Abstract
Objectives
To examine the completeness of the activities of daily living (ADL) items on admission and discharge assessments and the improvement in ADL performance among short-stay residents in the newly adopted Minimum Data Set (MDS) 3.0.
Design
Retrospective analysis of MDS admission and discharge assessments.
Setting
Nursing homes from July 1, 2011, to June 30, 2012.
Participants
New nursing home residents admitted from acute hospitals with corresponding admission and discharge assessments between July 1, 2011, and June 30, 2012, who had a length of stay of 100 days or less.
Measurements
ADL self-performance items, including bed mobility, transfer, walking in room, walking in corridor, locomotion on unit, locomotion off unit, dressing, eating, toilet use, and personal hygiene, at admission and discharge.
Results
The ADL self-performance items are complete at both admission and discharge, with less than 1% missing for any item. More than 60% of residents improved over the course of their post-acute stay. New short-stay nursing home residents with conditions such as cognitive impairment, delirium, dementia, heart failure, and stroke showed less improvement in ADL performance during their stay.
Conclusion
The discharge assessment data in the MDS 3.0 provide new information to researchers and providers to examine and track ADL performance. Nursing homes can identify and track patients who require more intensive therapies or targeted interventions to achieve functional improvement during their stay. Future research can examine facility-level measures to better understand how ADL improvement varies across facilities.
Keywords: Nursing home, Minimum Data Set (MDS), functional improvement
A substantial revision to the Minimum Data Set (MDS) for nursing homes, the MDS 3.0, was implemented in October 2010.1,2 In addition to its role in care planning, the MDS also is used for measuring and tracking the quality of care within and between nursing homes. Many of the modiflcations that were incorporated in the MDS 3.0 may improve the value of the MDS for assessing quality.
One of the changes in the MDS 3.0 is the collection of speci-flc assessment items at resident discharge. Previously, information regarding discharge location was reported in a separate discharge record, but no assessment of resident functioning was conducted on discharge. Assessment on discharge makes it possible to examine changes in patients’ functioning between admission and discharge across several dimensions, including mobility and the ability to perform activities of daily living (ADLs) independently.
Nursing homes have increasingly been used as a post-acute care setting for individuals who require rehabilitation and nursing services after a hospitalization.3,4 Post-acute stays are intended to be short as individuals recuperate and prepare to move back to their primary residence. Functional change measures the decline, improvement, or maintenance over time in ADLs and gives an indication of the extent to which post-acute care affected an individual’s health status and ability for independent mobility and self-care.
Since the earlier version of the MDS did not include a required assessment of patients’ functional status on discharge, few studies have reported on functional change for patients admitted to nursing homes for post-acute care. Studies assessing functional outcomes for short-stay residents tended to use samples of residents from a limited number of nursing homes where non-MDS functional data were collected to evaluate changes over the course of a nursing home stay.5–10 Alternatively, some validation studies conducted for the National Quality Forum evaluated functional measures for the post-acute population using data from 5-day and 14-day MDS assessments and found several of these measures to be valid.11 However, there are currently no measures of function that are endorsed or publicly reported for the post-acute population.12 Most studies documenting functional change in nursing homes have been restricted to the long-stay nursing home resident because there are quarterly assessments that document residents’ functioning at each one, making it possible to track change in functioning over time for long-stay residents.13–16
The lack of systematic national data on short-stay nursing home residents has precluded more thorough analyses of resident characteristics related to functional outcomes during post-acute stays and of facility-level performance. This article examines the completeness of the ADL items on admission and discharge assessments and the improvement in ADL performance among short-stay residents in the newly adopted MDS 3.0. It is the flrst comprehensive examination of how the ADL measures are reported in the real world using the new measurement instrument.
Methods
Data Sources
All resident data came from MDS 3.0 assessments. MDS assessments document residents’ demographic, functional, cognitive, and clinical characteristics and are required for all residents in Medicare- or Medicaid-certifled nursing homes. The assessments are completed on admission, every 90 days after admission, when there is a significant change in a resident’s status, and on discharge. If the resident’s stay is under Medicare Part A (as is the case for most admissions), there are additional reporting requirements. For these analyses, we used residents’ admission and discharge assessments.
Sample
The sample for these analyses included residents with corresponding admission and discharge (“return anticipated” and “return not anticipated”) assessments between July 1, 2011, and June 30, 2012, who were new entries (not readmissions) from an acute hospital as indicated on their MDS admission assessment (n = 1,062,607). Our sample was limited to individuals who had a length of stay in the nursing home of 100 days or less, so as to focus on the short-stay population (n = 1,028,405). We excluded individuals who were comatose (n = 510) or receiving hospice (n = 4859) at admission, as we were examining change in ADL functioning. Individuals who died in the nursing home within the 100-day time period were therefore excluded because they did not have a discharge assessment. This left us with a final sample of 1,023,036 individuals across 15,145 facilities.
We also examined subsamples derived from our main sample. These included (1) individuals whose discharge location was to the community (n = 840,097), as indicated on the discharge assessment, and (2) individuals who had a hip fracture on admission to the nursing home (n = 89,082), as indicated on the admission assessment. We chose these subsamples because we would expect greater improvement among these residents.
Variables
Outcome variable
The ADL self-performance items, including bed mobility, transfer, walking in room, walking in corridor, locomotion on unit, locomotion off unit, dressing, eating, toilet use, and personal hygiene, started being collected at discharge with the MDS 3.0. In addition to the new reporting requirements, this section now instructs that each activity must occur 3 or more times within the past 7 days to be coded on a scale of 0 (independent) to 4 (total dependence). If the activity occurred 2 or fewer times within the past 7 days, the item is coded 7 (occurred only once or twice) or 8 (activity did not occur). In the MDS 2.0, the physical functioning section separately specified the frequency of assistance needed for each code (0–4), but did not require a 3-time minimum occurrence. The previous version included code 8 (activity did not occur during past 7 days) but did not include code 7.
We examined each ADL self-performance item to determine completeness on both admission and discharge assessments for our sample. We calculated change in ADL self-performance between admission and discharge by using the long-form scale, early-loss ADLs, mid/late-loss ADLs, walking items, and locomotion items. The long-form ADL scale includes measures for bed mobility, transfer, locomotion on unit, dressing, eating, toilet use, and personal hygiene. This scale ranges from 0 to 28, with higher scores indicating greater impairment.17 The early-loss ADLs include dressing and personal hygiene; the mid/late-loss ADLs include bed mobility, transfer, eating, toilet use; the walking items include walking in the room and in the corridor; and the locomotion items include moving on and off the unit. For each of these scores, we recoded any items with scores of 7 or 8 (activity occurred only once or twice or activity did not occur) as totally dependent, code 4. This is consistent with the calculation of the long-form ADL scale from the MDS 2.0, in which items with scores of 8 were recoded to a score of 4.17 ADL change was calculated as the admission score minus the discharge score, so positive scores indicate improvement, whereas negative scores indicate decline.
We also analyzed ADL improvement between admission and discharge. For this outcome, we used the change in the long-form ADL score. We recoded individuals with negative change scores to 0 to indicate no improvement, so this improvement outcome variable ranged from 0 to 28.
Independent variables
We used a number of resident-level variables to examine the relationship between admission resident characteristics and ADL improvement. Demographic characteristics included age, gender, race (white/not white), and marital status (married/not married). We included a categorical variable for cognitive function indicating whether the resident was cognitively intact, moderately impaired, or severely impaired. For residents who had a Brief Interview for Mental Status (BIMS) score, we used the validated categories: (1) cognitively intact for resident with a BIMS score of 13 to 15, (2) moderately impaired for residents with a BIMS score of 8 to 12, and (3) severely impaired for residents with a BIMS score of 7 or lower.18 For residents who did not have a BIMS score, we calculated the Cognitive Performance Scale (CPS) score.19 We classified residents as (1) cognitively intact if they had a CPS score of 0 to 1, (2) moderately impaired if they had a CPS score of 2 to 4, and (3) severely impaired if they had a CPS score of 5 to 6. We analyzed whether the resident showed signs or symptoms of delirium (based on the Confusion Assessment Method [CAM] items),2 and selected diagnoses that influence active treatment in the nursing home or functioning (heart failure, arthritis, osteoporosis, hip fracture, other type of fracture, Alzheimer disease, dementia, depression, chronic obstructive pulmonary disease, stroke). We also controlled for the resident’s long-form ADL score at admission.
Analysis
To examine the factors influencing the degree of ADL improvement, we used a facility fixed-effect linear regression model controlling for resident-level characteristics. No independent variable had more than 3% missing data, so we chose to drop individuals rather than undertake multiple imputation for variables for our regression model. Our final sample for the regression analysis was 886,798 individuals across 14,987 facilities.
Results
Table 1 displays the individual item codes for each ADL self-performance item, along with the frequency of missing items, on admission and discharge assessments. The number of residents missing individual self-performance codes is slightly higher at discharge, but the number of missing items is low overall (less than 1% for each item). There were 67 residents at admission and 3829 residents at discharge (of 1,023,036 total residents at each time point) who were missing codes for all of the ADL self-performance items, so most residents with missing items were missing some items but not all.
Table 1.
Proportion of Residents Coded at Each Level for the ADL Self-Performance Items (n = 1,023,036)
| 0* | 1* | 2* | 3* | 4* | 7† | 8† | Missing | |
|---|---|---|---|---|---|---|---|---|
| Bed mobility | ||||||||
| Admission | 5.13 | 5.00 | 20.49 | 65.98 | 3.33 | 0.06 | 0.01 | 0.01 |
| Discharge | 14.57 | 13.92 | 27.89 | 40.89 | 2.23 | 0.08 | 0.02 | 0.41 |
| Transfer | ||||||||
| Admission | 2.62 | 4.88 | 22.08 | 64.77 | 5.01 | 0.29 | 0.34 | 0.01 |
| Discharge | 10.80 | 15.78 | 30.74 | 38.49 | 3.30 | 0.24 | 0.24 | 0.40 |
| Walk in room | ||||||||
| Admission | 3.14 | 8.13 | 27.74 | 25.90 | 0.27 | 3.18 | 31.54 | 0.11 |
| Discharge | 11.77 | 20.55 | 29.37 | 15.65 | 0.18 | 2.20 | 19.46 | 0.82 |
| Walk in corridor | ||||||||
| Admission | 2.54 | 8.55 | 24.83 | 23.16 | 0.34 | 4.87 | 35.58 | 0.13 |
| Discharge | 9.68 | 21.88 | 27.51 | 14.32 | 0.23 | 3.68 | 21.87 | 0.83 |
| Locomotion on unit | ||||||||
| Admission | 5.68 | 8.44 | 22.96 | 44.87 | 15.25 | 1.02 | 1.72 | 0.05 |
| Discharge | 14.55 | 20.34 | 25.82 | 27.70 | 8.93 | 0.71 | 1.24 | 0.71 |
| Locomotion off unit | ||||||||
| Admission | 4.51 | 7.23 | 17.73 | 40.74 | 21.74 | 3.10 | 4.87 | 0.08 |
| Discharge | 12.13 | 17.74 | 22.16 | 27.65 | 13.43 | 2.75 | 3.40 | 0.74 |
| Dressing | ||||||||
| Admission | 2.63 | 4.27 | 22.21 | 66.30 | 4.43 | 0.09 | 0.05 | 0.03 |
| Discharge | 9.60 | 13.39 | 30.42 | 42.60 | 3.12 | 0.10 | 0.05 | 0.72 |
| Eating | ||||||||
| Admission | 40.47 | 36.96 | 11.94 | 7.84 | 2.69 | 0.06 | 0.03 | 0.01 |
| Discharge | 46.28 | 36.07 | 9.26 | 5.77 | 2.13 | 0.06 | 0.04 | 0.41 |
| Toilet use | ||||||||
| Admission | 2.75 | 4.40 | 19.69 | 66.81 | 6.24 | 0.05 | 0.05 | 0.01 |
| Discharge | 10.08 | 13.60 | 28.19 | 43.20 | 4.40 | 0.07 | 0.06 | 0.41 |
| Personal hygiene | ||||||||
| Admission | 6.03 | 10.00 | 27.46 | 51.87 | 4.50 | 0.08 | 0.02 | 0.03 |
| Discharge | 14.67 | 18.68 | 29.23 | 33.20 | 3.40 | 0.09 | 0.03 | 0.71 |
Activity occurred 3 or more times:
0 = Independent (no help or staff oversight at any time)
1 = Supervision (oversight, encouragement, or cueing)
2 = Limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs or other non–weight-bearing assistance)
3 = Extensive assistance (resident involved in activity, staff provide weight-bearing support)
4 = Total dependence (full staff performance every time during entire 7-day period)
Activity occurred 2 or fewer times:
7 = Activity occurred only once or twice (activity did occur but only once or twice)
8 = Activity did not occur (activity did not occur or family and/or nonfacility staff provided care 100% of the time for that activity over the entire 7-day period)
The change in ADL self-performance measures between admission and discharge for the full sample and subsamples are presented in Table 2. Residents had a mean ADL change of 3.4 points between admission and discharge based on the long-form ADL scale. Individuals who were discharged home had a mean ADL change of 3.9 points, and individuals who had a hip fracture on admission had a mean ADL change of 3.8 points; these subsamples demonstrated greater improvement in ADL self-performance compared with the full sample across all scales. There were few individuals who declined in ADL self-performance during their stay.
Table 2.
Change in ADL Self-Performance Scores Between Admission and Discharge
| Mean Change (SD) | % No Change, Stable | % Improved | |
|---|---|---|---|
| Long-form ADL Scale 0–28 | |||
| Full sample | 3.35 (4.43) | 26.1 | 64.9 |
| Discharged home | 3.86 (4.48) | 22.8 | 70.4 |
| Hip fracture | 3.80 (4.52) | 23.3 | 69.6 |
| Early loss (dressing and personal hygiene) 0–8 | |||
| Full sample | 0.96 (1.53) | 48.9 | 45.9 |
| Discharged home | 1.11 (1.56) | 44.5 | 51.2 |
| Hip fracture | 1.08 (1.54) | 46.9 | 49.4 |
| Mid/late loss (bed mobility, transfer, eating, toilet use) 0–16 | |||
| Full sample | 1.78 (2.56) | 35.9 | 56.1 |
| Discharged home | 2.05 (2.59) | 32.6 | 61.2 |
| Hip fracture | 1.98 (2.58) | 33.3 | 60.0 |
| Walking (in room and corridor) 0–8 | |||
| Full sample | 1.32 (1.98) | 45.6 | 49.2 |
| Discharged home | 1.52 (2.02) | 41.1 | 54.5 |
| Hip fracture | 1.74 (2.13) | 39.5 | 57.1 |
| Locomotion (on and off unit) 0–8 | |||
| Full sample | 1.20 (1.93) | 47.4 | 46.8 |
| Discharged home | 1.37 (1.97) | 43.5 | 51.5 |
| Hip fracture | 1.42 (1.99) | 43.9 | 51.6 |
Table 3 presents the descriptive statistics for the sample used in the regression analysis (n = 886,798). The mean ADL score at admission was 16.4, and residents had an average length of stay of 30 days. As expected for this post-acute sample, most residents (>85%) had received greater than 3 hours of physical therapy within the previous 7 days, as reported on the admission assessment.
Table 3.
Descriptive Statistics for Regression Sample (n = 886,798)
| Variable | Mean (SD) or % |
|---|---|
| ADL improvement | 3.7 (4.2) |
| ADL score at admission | 16.4 (4.7) |
| Age | 77.4 (12.3) |
| Gender, female | 64.4 |
| Race, not white | 15.8 |
| Marital status, married | 35.0 |
| Cognition | |
| Cognitively intact | 71.0 |
| Moderately impaired | 19.3 |
| Severely impaired | 9.7 |
| Any signs of delirium | 2.9 |
| Heart failure | 18.2 |
| Arthritis | 29.8 |
| Osteoporosis | 12.1 |
| Hip fracture | 8.6 |
| Other type of fracture | 11.1 |
| Alzheimer disease | 2.9 |
| Dementia | 12.9 |
| Depression | 27.7 |
| Chronic obstructive pulmonary disease | 22.8 |
| Stroke | 10.1 |
| Length of stay | 29.6 (18.6) |
| Physical therapy, total minutes within past 7 days | |
| <1 h | 3.9 |
| 1–2 h | 2.2 |
| 2–3 h | 8.2 |
| ≥3 h | 85.7 |
Results from the regression model are shown in Table 4. Residents who had any signs of delirium improved by fewer points than residents without signs of delirium, and residents with increasing levels of cognitive impairment improved less than residents who were cognitively intact. Additionally, residents who had a diagnosis of Alzheimer’s disease or other dementia had less improvement than residents not so diagnosed. Residents who had a diagnosis of heart failure or stroke had less improvement than residents without these diagnosis indicators. Greater improvement was found for individuals who had a hip or other type of fracture at admission. Results were similar (not displayed) for the subsamples of residents who were discharged home and who had a hip fracture on admission, but they were greater in magnitude.
Table 4.
Regression Results Predicting ADL Improvement (n = 886,798,749)
| Variable | Coefficient Estimates (SE) | P Value |
|---|---|---|
| Intercept | −0.194 (0.084) | .020 |
| ADL score at admission | 0.161 (0.001) | <.001 |
| Age | 0.085 (0.002) | <.001 |
| Age2 | −0.001 (0.000) | <.001 |
| Gender, female | 0.031 (0.009) | .001 |
| Race, not white | −0.123 (0.013) | <.001 |
| Marital status, married | −0.454 (0.009) | <.001 |
| Cognition, cognitively intact | ||
| Moderately impaired | −0.761 (0.011) | <.001 |
| Severely impaired | −1.698 (0.016) | <.001 |
| Any signs of delirium | −0.733 (0.026) | <.001 |
| Heart failure | −0.401 (0.011) | <.001 |
| Arthritis | 0.218 (0.009) | <.001 |
| Osteoporosis | 0.040 (0.013) | .002 |
| Hip fracture | 0.333 (0.015) | <.001 |
| Other type of fracture | 0.272 (0.013) | <.001 |
| Alzheimer disease | −0.428 (0.025) | <.001 |
| Dementia | −0.416 (0.013) | <.001 |
| Depression | −0.205 (0.009) | <.001 |
| Chronic obstructive pulmonary disease | −0.143 (0.010) | <.001 |
| Stroke | −0.413 (0.014) | <.001 |
Model also includes a nursing facility fixed effect.
Discussion
We found that among our sample of short-stay residents, the ADL self-performance items are largely complete at both admission and discharge. For each ADL item, fewer than 1% of residents were missing codes on either admission or discharge assessments. This indicates that nursing facility staff are fulfilling the new requirement of assessing physical functioning on discharge, which permits new analyses of physical functioning over time among both short-stay and long-stay nursing home residents.
With the exception of the walking items, few residents are being coded as 7 (activity occurred only once or twice) or 8 (activity did not occur). This indicates that most of the functioning self-performance items are being observed and reported by staff. Because of the high numbers of individuals who do not receive a 0 to 4 code for the walking items at both time points, these measures will be difficult to track over time to observe real changes in self-performance.
Most residents improved in functioning over the course of their post-acute stay, with an average improvement of 3.4 points among the full sample on the long-form ADL scale. The magnitude of improvement was greater among the subsamples of residents who were discharged home and who had a hip fracture at admission for all function scales. The average improvement per day in the nursing home was 0.15 points. The overall improvement in ADL functioning was expected given that our samples included post-acute patients, most of whom were receiving physical therapy.
In the regression analysis, new short-stay nursing home residents with conditions such as delirium, cognitive impairment, and dementia showed less improvement in ADL performance during their stay. Our results are consistent with previous studies that have reported worse outcomes among individuals with delirium. These studies found that resolution of delirium early in the post-acute stay was associated with functional recovery.9,20 Nursing home staff should be educated and focus on resolving delirium symptoms at the beginning of the post-acute stay to facilitate functional recovery. Targeted interventions also should be considered for patients who have cognitive impairment or diagnosed dementia. We found that residents with a number of other diagnoses, such as heart failure and stroke, also showed less improvement in ADL functioning during their post-acute episode. Previous work has found that higher therapy intensity is associated with greater functional outcomes for patients who have stroke, orthopedic conditions, and cardiovascular and pulmonary conditions.7 In addition to higher therapy intensity, higher nursing staff levels have been shown to be related to better length-of-stay efficiency (improvement per day) and to a greater likelihood of being discharged to the community.6 Nursing homes should consider more intensive treatment for patients with these conditions to achieve greater functional improvement. All of these characteristics are included on the MDS admission assessment, so identifying patients who require more intensive treatment or targeted interventions could become part of the current admission process.
The completeness and accuracy of the ADL measures for full episodes of care is important for clinical staff who are tracking the progress of residents and determining appropriate discharge timing. More frequent assessment of these measures also is valuable for therapy staff who are working with individuals to achieve specific benchmarks of self-care. The measures for individual residents also can be aggregated to the facility-level to help facilities track their progress in ADL improvement among short-stay residents over time.
Overall, the results are in the expected direction, indicating that the ADL improvement measure is valid and sensitive. Additionally, these results indicate that adequate risk adjustment needs to be made to control for differences in the likelihood of functional improvement if a measure of physical functioning is used in future nursing home quality reporting.
This analysis has several limitations. To construct accurate patient episodes, we included only individuals whose admission date on their discharge assessment matched the admission date from their admission assessment. We may have excluded residents who were relevant to our analysis but who had inaccurate MDS reporting. We excluded individuals who died within the 100-day period who did not have a discharge assessment. This exclusion could overestimate functional improvement, because we observed only individuals who remained alive and received an assessment at discharge. Because the purpose of this analysis was to examine the completeness of the function items at discharge, we included only individuals who had a complete episode within the 100-day period (including a discharge assessment). If the missingness of discharge assessments is not random across facilities, it will be difficult to compare short-stay functional change between facilities. To assess the extent of missing assessments across facilities, we evaluated facility-level completion rates of MDS assessments for the period July 2011 to June 2012. We determined the rate of follow-up records occurring within 120 days of each admission to the facility, regardless of where the entry was from. Follow-up records included MDS discharge assessments and other types of MDS assessments (eg, quarterly, annual). If no follow-up MDS assessment was present, the tracking for the admission was incomplete, and it is unknown whether the admission ended in discharge or death or if the individual remained in the facility. We found that the mean facility-level MDS completion rate was 99.02% for the 15,681 facilities present during this time period. Overall, this indicates that facilities are complying with MDS requirements, and the missingness of discharge assessments is likely low.
Conclusion
The discharge assessment data in the MDS 3.0 provide new information to researchers and providers to examine and track quality across facilities. Future research can examine measures, such as therapy staff and minutes at the facility-level, to better understand how ADL improvement varies across facilities.
Acknowledgments
This study was funded by the National Institute on Aging (P01 AG-027296) and the Agency for Healthcare Research and Quality (T32 HS-000011). AW is currently employed at Mathematica Policy Research, but this work was completed while at Brown University.
Footnotes
The authors declare no conflicts of interest.
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