In 2007, it is estimated that over 5 million people in the United States over age 65 have Alzheimer's disease. That is 13% of persons over age 65. It is projected that the number will increase over 450,000 each year. As therapists you have prepared yourselves with the appropriate training to understand the status of these people and the approach to intervention.
How does your state or facility compare? How many people in your facility are reported to have Alzheimer's or dementias? There is a way to find out.
The MDS (Minimum Data Set) is a reporting tool that is required by State and Federal agencies on a set time frame for all residents of a nursing facility. Those who are utilizing their Medicare Part A benefit have more frequent submissions of their status. Those who reside in a nursing facility must have an MDS submitted no longer than every 90 days (or anytime there is a significant change in the Plan of Care). The MDS has over 200 reporting items on each patient for each assessment.
CMS (Centers for Medicare and Medicaid Services) consolidates every line submission of the MDS and makes available national reports. At the end of this article, you will find the references to access these reports. These reports are records of approximately 1.4 million people.
There are certain items in the MDS that are key indicators for us who are concerned about our intervention with Alzheimer's and dementias. Nursing may refer some status changes to us. We may screen for changes, behaviors, involvement in facility activities, and decline in participation in daily events. Do we have Maintenance Programs established for all residents with this disease process? How do we compare? Many of us have never seen the entire MDS in a paper form. Electronic submissions and MDS programs are the present process. At the end of this article you will be able to download the MDS forms. Most MDS programs are able to produce reports indicating the percentage of residents with indicators that we need to monitor.
The key reporting items to look for are: (All of the following statistics are from the March 2007 nation reports)
1) MDS Section I1q: This is checked if the patient has a diagnosis of Alzheimer's disease. Nationally 17.5% of all nursing home residents have this disease. States vary from 11.4% in Utah & Oregon to 26.7% in West Virginia.
MDS Section I1u: This is checked if the patient has dementia other than Alzheimer's disease. Nationally 38% of all nursing home residents have this indicated. States vary from 31% in New Jersey to 44.3% in Massachusetts & Michigan. The combination of these 2 indicators shows an average of 55.5% of all nursing home residents with a diagnosed cognitive impairment. In a building with 100 residents, that means 55 people.
2) MDS Section E1b: This is checked if the patient has verbal expressions of distress with repetitive questions (e.g. Where do I go? What do I do?) Nationally 7% of all nursing home residents are asking these questions. States vary from 3% reported in Alabama, California, Florida, and New York to 26% in Maine.
3) MDS Section N2: This section indicates the average amount of time the resident was involved in activities when awake and not receiving treatments or ADL care. Nationally 4.7% of all nursing home residents were involved in activities more than 2/3 of the time; 89.7% were involved in activities 1/3 of the time, and 5.4% were involved in activities less than 1/3 of the time. This may be difficult to judge how facilities are reporting 'awake time.' What is the pattern in your building?
4) MDS Section F1e: This is the Psychosocial Well-Being area and this line is checked if the resident pursues involvement in the life of the facility (e.g. has friends or is involved in group activities or responds positively to new activities). Nationally 15.7% of all nursing home residents are indicated with this trait/ability. Do the other 84.3% of the people in the building have a friend?
5) MDS Section E1o: This is in the Mood and Behavior Patterns and indicates 'loss of interest' or 'withdrawal from activities of interest.' Nationally, it is reported that 5% of nursing home residents are reported in this quarter of sadly experiencing this. Do we get referrals for this symptom of an underlying concern?
So what can these numbers tell us?
The US Census Bureau statistics from 2000 indicate that 35 million United States residents were over 65. That number has grown in the last 7 years and now 5 million have Alzheimer's disease. It is estimated that in 2007 13% of the persons over 65 have Alzheimer's disease. Of that 5 million we know of, 17.5% are in nursing homes (875,000). Another 38% are in nursing homes with a dementia, other than Alzheimer's.
Do we truly know the people living in our facility?
How can we 'find' them?
The constraints of productivity are a reality for all therapists. Screenings are either not a common practice or based only on nursing referrals. A request for a MDS report would give a picture of all the residents. We then need to be aware of these people, and monitor their involvement in the life of the facility. Your specific knowledge on intervention that can change the MDS scores is invaluable. Remember that nursing is dedicated to total care. You can reduce that burden of care and assist the Activity Director in designing programs.
Do we have skilled intervention programs in place for 55.5% of the cognitively impaired residents? 7% nationally verbally express distress. In a building with 100 residents, do you have Maintenance Programs for those 7 residents? In a building with 100 residents, do you have interest/needs and a program for 5.4% that are involved less than 1/3 of their awake time? Can we professionally feel good about 84.3% of the residents "not having a friend'? Can we help those 5% who lose interest or withdraw?
Can we make a difference not only in the lives of these people but also on the MDS reporting tool? The answer is YES! Your identification and documentation skills are essential. Document as if you are standing before a Review Board. Put your beliefs into writing.
Take these percentages and look at your own facility and intervention. Find those residents who are under the radar and slowly slipping into disability.
Can we provide skilled intervention when there is not a referral for ''significant change''?
YES. The referral can come from you. Identify your concern and expected outcome. All disciplines can identify and intervene. Have nursing document in the medical chart the identified disability by the therapist. Request a doctor order for the development of a Maintenance Program. State the inability and the expected outcome. You are hired by the facility to provide a level of knowledge and intervention that the nursing staff is not trained to do. The following reference is from the Medicare Benefit Policy Manual (Pub 102, Chap 15, Section 220.2b):
- "There must be an expectation that the patient's condition will improve significantly in a reasonable (and generally predictable) period of time, or the services must be necessary for the establishment of a safe and effective maintenance program required in connection with a specific disease state. In the case of a progressive degenerative disease, service may be intermittently necessary to determine the need for assistive equipment and/or establish a program to maximize function (see item D for descriptions of maintenance services); and
- "The amount, frequency, and duration of the services must be reasonable under accepted standards of practice."
SUMMARY
Review your own facility and the persons that might be 'hidden" with a slow loss of ability. Compare your interventions and Care Plans that you have established. Find those people with dementias or Alzheimer's who do not surface as being "significant." Continue to care so much that you will defend your interventions.
Thank you.
References:
MDS Form
http://www.cms.hhs.gov/NursingHomeQualityInits/downloads/MDS20MDSAllForms.pdf
MDS Reports
http://www.cms.hhs.gov/MinimumDataSets20/
Go to MDS Active Resident Information. The 1st report will give National statistics and then you can ask for specific States.