, the person may not notice a change in ability to concentrate or that they move slowly. The person may tell you that he/she has no problem concentrating or watching TV, when in reality, they do not watch programs because they cannot concentrate on the program and remember what happened from the beginning to the end. The person may tell you that it is important for him/her to read a newspaper and keep up with the news, when he/she is no longer able to comprehend the newspaper. (Of course, this is not reason to stop the delivery of the newspaper to the person, but it must be done with the knowledge that the person will need individual assistance in order to enjoy what is written.)
The persons may say it is important that they choose their own clothing but are unable to choose clothing appropriate for the weather and/or occasion. (Again, this means we would honor their choice to choose their clothing, knowing they will need some assistance.)
In addition, the persons do not have the ability to use a calendar, (although they may be able to identify the date), so they would not be able to provide accurate frequencies regarding the mood questions.
To get a truly accurate picture, the interviewer should understand dementia and recognize the need to observe for these abilities/deficits, instead of just relying on the resident's report.
Persons performing in Allen Cognitive Level 3 often have significantly impaired communication. They may be able to speak in phrases or sentences; however, they frequently lose their train of thought due to poor short-term memory and poor attention. Or they may have word-finding problems and substitute with inappropriate words.
With this population, the interviewer must present all questions in a clear and simple manner, break down questions into parts, and recognize when the person does not comprehend the question. The interview process does recommend that family or significant others become involved in the assessment if there are three "nonsensical responses" or no responses.
Persons performing at level 2 and below would not be able to verbally respond to the interview; however, the person still has the ability to communicate preferences. They communicate in response to stimulation through changes in facial expressions, changes in emotional status, gross motor movements, or postures.
The emphasis on the resident becoming an active part of the care plan is a significant positive step in long-term care. However, it will take the abilities of a highly skilled interviewer in order to yield accurate responses from the majority of the residents who have dementia. That interviewer will need a working knowledge of the abilities and deficits of persons in the different stages of dementia (which is not gained through the use of the BIMS) and an excellent knowledge of techniques to facilitate the resident's best abilities for receptive and expressive communication. Without this knowledge and skill, the resident's needs and desires may not be identified.
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Any resident, who is verbal, beyond sounds, must go through the interview process. These residents are at risk to be scored at excess disability levels. An "interpreter" can be requested. This can be a family member or significant other. For LTC residents, it may be possible for the Dementia Capable trained staff, who are already familiar with the resident, to participate in the Quarterly or Annual MDS interviews. That would have to be recorded on the staff interview form. The end result would truly be a care plan reflecting person-centered care and best ability level!
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