Hear ye!  Hear Ye!  RAPs are out!  CATs and CAAs are in!

I chuckle as I write this blog post knowing that few of my regular readers will understand, and have probably clicked off by now.  But the few of you who remain know how important this topic is to long-term care.

Dr. Jeffrey M Levine On October 30, 2009 CMS finally released the RAI Users Manual V 3.0 which contains the long awaited MDS 3.0.  These mandatory assessment tools will go into effect in all Medicare certified skilled nursing facilities on October 1, 2010.  They are accompanied by a new, more complex RUGs IV Payment System which adds several new categories and significantly increases payments weighted toward clinically complex residents.

You may already know that RAI stands for "Resident Assessment Instrument," and that this tool is mandated for all residents of Medicare certified skilled nursing facilities by the Nursing Home Reform Amendments, or OBRA-87.  The RAI is the cornerstone upon which is built the processes of care planning, reimbursement, and quality improvement in the nursing home.  The current RAI Version 2.0 has been in use for the past 15 years, and the revised version will go into effect very soon.

Changes in the new RAI are numerous.  Many assessment areas have undergone major revisions including cognitive patterns, depression, behavior, and falls.  A new assessment section was added for pain.  MDS 3.0 has adapted resident interviews for some sections to increase the resident’s voice in the care planning process.  The skin component (Section M), which deals with pressure ulcers, is significantly expanded and will force most facilities to completely revamp their skin tracking programs.

The old RAI used Resident Assessment Protocols (RAPs) as a link between the Minimum Data Set (MDS) and the care plan.  The RAPs are now discarded in favor of an expanded system which includes the Care Assessment Triggers (CATs) and Clinical Assessment Areas (CAAs).  The CATs will serve the same purpose as RAPs, guiding the interdisciplinary team toward a comprehensive assessment.

The CAAs serve as extended resident assessment areas, and facilities are instructed to choose current clinical protocols, tools, and resources for this process which must be identifiable on request by CMS.  According to the RAI User’s Manual, CAAs are “decision facilitators.” The rationale for these architectural changes in the RAI lies in the criticism that MDS 2.0 did not employ standardized assessments which compromised its reliability and accuracy.

Has your facility started on the learning curve for MDS 3.0?  If not, time is quickly ticking to October 1, 2010 and you have a long way to go.

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The  RAI User’s Manual V 3.0 can be downloaded here

A reference for this post was Rahman AN et al, The Nursing Home Minimum Data Set Assessment Instrument:  Manifest Functions and Unintended Consequences. The Gerontologist, 49(6), 727-735.