The Minimum Data Set - Home Care (MDS-HC) form is a comprehensive clinical assessment tool used by healthcare providers to determine the eligibility of individuals for long-term care services under MassHealth. It covers various aspects of an individual's health and social needs, ensuring that they receive appropriate care tailored to their specific requirements. The form must be completed by qualified professionals, including registered nurses and licensed social workers, who certify the accuracy and completeness of the information provided. If you or a loved one are preparing to apply for long-term care services, understanding and completing the MDS-HC form accurately is a crucial step. Click the button below to learn more about how to fill out the form.
The Commonwealth of Massachusetts, through its Executive Office of Health and Human Services Division of Medical Assistance, has introduced significant changes to the clinical assessment forms used for determining eligibility for MassHealth long-term-care services. As detailed in the January 2003 MassHealth Chronic Disease and Rehabilitation Hospital Bulletin 83, the traditional Long Term Care Assessment form has been replaced by two new forms, including the Minimum Data Set – Home Care (MDS-HC), to streamline the referral process for services such as nursing-facility and adult-day-health services. With the goal of enhancing communication between providers and the Division, these forms are instrumental in delivering effective care coordination. The MDS-HC, in particular, is to be completed by an assessment coordinator, specifically a registered nurse, who certifies the accuracy and completeness of the assessment, with certain sections potentially being filled out by a licensed social worker. The introduction of these forms marks a critical step in improving the assessment process for long-term care services in Massachusetts, requiring chronic disease and rehabilitation hospitals to update their procedures in line with these new standards.
COMMONWEALTH OF MASSACHUSETTS
EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES
DIVISION OF MEDICAL ASSISTANCE
600 Washington Street Boston, MA 02111 www.mass.gov/dma
MassHealth
Chronic Disease and
Rehabilitation Hospital Bulletin 83
January 2003
TO: Chronic Disease and Rehabilitation Hospitals Participating in MassHealth
FROM: Wendy E. Warring, Commissioner
RE:
Changes in Clinical Assessment Forms
Background
The Division determines clinical eligibility for MassHealth long-term-care
services based upon documentation submitted by the provider. The Long
Term Care Assessment form has been replaced by two new forms in
order to facilitate communication between providers and the Division.
New Forms
Attached to this bulletin are copies of the two new forms required for
approving referrals for long-term-care services, including, but not limited
to, nursing-facility and adult-day-health services.
• Request for Services (RFS-1) (formerly called the MassHealth
Long Term Care Assessment form)
• Minimum Data Set – Home Care (MDS-HC)
Chronic disease and rehabilitation hospitals must begin using these new
forms by February 1, 2003. Please discard all previous versions of the Long
Term Care Assessment form.
Who May Complete
The MDS-HC must be completed by an assessment coordinator. The
the MDS-HC
assessment coordinator must be a registered nurse who certifies the
accuracy and completeness of the MDS-HC.
The following sections of the MDS-HC may be completed by a licensed
social worker (LSW, LCSW, or LICSW).
AA – Name and Identification Numbers
BB – Personal Items
CC – Referral Items
B – Cognitive Patterns
C – Communication/Hearing Patterns
E – Mood and Behavior Patterns
F – Social Functioning
G – Informal Support Services
O – Environmental Assessment
CONTINUED ON BACK
Page 2
Each person who completes a portion of the MDS-HC must sign and
certify the sections he or she completes in Section R – Assessment
(cont.)
Information (Other Signatures, Title, Sections, Date).
Qualifications for
The registered nurse or social worker must be licensed by the
Completing the Forms
Massachusetts Board of Registration.
ICD-9-CM Codes
The MDS-HC assessment requires the use of the ICD-9-CM codes for
medical diagnoses.
Trainings
The Division holds periodic trainings for providers. You will receive notice
of trainings when they are scheduled.
Supplies of the Forms
You may photocopy the forms as needed. To obtain supplies of the
forms, use the information below to mail or fax your request. Include your
provider number, address, telephone number, the exact title of the form,
and the desired quantity.
MassHealth Forms Distribution
P.O. Box 9101
Somerville, MA 02145
Fax: 703-917-4087
Questions
If you have any questions about this bulletin, please contact MassHealth
Provider Services at 617-628-4141 or 1-800-325-5231.
MINIMUM DATA SET - HOME CARE (MDS-HC)©
•Unless otherwise noted, score for last 3 days
•Examples of exceptions include IADLs/Continence/Services/Treatments where status scored over last 7 days
SECTION AA. NAME AND IDENTIFICATION NUMBERS
1.
NAME OF
CLIENT
a. (Last/Family Name)
b. (First Name)
c. (Middle Initial)
2.
CASE
RECORD
NO.
3.
GOVERN-
a. Pension (Social Security) Number
MENT
PENSION
AND HEALTH
b.
Health
insurance
number
(or
other comparable insurance number)
INSURANCE
NUMBERS
SECTION BB. PERSONAL ITEMS (Complete at Intake Only)
GENDER
1. Male
2. Female
BIRTHDATE
Month
Day
Year
RACE/
(Check all that apply)
ETHNICITY
RACE
Native Hawaiian or other Pacific
*
American Indian/Alaskan
Islander
d.
White
Native
a.
e.
Asian
ETHNICITY:
Black or African American
c.
Hispanic or Latino
f.
4.
MARITAL
1. Never married
3. Widowed
5. Divorced
STATUS
2. Married
4. Separated
6. Other
5.LANGUAGE Primary Language
0. English
1. Spanish
2. French
3. Other
6.
EDUCATION
1. No schooling
5. Technical or trade school
(Highest
2. 8th grade/less
6. Some college
Level
3. 9-11 grades
7. Bachelor's degree
Completed)
4. High school
8. Graduate degree
7.RESPONSI- (Code for responsibility/advanced directives)
BILITY/
0. No
1. Yes
ADVANCED
DIRECTIVES a. Client has a legal guardian
b. Client has advanced medical directives in place (for example, a do not hospitalize order)
SECTION CC. REFERRAL ITEMS (Complete at Intake Only)
1.DATE CASE
OPENED/
REOPENED
REASON
1. Post hospital care
4. Eligibility for home care
FOR
2. Community chronic care
5. Day care
REFERRAL
3. Home placement screen
GOALS OF
(Code for client/family understanding of goals of care)
CARE
a. Skilled nursing treatments
d. Client/family education
b. Monitoring to avoid clinical
e. Family respite
complications
c. Rehabilitation
f. Palliative care
4.TIME SINCE Time since discharge from last in-patient setting (Code for most
LAST recent instance in LAST 180 DAYS)
HOSPITAL
0. No hospitalization within 180 days
3. Within 15 to 30 days
STAY
1. Within last week
4. More than 30 days ago
2. Within 8 to 14 days
5. WHERE
1. Private home/apt. with no home care services
LIVED AT
2. Private home/apt. with home care services
TIME OF
3. Board and care/assisted living/group home
4. Nursing home
5. Other
6. WHO LIVED
1. Lived alone
WITH AT
2. Lived with spouse only
3. Lived with spouse and other(s)
4. Lived with child (not spouse)
5. Lived with other(s) (not spouse or children)
6. Lived in group setting with non-relative(s)
7.PRIOR NH Resided in a nursing home at anytime during 5 YEARS prior to case
PLACEMENT opening
8.RESIDENTIAL Moved to current residence within last two years
HISTORY
SECTION A. ASSESSMENT INFORMATION
1.ASSESSMENT Date of assessment
REFERENCE
DATE
2.REASONS Type of assessment
FOR 1. Initial assessment
ASSESS- 2. Follow-up assessment
MENT 3. Routine assessment at fixed intervals
4.Review within 30-day period prior to discharge from the program
5.Review at return from hospital
6.Change in status
7.Other
SECTION B. COGNITIVE PATTERNS
1.MEMORY (Code for recall of what was learned or known)
RECALL
0. Memory OK
1. Memory problem
ABILITY
a. Short-term memory OK — seems/appears to recall after 5 minutes
b. Procedural memory OK—Can perform all or almost all steps in a
multitask sequence without cues for initiation
COGNITIVE
a. How well client made decisions about organizing the day (e.g., when
SKILLS FOR
to get up or have meals, which clothes to wear or activities to do)
DAILY
0.
INDEPENDENT—Decisions consistent/reasonable/safe
DECISION-
MAKING
MODIFIED INDEPENDENCE—Some difficulty in new situations
only
MINIMALLY IMPAIRED—In specific situations, decisions become
poor or unsafe and cues/supervision necessary at those times
MODERATELY IMPAIRED—Decisions consistently poor or un-
safe, cues/supervision required at all times
SEVERELY IMPAIRED—Never/rarely made decisions
b. Worsening of decision making as compared to status of 90 DAYS
AGO (or since last assessment if less than 90 days)
3.INDICATORS a. Sudden or new onset/change in mental function over LAST 7 DAYS
OF DELIRIUM (including ability to pay attention, awareness of surroundings, being
coherent, unpredictable variation over course of day)
b. In the LAST 90 DAYS (or since last assessment if less than 90
days), client has become agitated or disoriented such that his or
her safety is endangered or client requires protection by others
SECTION C. COMMUNICATION/HEARING PATTERNS
1. HEARING
0.HEARS ADEQUATELY—Normal talk, TV, phone, doorbell
1.MINIMAL DIFFICULTY—When not in quiet setting
2.HEARS IN SPECIAL SITUATIONS ONLY—Speaker has to adjust tonal quality and speak distinctly
3.HIGHLY IMPAIRED —Absence of useful hearing
2.MAKING (Expressing information content—however able)
SELF
0. UNDERSTOOD—Expresses ideas without difficulty
UNDERSTOOD
1. USUALLY UNDERSTOOD—Difficulty finding words or finishing thoughts
(Expression)
BUT if given time, little or no prompting required
2. OFTEN UNDERSTOOD—Difficulty finding words or finishing thoughts,
prompting usuallly required
3. SOMETIMES UNDERSTOOD—Ability is limited to making concrete
requests
4. RARELY/NEVERUNDERSTOOD
3.ABILITY TO (Understands verbal information—however able)
UNDER-
0. UNDERSTANDS—Clear comprehension
STAND
1. USUALLY UNDERSTANDS—Misses some part/intent of message,
OTHERS
BUT comprehends most conversation with little or no prompting
(Comprehen-
2. OFTEN UNDERSTANDS—Misses some part/intent of message;with
sion)
prompting can often comprehend conversation
3. SOMETIMES UNDERSTANDS—Responds adequately to simple, di-
rect communication
4. RARELY/NEVERUNDERSTANDS
COMMUNICA-
Worsening in communication (making self understood or understand-
TION
ing others) as compared to status of 90 DAYS AGO (or since last
DECLINE
assessment if less than 90 days)
SECTION D. VISION PATTERNS
1.VISION (Ability to see in adequate light and with glasses if used)
0.ADEQUATE—Sees fine detail, including regular print in newspapers/ books
1.IMPAIRED—Sees large print, but not regular print in newspapers/ books
2.MODERATELY IMPAIRED—Limited vision; not able to see newspa- per headlines, but can identify objects
3.HIGHLY IMPAIRED—Object identification in question, but eyes ap- pear to follow objects
4.SEVERELY IMPAIRED—No vision or sees only light, colors, or shapes; eyes do not appear to follow objects
2.VISUAL Saw halos or rings around lights, curtains over eyes, or flashes of LIMITATION/ lights
DIFFICUL-
TIES
VISION
Worsening of vision as compared to status of 90 DAYS AGO (or since
last assessment if less than 90 days)
MDS-HC Version 2.0 — July 21, 1999
MDS-HC - Pg 1
SECTION E. MOOD AND BEHAVIOR PATTERNS
1. INDICATORS OF
DEPRES-
SION,
ANXIETY,
(Code for observed indicators irrespective of the assumed cause)
0.Indicator not exhibited in last 3 days
1.Exhibited 1-2 of last 3 days
2.Exhibited on each of last 3 days
1. TWO KEY
(A)
(B)
INFORMAL
PrIm
Secn
HELPERS
If needed, willingness (with ability) to increase help:
Primary (A)
0. More than 2 hours 1. 1-2 hours per day
2. No
SAD MOOD
a. A FEELING OF SADNESS OR BEING DEPRESSED, that life is not worth living, that nothing matters, that he or she is of no use to anyone or would rather be dead
b.PERSISTENTANGER WITH SELF OR OTHERS— e.g., easily annoyed, anger at care received
c.EXPRESSIONS OF WHAT APPEARTO BE UNREAL- ISTIC FEARS—e.g., fear of being abandoned, left alone, being with others
d.REPETITIVEHEALTHCOM- PLAINTS—e.g., persistently seeks medical attention, obsessive concern with body functions
e.REPETITIVEANXIOUSCOM- PLAINTS,CONCERNS—e.g., persistently seeks attention/ reassurance regarding sched- ules, meals, laundry, clothing, relationship issues
f.SAD,PAINED,WORRIED FA- CIAL EXPRESSIONS — e.g.,
furrowed brows
g.RECURRENTCRYING,TEAR- FULNESS
h.WITHDRAWALFROMACTIVI- TIES OF INTEREST—e.g., no interest in long standing ac- tivities or being with family/ friends
i . REDUCED SOCIAL INTER-
ACTION
and
j . — Advice or emotional support
Secondary (B)
k. — IADL care
(cont)
l. — ADL care
CAREGIVER
A caregiver is unable to continue in caring activities—e.g., decline in
the health of the caregiver makes it difficult to continue
Primary caregiver is not satisfied with support received from family
and friends (e.g., other children of client)
Primary caregiver expresses feelings of distress, anger or depression
NONE OF ABOVE
EXTENT OF
For instrumental and personal activities of daily living received over the
LAST 7 DAYS, indicate extent of help from family, friends, and
neighbors
HOURS
HELP
(HOURS
a. Sum of time across five weekdays
OF CARE,
ROUNDED)
b. Sum of time across two weekend days
2.MOOD Mood indicators have become worse as compared to status of 90
DECLINE days ago (or since last assessment if less than 90 days)
3.BEHAVIORAL Instances when client exhibited behavioral symptoms. If EXHIBITED, ease of SYMPTOMS altering the symptom when it occurred.
0.Did not occur in last 3 days
1.Occurred, easily altered
2.Occurred, not easily altered
a.WANDERING—Moved with no rational purpose, seemingly oblivious to needs or safety
b.VERBALLY ABUSIVE BEHAVIORAL SYMPTOMS—Threatened, screamed at, cursed at others
c.PHYSICALLY ABUSIVE BEHAVIORAL SYMPTOMS—Hit, shoved, scratched, sexually abused others
d.SOCIALLY INAPPROPRIATE/DISRUPTIVE BEHAVIORAL SYMP- TOMS—Disruptive sounds, noisiness, screaming, self-abusive acts, sexual behavior or disrobing in public, smears/throws food/feces, rummaging, repetitive behavior, rises early and causes disruption
e.RESISTS CARE—Resisted taking medications/injections, ADL as- sistance, eating, or changes in position
4.CHANGES IN Behavioral symptoms have become worse or are less well tolerated BEHAVIOR by family as compared to 90 DAYS AGO (or since last assessment if
SYMPTOMS less than 90 days)
0. No, or no change in behavioral symptoms
SECTION F. SOCIAL FUNCTIONING
1.INVOLVE- a. At ease interacting with others (e.g., likes to spend time with others)
0. At ease
1. Not at ease
b. Openly expresses conflict or anger with family/friends
2.CHANGE IN As compared to 90 DAYS AGO (or since last assessment if less than
SOCIAL 90 days ago), decline in the client's level of participation in social,
ACTIVITIES religious, occupational or other preferred activities. IF THERE WAS A
DECLINE, client distressed by this fact
0. No decline
1. Decline, not distressed
2. Decline, distressed
3. ISOLATION a. Length of time client is alone during the day (morning and afternoon)
0. Never or hardly ever
1. About one hour
2. Long periods of time—e.g., all morning
3. All of the time
b. Client says or indicates that he/she feels lonely
SECTION G. INFORMAL SUPPORT SERVICES
SECTION H. PHYSICAL FUNCTIONING:
•IADL PERFORMANCE IN 7 DAYS
•ADL PERFORMANCE IN 3 DAYS
1.IADL SELF PERFORMANCE—Code for functioning in routine activities around the home or in the community during the LAST 7 DAYS,
(A)IADL SELF PERFORMANCE CODE (Code for client's performance during LAST 7 DAYS)
0.INDEPENDENT—did on own
1.SOME HELP—help some of the time
2.FULL HELP—performed with help all of the time
3.BY OTHERS—performed by others
8.ACTIVITY DID NOT OCCUR
(B)IADL DIFFICULTY CODE How difficult it is (or would it be) for client to do
activity on ownPerformance
0.NO DIFFICULTY
1.SOME DIFFICULTY—e.g., needs some help, is very slow, or fatiguesDifficulty
2.GREAT DIFFICULTY—e.g., little or no involvement in the activity is possible
a.MEAL PREPARATION—How meals are prepared (e.g., planning meals, cooking, assembling ingredients, setting out food and utensils)
b.ORDINARY HOUSEWORK—How ordinary work around the house is performed (e.g., doing dishes, dusting, making bed, tidying up, laundry)
c.MANAGING FINANCE—How bills are paid, checkbook is balanced, household expenses are balanced
d.MANAGING MEDICATIONS—How medications are managed (e.g., remembering to take medicines, opening bottles, taking correct drug dosages, giving injections, applying ointments)
e.PHONE USE—How telephone calls are made or received (with assistive devices such as large numbers on telephone, amplification as needed)
f.SHOPPING—How shopping is performed for food and household items (e.g., selecting items, managing money)
g.TRANSPORTATION—How client travels by vehicle (e.g., gets to places beyond walk- ing distance)
2.ADL SELF-PERFORMANCE—The following address the client's physical functioning in routine personal activities of daily life, for example, dressing, eating, etc. during the LAST 3 DAYS, considering all episodes of these activities. For clients who performed an activity indepen- dently, be sure to determine and record whether others encouraged the activity or were present to supervise or oversee the activity [Note—For bathing, code for most dependent single episode in LAST 7 DAYS]
0.INDEPENDENT—No help, setup, or oversight —OR— Help, setup, oversight provided only 1 or 2 times (with any task or subtask)
1.SETUP HELP ONLY—Article or device provided within reach of client 3 or more times
2.SUPERVISION—Oversight, encouragement or cueing provided 3 or more times during last 3 days —OR— Supervision (1 or more times) plus physical assistance provided only 1 or
TWO KEY
INFORMAL HELPERS
Secondary
NAME OF PRIMARY AND SECONDARY HELPERS
b. (First)
c. (Last/Family Name)
d. (First)
e. Lives with client
0. Yes
1. No
2. No such helper [skip other items in
the appropriate column]
f.Relationship to client
0. Child or child-in-law 2. Other Relative
1. Spouse
3. Friend/neighbor
Areas of help:
g. — Advice or emotional support h. — IADL care
i. — ADL care
2 times (for a total of 3 or more episodes of help or supervision)
3.LIMITED ASSISTANCE—Client highly involved in activity;received physical help in guided maneuvering of limbs or other non-weight bearing assistance 3 or more times —OR— Combination of non-weight bearing help with more help provided only 1 or 2 times during period (for a total of 3 or more episodes of physical help)
4.EXTENSIVE ASSISTANCE—Client performed part of activity on own (50% or more of subtasks), but help of following type(s) were provided 3 or more times:
—Weight-bearing support —OR—
—Full performance by another during part (but not all) of last 3 days
5.MAXIMAL ASSISTANCE—Client involved and completed less than 50% of subtasks on own (includes 2+ person assist), received weight bearing help or full performance of certain subtasks 3 or more times
6.TOTAL DEPENDENCE—Full performance of activity by another
8. ACTIVITY DID NOT OCCUR (regardless of ability)
MDS-HC - Pg 2
2. ADLSELF-PERFORMANCE(cont)
a. MOBILITY IN BED—Including moving to and from lying position, turning side to side, and
positioning body while in bed.
b. TRANSFER—Including moving to and between surfaces—to/from bed, chair, wheelchair,
standing position. [Note—Excludes to/from bath/toilet]
c. LOCOMOTION IN HOME—[Note—If in wheelchair, self-sufficiency once in chair]
d. LOCOMOTION OUTSIDE OF HOME—[Note—If in wheelchair, self-sufficiency once in
chair]
e. DRESSING UPPER BODY—How client dresses and undresses (street clothes,under-
wear) above the waist, includes prostheses, orthotics, fasteners, pullovers, etc.
f. DRESSING LOWER BODY—How client dresses and undresses (street clothes, under-
wear) from the waist down, includes prostheses, orthotics, belts, pants, skirts, shoes,
and fasteners
3.BOWEL CONTI- NENCE
In LAST 7 DAYS, control of bowel movement (with appliance or bowel continence program if employed)
0.CONTINENT—Complete control; DOES NOT USE ostomy device
1.CONTINENT WITH OSTOMY—Complete control with use of ostomy device that does not leak stool
2.USUALLY CONTINENT—Bowel incontinent episodes less than weekly
3.OCCASIONALLY INCONTINENT—Bowel incontinent episode once a week
4.FREQUENTLY INCONTINENT—Bowel incontinent episodes 2-3 times a week
5.INCONTINENT—Bowel incontinent all (or almost all) of the time
8.DID NOT OCCUR—No bowel movement during entire 7 day assessment period
g. EATING—Including taking in food by any method, including tube feedings.
h. TOILET USE—Including using the toilet room or commode, bedpan, urinal, transferring
on/off toilet, cleaning self after toilet use or incontinent episode, changing pad, managing
any special devices required (ostomy or catheter), and adjusting clothes.
i . PERSONAL HYGIENE—Including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (EXCLUDE baths and showers)
j . BATHING—How client takes full-body bath/shower or sponge bath (EXCLUDE washing of back and hair). Includes how each part of body is bathed: arms, upper and lower legs, chest, abdomen, perineal area. Code for most dependent episode in LAST 7 DAYS
3.ADLDECLINE ADL status has become worse (i.e., now more impaired in self perfor- mance) as compared to status 90 days ago (or since last assessment
if less than 90 days)
PRIMARY
0. No assistive device
3. Scooter (e.g., Amigo)
MODES OF
1. Cane
4. Wheelchair
LOCOMO-
2. Walker/crutch
8. ACTIVITY DID NOT OCCUR
a. Indoors
b. Outdoors
5.
STAIR
In the last 3 days, how client went up and down stairs (e.g., single or
CLIMBING
multiple steps, using handrail as needed)
0. Up and down stairs without help
1. Up and down stairs with help
2. Not go up and down stairs
STAMINA
a. In a typical week, during the LAST 30 DAYS (or since last assess-
ment), code the number of days client usually went out of the house
or building in which client lives (no matter how short a time period )
0. Every day
2. 1 day a week
1. 2-6 days a week
3. No days
b. Hours of physical activities in the last 3 days (e.g., walking, cleaning
house, exercise)
0. Two or more hours
1. Less than two hours
7.FUNCTIONAL
Client believes he/she capable of increased functional independence
POTENTIAL
(ADL, IADL, mobility)
Caregivers believe client is capable of increased functional indepen-
dence (ADL, IADL, mobility)
Good prospects of recovery from current disease or conditions, im-
proved health status expected
SECTION I. CONTINENCE IN LAST 7 DAYS
1. BLADDER
a. In LAST 7 DAYS control of urinary bladder function (with appliances
CONTI-
such as catheters or incontinence program employed) [Note—if
NENCE
dribbles, volume insufficient to soak through underpants]
0.CONTINENT —Complete control; DOES NOT USE any type of catheter or other urinary collection device
1.CONTINENTWITH CATHETER—Complete control with use of any type of catheter or urinary collection device that does not leak urine
2.USUALLY CONTINENT—Incontinent episodes once a week or less
3.OCCASIONALLY INCONTINENT—Incontinent episodes 2 or more times a week but not daily
4.FREQUENTLY INCONTINENT—Tends to be incontinent daily, but some control present
5.INCONTINENT—Inadequate control, multiple daily episodes
8. DID NOT OCCUR —No urine output from bladder
b.Worsening of bladder incontinence as compared to status 90 DAYS AGO (or since last assessment if less than 90 days)
0. No1. Yes
BLADDER
(Check all that apply in LAST 7 DAYS)
DEVICES
Use of pads or briefs to protect against wetness
Use of an indwelling urinary catheter
SECTION J. DISEASE DIAGNOSES
Disease/infection that doctor has indicated is present and affects client's status, requires treat- ment, or symptom management. Also include if disease is monitored by a home care professional or is the reason for a hospitalization in LAST 90 DAYS (or since last assessment if less than 90 days)
[blank]. Not present
1.Present—not subject to focused treatment or monitoring by home care professional
2.Present—monitored or treated by home care professional
[If no disease in list, check J1ac, None of Above]
DISEASES
HEART/CIRCULATION
p. Osteoporosis
a. Cerebrovascular accident
SENSES
(stroke)
q. Cataract
b. Congestive heart failure
r. Glaucoma
c. Coronary artery disease
PSYCHIATRIC/MOOD
d. Hypertension
s. Any psychiatric diagnosis
e. Irregularly irregular pulse
INFECTIONS
f. Peripheral vascular disease
t. HIV infection
NEUROLOGICAL
u. Pneumonia
g. Alzheimer's
v. Tuberculosis
h. Dementia other than
w. Urinary tract infection (in
Alzheimer's disease
LAST 30 DAYS)
i . Head trauma
OTHER DISEASES
j . Hemiplegia/hemiparesis
x. Cancer—(in past 5 years)
k. Multiple sclerosis
not including skin cancer
l . Parkinsonism
y. Diabetes
MUSCULO-SKELETAL
z . Emphysema/COPD/asthma
m.Arthritis
aa. Renal Failure
n. Hip fracture
ab.Thyroid disease (hyper or
o. Other fractures (e.g., wrist,
hypo)
vertebral)
ac. NONE OF ABOVE
ac.
OTHER
•
CURRENT
OR MORE
DETAILED
DIAGNOSES
AND ICD-9
CODES
SECTION K. HEALTH CONDITIONS AND PREVENTIVE HEALTH
MEASURES
PREVENTIVE
(Check all that apply—in PAST 2YEARS)
HEALTH
Blood pressure measured
(PAST TWO
Received influenza vaccination
YEARS)
Test for blood in stool or screening endoscopy
IF FEMALE: Received breast examination or mammography
PROBLEM
(Check all that were present on at least 2 of the last 3 days)
CONDITIONS
Diarrhea
Loss of appetite
PRESENT ON
2 OR MORE
Difficulty urinating or urinating
Vomiting
DAYS
3 or more times at night
Fever
(Check all present at any point during last 3 days)
PHYSICAL HEALTH
Shortness of breath
Chest pain/pressure at rest or
MENTAL HEALTH
on exertion
Delusions
No bowel movement in 3 days
Hallucinations
g.
Dizziness or lightheadedness
h.
Edema
MDS-HC - Pg 3
PAIN
a. Frequency with which client complains or shows evidence of pain
0. No pain (score b-e as 0)
2. Daily - one period
1. Less than daily
3. Daily - multiple periods
(e.g., morning and evening)
b. Intensity of pain
0. No pain
2. Moderate
4. Times when pain is horrible
1. Mild
3. Severe
or excruciating
c. From client's point of view, pain intensity disrupts usual activities
d. Character of pain
1. Localized - single site
2. Multiple sites
e. From client's point of view, medications adequately control pain
0. Yes or no pain
1. Medications do not
2. Pain present,
adequately control pain
medication not
taken
5.FALLS Number of times fell in LAST 90 DAYS (or since last assessment if FREQUENCY less than 90 days) If none, code "0"; if more than 9, code "9"
DANGER OF
(Code for danger of falling)
FALL
a. Unsteady gait
b. Client limits going outdoors due to fear of falling (e.g., stopped
using bus, goes out only with others)
7.
LIFE STYLE
(Code for drinking or smoking)
(Drinking/
Smoking)
a. In the LAST 90 DAYS (or since last assessment if less than 90 days),
client felt the need or was told by others to cut down on drinking, or
others were concerned with client's drinking
b. In the LAST 90 DAYS (or since last assessment if less than 90 days),
client had to have a drink first thing in the morning to steady nerves
(i.e., an "eye opener") or has been in trouble because of drinking
c. Smoked or chewed tobacco daily
8.HEALTH (Check all that apply)
Client feels he/she has poor health (when asked)
INDICATORS
Has conditions or diseases that make cognition, ADL, mood, or
behavior patterns unstable (fluctuations, precarious, or deteriorating)
Experiencing a flare-up of a recurrent or chronic problem
Treatments changed in LAST 30 DAYS (or since last assessment if
less than 30 days) because of a new acute episode or condition
Prognosis of less than six months to live—e.g., physician has told
client or client's family that client has end-stage disease
9.OTHER (Check all that apply)
Fearful of a family member or caregiver
Unusually poor hygiene
Unexplained injuries, broken bones, or burns
Neglected, abused, or mistreated
Physically restrained (e.g., limbs restrained, used bed rails,
constrained to chair when sitting)
SECTION L. NUTRITION/HYDRATION STATUS
WEIGHT
(Code for weight items)
a. Unintended weight loss of 5% or more in the LAST 30 DAYS [or 10%
or more in the LAST 180 DAYS]
b. Severe malnutrion (cachexia)
c. Morbid obesity
CONSUMP-
(Code for consumption)
a. In at least 2 of the last 3 days, ate one or fewer meals a day
b. In last 3 days, noticeable decrease in the amount of food client
usually eats or fluids usually consumes
c. Insufficient fluid—did not consume all/almost all fluids during last
3 days
d.Enteral tube feeding
3.SWALLOWING 0. NORMAL—Safe and efficient swallowing of all diet consistencies
1.REQUIRES DIET MODIFICATION TO SWALLOW SOLID FOODS (mechanical diet or able to ingest specific foods only)
2.REQUIRES MODIFICATION TO SWALLOW SOLID FOODS AND LIQUIDS (puree, thickened liquids)
3.COMBINED ORAL AND TUBE FEEDING
4.NO ORAL INTAKE (NPO)
SECTION M. DENTAL STATUS (ORAL HEALTH)
ORAL
Problem chewing (e.g., poor mastication, immobile jaw, surgical resec-
tion, decreased sensation/motor control, pain while eating)
Mouth is "dry" when eating a meal
Problem brushing teeth or dentures
SECTION N. SKIN CONDITION
SKIN
Any troubling skin conditions or changes in skin condition (e.g., burns,
PROBLEMS
bruises, rashes, itchiness, body lice, scabies)
ULCERS
Presence of an ulcer anywhere on the body. Ulcers include any area of
(Pressure/
persistent skin redness (Stage 1); partial loss of skin layers (Stage 2);
deep craters in the skin (Stage 3); breaks in skin exposing muscle or
Stasis)
bone (Stage 4).[Code 0 if no ulcer,otherwise record the highest ulcer
stage (Stage 1-4).]
a. Pressure ulcer—any lesion caused by pressure, shear forces,
resulting in damage of underlying tissues
b. Stasis ulcer—open lesion caused by poor circulation in the lower
extremities
OTHERSKIN
Burns (second or third
Surgical wound
REQUIRING
degree)
TREATMENT
Corns, calluses, structural prob-
Open lesions other than
lems, infections, fungi
ulcers, rashes, cuts (e.g.,
cancer)
Skin tears or cuts
HISTORY OF
Client previously had (at any time) or has an ulcer anywhere on the
RESOLVED
body
PRESSURE
WOUND/
(Check for formal care in LAST 7 DAYS)
ULCER
Antibiotics, systemic or topical
Dressings
Surgical wound care
Other wound/ulcer care (e.g., pressure relieving device, nutrition, turn-
ing, debridement)
SECTION O. ENVIRONMENTAL ASSESSMENT
HOME
Lighting in evening (including inadequate or no lighting in living room,
ENVIRON-
sleeping room, kitchen, toilet, corridors)
Flooring and carpeting (e.g., holes in floor, electric wires where client
[Check any
walks, scatter rugs)
of following
that make
Bathroom and toiletroom (e.g., non-operating toilet, leaking pipes, no
home
rails though needed, slippery bathtub, outside toilet)
environment
hazardous or
Kitchen (e.g., dangerous stove, inoperative refrigerator, infestation by
uninhabit-
rats or bugs)
able (if none
apply, check
Heating and cooling (e.g., too hot in summer, too cold in winter, wood
NONE OF
stove in a home with an asthmatic)
ABOVE; if
temporarily
Personal safety (e.g., fear of violence, safety problem in going to
in institution,
mailbox or visiting neighbors, heavy traffic in street)
base
Access to home (e.g., difficulty entering/leaving home)
assessment
on home
Access to rooms in house (e.g., unable to climb stairs)
visit)]
i.
LIVING
a. As compared to 90 DAYS AGO (or since last assessment), client
ARRANGE-
now lives with other persons—e.g., moved in with another person,
other moved in with client
b. Client or primary caregiver feels that client would be better off in
another living environment
0. No 1. Client only
2. Caregiver only 3. Client and caregiver
SECTION P. SERVICE UTILIZATION (IN LAST 7 DAYS)
FORMAL
Extent of care or care management in LAST 7 DAYS (or since last
assessment if less than 7 days) involving
(C)
(Minutes
# of
Days
Hours
Mins
rounded to
a. Home health aides
even 10
minutes)
b. Visiting nurses
c. Homemaking services
d. Meals
e. Volunteer services
f. Physical therapy
g. Occupational therapy
h. Speech therapy
i. Day care or day hospital
j. Social worker in home
MDS-HC - Pg 4
2. SPECIAL
Special treatments, therapies, and programs received or scheduled during the
TREAT-
LAST 7 DAYS (or since last assessment if less than 7 days) and adherence to
MENTS,
the required schedule. Includes services received in the home or on an
THERAPIES,
outpatient basis.
PROGRAMS
[Blank]. Not applicable
2. Scheduled, partial adherence
1.Scheduled, full adherence as prescribed 3. Scheduled, not received [If no treatments provided, check NONE OF ABOVE P2aa]
RESPIRATORYTREATMENTS
o. Occupational therapy
p. Physical therapy
a. Oxygen
b. Respirator for assistive
breathing
q. Day center
c. All other respiratory treat-
r.
Day hospital
ments
s. Hospice care
OTHERTREATMENTS
t. Physician or clinic visit
d. Alcohol/drug treatment
u. Respite care
program
e. Blood transfusion(s)
SPECIAL PROCEDURES DONE
IN HOME
Chemotherapy
v. Daily nurse monitoring (e.g.,
g. Dialysis
EKG, urinary output)
h. IV infusion - central
w. Nurse monitoring less than
i .
IV infusion - peripheral
daily
j .
Medication by injection
x. Medical alert bracelet or elec-
k. Ostomy care
tronic security alert
y.
Skin treatment
l .
Radiation
m. Tracheostomy care
z .
Special diet
THERAPIES
aa. NONE OF ABOVE
aa.
n. Exercise therapy
3.MANAGE- Management codes:
MENT OF
0. Not used
EQUIPMENT
1. Managed on own
(In Last 3
2. Managed on own if laid out or with verbal reminders
Days)
3. Partially performed by others
4. Fully performed by others
c. Catheter
b. IV
d. Ostomy
4.VISITS IN Enter 0 if none, if more than 9, code "9" LAST90
a. Number of times ADMITTED TO HOSPITAL with an overnight stay
OR
SINCELAST
b. Number of times VISITED EMERGENCY ROOM without an overnight
ASSESSMENT
stay
c. EMERGENT CARE—including unscheduled nursing, physician, or therapeutic visits to office or home
5.TREATMENT Any treatment goals that have been met in the LAST 90 DAYS (or since
GOALS last assessment if less than 90 days)
6.OVERALL Overall self sufficiency has changed significantly as compared to
CHANGE IN status of 90 DAYS AGO (or since last assessment if less than 90 days)
CARE NEEDS 0. No change 1. Improved—receives
2. Deteriorated—
fewer supports
receives more support
7.TRADE OFFS Because of limited funds, during the last month, client made trade-offs among purchasing any of the following: prescribed medications, suffi- cient home heat, necessary physician care, adequate food, home care
SECTION Q. MEDICATIONS
1.NUMBER OF Record the number of different medicines (prescriptions and over the
MEDICA-
counter), including eye drops, taken regularly or on an occasional basis
in the LAST 7 DAYS (or since last assessment)[If none, code "0", if
TIONS
more than 9, code "9"]
2.RECEIPT OF Psychotropic medications taken in the LAST 7 DAYS (or since last PSYCHO- assesssment) [Note—Review client's medications with the list that
TROPIC applies to the following categories]
MEDICATION
a. Antipsychotic/neuroleptic
c. Antidepressant
b. Anxiolytic
d. Hypnotic
3.MEDICAL Physician reviewed client's medications as a whole in LAST 180 DAYS OVERSIGHT (or since last assessment)
0.Discussed with at least one physician (or no medication taken)
1.No single physician reviewed all medications
4.COMPLI- Compliant all or most of time with medications prescribed by physician
ANCE/ (both during and between therapy visits) in LAST 7 DAYS
ADHERENCE
WITH
0. Always compliant
1. Compliant 80% of time or more
2. Compliant less than 80% of time, including failure to purchase
prescribed medications
3.NO MEDICATIONS PRESCRIBED
=When box blank, must enter number or letter a. = When letter in box, check if condition applies
©Copyright interRAI, 1994,1996, 1997, 1999
5.LIST OF ALL List prescribed and nonprescribed medications taken in LAST 7 DAYS (or since MEDICATIONS last assessment)
a.Name and Dose—Record the name of the medication and dose ordered.
b.Form: Code the route of Administration using the following list:
By mouth (PO)
5. Subcutaneous (SQ)
9. Enteral tube
Sub lingual (SL)
6. Rectal (R)
10. Other
Intramuscular (IM)
Topical
Intravenous (IV)
8. Inhalation
c. Number taken—Record the amount of medication administered each time
the medication is given
d. Freq: Code the number of times per day, week, or month the medication is
administered using the following list:
PRN. As necessary
5D.
Five times daily
QH.
Every hour
QOD. Every other day
Q2H.
Every two hours
QW.
Once each wk
Q3H.
Every three hours
2W.
Two times every week
Q4H.
Every four hours
3W.
Three times every week
Q6H.
Every six hours
4W.
Four times each week
Q8H.
Every eight hours
5W.
Five times each week
QD.
Once daily
6W.
Six times each week
BID.
Two times daily
1M.
Once every month
(includes every 12 hrs)
2M.
Twice every month
TID.
Three times daily
C.
Continuous
QID.
Four times daily
O.
Other
a. Name and Dose
b. Form
c. Number d. Freq.
Taken
a._________________________________________________________________________
b._________________________________________________________________________
c._________________________________________________________________________
d._________________________________________________________________________
e._________________________________________________________________________
f._________________________________________________________________________
g._________________________________________________________________________
h._________________________________________________________________________
i._________________________________________________________________________
j._________________________________________________________________________
k._________________________________________________________________________
SECTION R. ASSESSMENT INFORMATION
1.SIGNATURES OF PERSONS COMPLETINGTHE ASSESSMENT:
a.Signature of Assessment Coordinator
b.Title of Assessment Coordinator
c.Date Assessment Coordinator signed as complete
d. Other Signatures
Title
Sections
Date
* Country specific
MDS-HC - Pg 5
Request for Services
Type of clinical eligibility determination all requested services.
Service(s) requested
Pre-admission nursing facility (NF)
Home and community
based services (HCBS) waiver
Adult day health (ADH)
Adult foster care (AFC)
Program for All-inclusive Care
for the Elderly (PACE)
Group adult foster care (GAFC)
Nursing facility use only
Conversion
Continued stay
Short term review
Transfer NF to NF
Retrospective
Member information
Member/applicant
Last name
First name
Telephone
Address
City
Zip
Check one
GAFC/
member
application pending
Assisted living residence
MassHealth ID number
Date application iled
Date SSI-G application iled
Next of kin/Responsible party
Physician
Screening for mental illness, mental retardation, and developmental disability
Does the member/applicant have any of the following diagnoses/conditions? Check all that apply.
Mental illness
Specify:
Mental retardation without related condition
Developmental disability with related condition that occurred prior to age 22.
Check all that apply.
Autism
Deafness/severe hearing impairment
Multiple sclerosis
Severe learning disability
Blindness/severe visual impairment
Epilepsy/seizure disorder
Muscular dystrophy
Spina biida
Cerebral palsy
Head/brain injury
Orthopedic impairment
Spinal cord injury
Major mental illness
Cystic ibrosis
Speech/language impairment
RFS-1 (Rev. 10/02)
OVER
Name of member/applicant
Community services recommended
Skilled nursing
HCBS waiver
Rest home
Homemaker
Physical therapy
Elderly housing
Personal emergency response system
Meals
Occupational therapy
Adult foster care
Adult day health
Transportation
Speech therapy
Group adult foster care
PACE
Chore service
Mental health services
Home health aide
Grocery shopping/delivery
Assisted living
Social worker services
Congregate housing
Personal care/homemaker
Other:
Additional information
1. Is the home or apartment available for the member or applicant?
yes
no
Is there a caregiver to assist the member in the community?
Has the member or applicant experienced unexplained weight gain in the last 30 days?
Does the member or applicant receive personal care/homemaker services?
If yes:
days per week
hours per week
Has the member or applicant experienced a signiicant change in condition in the last 30 days?
improvement
deterioration
Indicate the changes below.
For nursing facility requests only
1.Does the nursing facility member/applicant express an interest to remain in or return to the community?
2.Is the nursing facility stay expected to be short-term (up to 90 days)?
3.Is the nursing facility stay expected to be long-term (more than 90 days)?
Referral source Name of registered nurse completing this form
Signature
Print name
Name of organization
For community providers:
For nursing facility providers:
Attach the MDS-HC and Physician’s Summary form according to provider’s regulations/guidelines.
Attach the most recent comprehensive MDS, current quarterly MDS, and current physician orders.
Filling out the Minimum Data Set - Home Care (MDS-HC) form is a crucial step towards ensuring proper care and support for individuals requiring long-term care services. The details you provide will help the Massachusetts Executive Office of Health and Human Services make informed decisions regarding the necessary care plans. Let's walk you through the process of completing the MDS-HC form in the Commonwealth of Massachusetts, ensuring all the pertinent details are accurately captured.
After reviewing the form for accuracy, make sure that all required sections are correctly completed and signed by the appropriate persons, be it a registered nurse or a licensed social worker, as stipulated. This meticulous documentation is vital for establishing the needs and preferences of the client, facilitating an optimized care plan tailored to their specific situation.
Who is qualified to complete the MDS-HC?
The MDS-HC, or Minimum Data Set – Home Care, must be completed by an assessment coordinator who is a registered nurse. The nurse certifies the accuracy and completeness of the form. However, certain sections of the MDS-HC can be completed by a licensed social worker. Each completing individual must sign and certify the sections they complete. Both the registered nurse and the social worker must be licensed by the Massachusetts Board of Registration.
What is the purpose of the MDS-HC?
The MDS-HC form is used to document clinical eligibility for long-term-care services under MassHealth. It facilitates communication between providers and the Division of Medical Assistance, helping to ensure that individuals receive appropriate long-term-care services, including nursing-facility and adult-day-health services. By assessing various aspects of a client’s health and social needs, the MDS-HC supports the goal of providing comprehensive and coordinated care.
Are there any specific training requirements for completing the MDS-HC?
Yes, the Division of Medical Assistance holds periodic trainings for providers on how to properly complete the MDS-HC. These trainings are designed to ensure that individuals responsible for completing the forms are aware of the latest requirements and best practices. Providers will receive notice of these trainings when they are scheduled, ensuring they have the opportunity to stay informed and up-to-date.
How can I obtain copies of the MDS-HC form?
Providers are allowed to photocopy the MDS-HC form as needed for their practice. Additionally, supplies of the form can be obtained by mailing or faxing a request to MassHealth Forms Distribution. The request must include the provider number, address, telephone number, the exact title of the form, and the desired quantity to ensure accurate and timely delivery.
One common mistake made when completing the Minimum Data Set – Home Care (MDS-HC) form is incorrect or incomplete filling of Section AA, which concerns patient identification information. Properly entering the client's full name, case record number, and insurance numbers is critical. Failing to provide complete and accurate information in this initial section can result in processing delays or issues with service approval.
Another area often prone to errors is Section BB, specifically questions related to personal items such as gender, birthdate, race/ethnicity, marital status, language, and education level. It is crucial to check all boxes that apply under race/ethnicity and ensure the birthdate is correctly filled in with the month, day, and year to avoid misunderstandings or misrepresentations of the individual's demographic information.
Sections B and C, which focus on cognitive patterns and communication/hearing patterns, respectively, commonly witness a misunderstanding of the scoring criteria. Assessment coordinators or licensed social workers might inaccurately score a client's cognitive and communication abilities if they are not thoroughly familiar with the client's daily behavior and communication effectiveness. This can lead to an inaccurate portrayal of the client's needs and capabilities.
A significant oversight occurs in the medication and health conditions sections, where the requirement of using the ICD-9-CM codes for diagnoses is often overlooked. Without these codes, the form lacks the precise medical information necessary for appropriate service allocation and may lead to denial of needed services.
Error in the completion of the ADL (Activities of Daily Living) and IADL (Instrumental Activities of Daily Living) sections is also frequent. The error typically arises from not accurately observing or reporting the client's performance and difficulty levels over the specified period. This incorrect reporting can result in services that do not match the client’s actual needs.
The oversight of the caregiver's status and the client's potential for functional improvement, as referenced in the mood and behavior patterns along with the informal support services sections, often leads to a misrepresentation of the social support and rehabilitation potential. Assessment errors here can significantly impact the development of a comprehensive care plan that accurately addresses both immediate and long-term needs.
Last but not least, a common mistake is failing to properly certify sections of the MDS-HC that have been completed. Each person who completes a portion of the MDS-HC must sign and certify the sections he or she completes in Section R - Assessment Information (Other Signatures, Title, Sections, Date). Oversight in this area can question the validity of the entire assessment, potentially delaying the approval process for needed services.
When handling cases related to long-term care for chronic diseases and rehabilitation, the Minimum Data Set – Home Care (MDS-HC) form is crucial. However, several other documents often complement the MDS-HC to provide a comprehensive overview of the individual's health status and needs. These documents ensure thorough communication between health providers, patients, and the Massachusetts Executive Office of Health and Human Services Division of Medical Assistance. Together, they support a seamless process for determining eligibility and providing appropriate long-term care services.
Incorporating these documents with the MDS-HC form creates a robust framework for assessing, planning, and managing long-term care services for individuals with chronic conditions and rehabilitation needs. Each document plays a vital role in ensuring patient-centered care, addressing medical, personal, and legal aspects critical for comprehensive health management.
The Minimum Data Set - Home Care (MDS-HC) form shares similarities with numerous healthcare and social service-related documents, specifically in its structured assessment and information collection approach for individual care planning. Understanding these parallels can illuminate the broader ecosystem of coordinated care documentation.
The MDS-HC bears resemblance to the Outcome and Assessment Information Set (OASIS) document used in home health care settings. Both are comprehensive assessments designed to evaluate an individual’s health status, functional capacity, and needs to determine the appropriate level of care and services. While the MDS-HC is tailored towards individuals requiring long-term care, OASIS focuses on the needs of patients receiving home health services, underlining their shared goal of supporting accurate care planning and delivery.
Another similar document is the Patient Health Questionnaire (PHQ-9), a tool widely utilized by healthcare providers to screen for depression. Like the section in the MDS-HC that addresses mood and behavior patterns, the PHQ-9 helps in identifying mental health needs and planning appropriate interventions. This highlights the importance both documents place on understanding and integrating mental health into the holistic care plan.
The Functional Independence Measure (FIM) instrument also mirrors the MDS-HC in its assessment of an individual's physical and cognitive disabilities and their impact on daily activities. Both tools are crucial in rehabilitation and long-term care settings, providing a basis for measuring patient progress over time. While the MDS-HC offers a broader scope, incorporating social support and environmental factors, the core objective of facilitating targeted, effective care remains consistent across both.
Lastly, the Comprehensive Geriatric Assessment (CGA) shares several objectives with the MDS-HC, focusing on evaluating older adults to develop a coordinated and integrated plan for treatment and long-term follow-up. The CGA assesses multiple domains of health and well-being, similar to the MDS-HC’s wide-ranging topics, emphasizing the importance of a multifaceted approach to care tailored to the unique needs of the elderly population.
Collectively, these documents underscore the healthcare industry's emphasis on detailed, patient-centered assessments to guide care planning and delivery. Despite their varied specific purposes and settings, their common thread is the commitment to improving health outcomes through comprehensive evaluation and responsive care strategies.
Filling out the Minimum Data Set – Home Care (MDS-HC) form is an essential process for chronic disease and rehabilitation hospitals participating in MassHealth. It's critical to ensure accuracy and completeness to facilitate communication between providers and the Division of Medical Assistance. Here are several do's and don'ts to consider when filling out the MDS-HC form:
Adhering to these guidelines can help in the accurate and efficient completion of the MDS-HC form, ensuring that patients receive the care and services they need in a timely fashion.
There are many misconceptions surrounding the Minimum Data Set – Home Care (MDS-HC) form, which can lead to confusion and errors in its completion and utilization. Below are ten common misunderstandings clarified to provide a better grasp of the form's purpose, requirements, and implications.
This is incorrect. The MDS-HC is specifically designed for home care settings to evaluate the needs and services for individuals receiving long-term care services at home, not just in nursing facilities.
Only an assessment coordinator, who must be a registered nurse (RN), can complete the MDS-HC, certifying its accuracy and completeness. Certain sections may be completed by a licensed social worker.
In fact, the Executive Office of Health and Human Services provides periodic training for providers. This training is crucial for ensuring the accurate completion of the MDS-HC.
The form is utilized not only for initial assessments but also for follow-ups, routine assessments at fixed intervals, and reviews prior to discharge, among other reasons.
Contrary to this belief, the use of ICD-9-CM codes is required for medical diagnoses in the MDS-HC assessment process.
While the bulletin does not specify submission methods, providers should verify with MassHealth for current practices as electronic health records and submissions have become more common.
Actually, the MDS-HC contains sensitive personal health information and must be handled according to HIPAA regulations and MassHealth policies to protect patient privacy.
Though it is used within Massachusetts' MassHealth system, understanding and correctly implementing the MDS-HC can have implications for receiving federal funding and complying with federal regulations.
Providers are indeed allowed to photocopy the form as needed but should always ensure they are using the most current version and comply with MassHealth policies and procedures.
MassHealth has a provider services contact for questions, highlighting the availability of support for providers needing clarification or assistance with the MDS-HC.
By dispelling these misunderstandings, healthcare providers can ensure that they are correctly completing and utilizing the MDS-HC form, thereby enhancing the quality of care for individuals receiving long-term services and supports.
Filling out and using the Minimum Data Set – Home Care (MDS-HC) form requires attention to detail and a comprehensive understanding of the form's requirements. Here are four key takeaways to guide providers through the process:
Health Proxy Definition - Agents are authorised to make all health care decisions, except where specifically limited by the individual.
Notice of Right to Cure Default Car - A clear, statutory-based document providing guidance on how to address a loan default situation, safeguarding borrower's rights.