MORNING SESSION

    DR. WOOD: Secretary's Advisory Committee on Regulatory Reform. This is actually the third meeting of the group. For those of you who are in the audience, this group was chartered by the secretary to find solutions to the burden of regulation that specifically interferes with the care of patients and that makes it harder for people to get good service and also which interferes with or makes the process of administering the program less efficient and leads to ineffectiveness.

    Now in this process, the problems are ones that are not new. I think everyone on the Committee and most of you in the audience know the problems very well. But what we're interested in hearing specifically is some of you sharing your comments with us or some ideas about solutions. And we're anxious to hear any ideas that you have in that regard. We are not in the business of developing new regulations and we are not in a position to talk about payment policy issues or statutory problems. Those are things that we can flag for the agency to work on or for HHS to work on later but our specific charge is to find solutions for regulatory problems.

    So for those of you who are contemplating perhaps making comments later today, if you can think about those in that context and perhaps concentrate on some specific ideas that you might have about how we can do things better, that would be for the Committee members extremely helpful and we will probably engage you to some degree in questions where there might be some extremely innovative thoughts that you might have.

    We had a very good hearing in Miami where we addressed three major subject topics. Those -- for the interest of those of you in the audience who are in (phonetic) and beneficiary communications and the OASIS Data set and you used a format actually that was quite helpful when we tried to review the original intent of the statute or the intent of the program so we could understand what the design was intended to accomplish and then we would look at how the regulations were written and how they're actually working in the field to make sure that we're actually achieving what those original goals were. And our effort is to find ways that we can make those particularly better.

    I think all of you who are in the audience and those of us who are around the table who work in healthcare or who are healthcare beneficiary and the patients understand that there is a growing pressure of reimbursement limits and then the pressure of work that is imposed by regulations. It will be harder for us to make decisions about reimbursement but we simply have to find ways that we can solve some of these regulatory issues that take away from care.

    For example, for every hour that any of us spends in paperwork or doing things that are not going to help us take care of patients, that's an hour that we can't devote to direct patient care and it's an hour of resource that is spent that otherwise then wasted. So that's what we're really trying to accomplish.

    Before we get into the heart of today's discussion, I'd like to introduce Ms. Leslie Norwalk who has some announcements and then I'll ask Christy to make some housekeeping announcements as well but Ms. Norwalk was counselor to Mr. Scully. We've been pleased to have her with us from Miami and she actually joined after our first meeting but it's always been great to have you with us, Leslie.

    MS. NORWALK: Thank you. Good morning, everybody. First, welcome from the Secretary. He's sorry he can't make it today and the Assistant Secretary for planning and evaluation, Bobby Judell (phonetic) and my boss, Tom Scully, are both required to testify on their appropriations this week and unfortunately also could not make it out of Congress for us to see them.

    But I do bring their greetings and I have a couple of announcements. First, I'd like to let you all know that Jeff Bloom, who is currently now a full member of the Committee, Jeff is an active member of the Patients and Consumers Coalition, a broadbased coalition of groups of advocates that -- groups that advocate for positive change of the FDA and we're happy to announce that he is now a full fledged member of the Committee.

    In addition, I'd like to say hello to Suzanne Pattee who comes us to from the Cystic Fibrosis Foundation where she is the vice president of public policy and education affairs and she -- while she is currently only a consultant to this Committee, we hope that the paperwork and all the other things that go along that we're trying to reduce here, at some point in the very near future she'll be a full fledged member of the Committee and we're very glad to have you with us even in this capacity.

    So one of the things that came up at the January hearing in Washington that was of concern was the requirements that we impose, that CMS imposes on hospitals to collect Medicare secondary payer information both for recurring outpatient services and for hospital reference labs. In response to that, the comments that we've heard at the January Committee, we decided to change the collection information from 30 days for recurring outpatient services and 60 days for hospital reference labs. However, there was some concern both from the American Hospital Association and from others that this was not enough. So I'm happy to announce that we have decided to revise our policy and extend these time periods to require the collection of this information every 90 days for both hospital outpatient service and lab services for those recurring patients. So we certainly hope to be able to make these sorts of announcements as we go forward that when something is brought to our attention as being overly burdensome and not adding to patient safety, equality, et cetera, that we can in fact revise our policies to make life easier for all of our stakeholders.

    So that's our first announcement this particular morning and with that, Christy, I will turn it over to you. But thank you for all participating. I do appreciate it.

    MS. SCHMIDT: Just three quick things. We have a Spanish language translator with us this morning. Would you introduce yourself so people know where you are and people who are coming in from the public are being informed of her presence. But say hello.

    INTERPRETER: My name is Isabelle and for most of the Spanish, I'll be happy to translate.

    MS. SCHMIDT: Also for the panel members and Committee members, there are our site visit trip schedule is here. There were three options for today. To go to Good Samaritan Regional Medical Center, to go to Phoenix Mountain Nursing Home and go to Pacificare Desert Regional Customer Service Center. Please look at this at the break and then decide which of these you might like to attend and we'll have a sign up sheet at that point.

    Similarly, for those of you who may have later flights tomorrow or may be going out on Friday, there are two optional site visits tomorrow to the Gila River Health Care Corporation and to the Guadalupe Family Health Center.

    And finally, I just want to remind the panelists about -- there's a light system. This hearing we should be able to see it. It's right in front of that computer by Ms. Long. Thank you.

    DR. WOOD: Before we begin with a discussion of the minimum data set and again following the format we used successfully in Miami, our initial goal was to understand what it is we're trying to accomplish and for that, we are pleased to have with us today Mr. Tom Hoyer who is the director of the Chronic Care Policy group at CMS and he will begin with that background. So I'm happy to invite Tom to the podium to share that with us.

    MR. HOYER: Thank you all very much, Dr. Wood. I hope you all can hear me. The qualification I have for standing here is that I've worked for CMS for more than 30 years now and have been involved with Medicare's SNF benefit and nursing homes for a good 20 or 25 of that.

    The first thing I'd like to say is that the idea of assessment in assessment instruments has been discussed for a very long time and at least actively in the department since the 1970's when the Office of Nursing Home Reform was put together to look at quality of care in nursing homes.

    The minimum data set or MDS has its modern roots in the 1986 report of the Institute of Medicine entitled "Improving the Quality of Care in Nursing Homes." My sole visual is to show you a xerox of the report cover. The study was commissioned by CMS as the price of lifting a Congressional embargo on nursing home rule making. It is a means of taking neutral advice on how to make a fresh start in regulating the quality of nursing homes.

    Just to go back, this came at a time when nursing homes and nursing home occupancy were experiencing the explosive growth occasioned by Medicare and Medicaid and people were increasingly concerned about quality of care and not too sure what to do about it.

    There was a fairly well known court case in the 70's called Smith v. O'Halloran, Smith being a nursing home patient I believe in Colorado and O'Halloran being the Medicaid director. The gravamen of the lawsuit was that the state had failed to assure that the care in nursing homes was of appropriate quality. Naturally, the Department of Health and Human Services was soon a party to the suit and our argument surprisingly enough was that there was nothing in the law that authorized or required us to assure that quality care was being provided in nursing homes. We argued that the law, and it was true, laid out the conditions of participation that related for example to fire safety and to the employment of qualified nurses, to dietary advice. We argued that because in fact in our survey process, we didn't have the technology to identify an appropriate quality and as a result, we didn't have the capacity to enforce fielding even if we had been able to develop it. The care was of inappropriate quality.

    We felt hamstrung as a department to go beyond what the law said. The study -- what happened in the end was in the Nursing Home Reform Statute of 1987, there was as a result of that one lawsuit, a strong and expressive statement that said it is the duty and responsibility of the Secretary to assure that all patients reach the highest practical level of physical, mental and psychosocial well being. So it was -- it took a statutory change really to put us squarely in the business of quality.

    The Institute of Medicine's report said specifically, "providing high quality care requires careful assessment of each resident's functional, mental, medical and psychosocial status upon admission and reassessment periodically thereafter." The study also listed basic uses for the information including care planning, looking at case mix with the survey process for quality assurance, for utilization review, and finally for Medicaid payment purposes because some Medicaid programs at that point were looking at prospective payment systems based on resource utilization groups. As has the Medicare program since then.

    The elements of the Institute of Medicine's study provided the basis for the nursing home reform statute enacted in the Omnibus Reconciliation Act of 1987. And I must tell you many of those provisions were expressedly included in that statute which is actually about 15 pages long as compared to the first set of nursing home conditions in the statute which was less than one page long.

    I'd like to read to you because it's very brief, three of the specific things that the statute says about assessment. It says:

"The Secretary shall specify a minimum data set of core elements and common definitions for use by nursing facilities in conducting the assessments required under the law and establish guidelines for the utilization of the data and designate one or more instruments for use by nursing facilities."

    It then requires each facility to conduct a comprehensive accurate standardized reproducible assessment of each resident's functional capacity using the MDS and finally it requires that the assessment be used in developing, reviewing and revising the resident's plan of care.

    The original MDS data set was developed under contract with CMS through a broad process of consultation with the industry, with professional associations and with advocates. And that resulted in the comprehensive data elements that now make up the MDS. It has already been revised one time and we're now using MDS2. CMS is currently working to revise it again with the objective of reflecting the current clinical science, refining problematic elements and removing clinically irrelevant elements. That work is currently in process.

    Nursing home reform in 1987 was expected to increase the cost of providing care under Medicare and Medicaid and the law explicitly required states to increase their rates to reflect those additional costs on the Medicaid side. Medicare at the time was paying on a cost basis and some of those costs were -- did show up on the bottom line of the cost report.

    CMS decided to use MDS as the source of data for its prospective payment system consistent with the Institute of Medicine's own thoughts and because we thought the same information that establishes -- that goes for looking at quality is good enough for looking at payment.

    Building on this concept, the Congress in 2000 enacted Section 545 of the Benefits Improvement and Protection Act which required the Secretary in consultation with Medpak (phonetic) and the Agency for Health Care, Research and Quality and qualified organizations representing providers, suppliers and advocates to report to the Congress on the development of standard instruments for the assessment of health and functional status of patients in all kinds of Medicare settings. Virtually every Medicare provider setting. And asked for a report in 2005 that would include the common elements among assessments that are comparable and statistically compatible but would include only the elements that are needed to meet program objectives and a plan under which standard instruments could replace the ones we currently use. That's a whopping task and the Assistant Secretary for Planning and Evaluation has already commissioned some research designated to help set the agenda for further study.

    But I mentioned this statutory provision because it certainly is evidence that the Congress is looking at patient data as a source of payment and quality information for the future.

    And while it recognizes that we have had to move quickly because of PBA97 to implement these payment systems we now have, certainly there needs to be some stock taking, some stepping back and some attempt in the future to proceed with an orderly parsimonious instrument that can do the things we need to have done.

    To go back to MDS, I can tell you Secretary Thompson is personally interested in this. I had the occasion to brief him on a payment regulation shortly after he came and he looked me directly in the eye and said, "You need to do something about MDS." And after I finished saying, "Well, gee," I said that I could not do it in the regulation I was briefing him about but I could certainly do it immediately thereafter. And from the look in his eye, I took away the feeling that perhaps I had better get busy. And so we in CMS to do that.

    We looked at the options for reducing burden. In doing that, we recognized and of course you need to realize that the MDS is a highly automated process. Programs developed by CMS are used by facilities to submit to that, used by states to receive and transmit it to us, and used by us both for quality purpose and to determine payment. So there is a very significant web of complicated programming involved in MDS.

    There's also, if one were to make changes, the needs for new manuals and forms, the need for training, and not the least, the need to consult with the states which also use this data for quality assurance and surveys and many of them for their own Medicaid programs.

    There are also two sets of regulatory authorities to look to in attempting to see where you can go. One of the nursing home requirements themselves which as I pointed out from the statute require a data set comprehensive enough to provide the actual basis for patient assessment, care planning and a rule assessment. Now those assessments are currently required within 14 days of admission, at the 90th day, and annually thereafter.

    The other place to look is at our prospective payment regulations which have established additional assessment dates for purposes of determining payment and those occur at days five, 30 and 60. Those requires also would need to be changed by regulations and of course, we would need to do some changes in programming, training and the like but those things are at least not embedded in the statute and there is not with those requirements the need to have a completely comprehensive document.

    So what we have done after looking at the costs and the time frames for changing MDS as a whole and just changing it for the payment systems resolved to commit ourselves more strongly to developing MDS3, the complete overhaul of the instrument with respect to the nursing home requirements and to look for more immediate changes to the payment systems and we have been studying ways to do that. I may have some more comments on that at a later time.

    I wanted to wrap up by saying that I've had a chance to look at several issue statements for the Secretary's Advisory Committee that relate to this. One of them recommends that we revise the, I'm sorry, one of them recommends that we make it very clear that the assessment itself is a part of the medical record and not allow the situation where surveyors are looking for information to support -- the medical record to support the contents of the assessment. We agree with that. We think the assessment is an integral part of the medical record and compliments it and of course, we don't have an objection to looking at the whole record to determine whether the entries as a whole are consistent. What we don't require are duplicate of entries then. We can be sure we will be dispelling any uncertainty about that.

    Another one -- another of the comments suggested are the user manual for the resident assessment instrument is out of date. It should be updated. I can tell you that we have currently commissioned updates for the major manual and some other things as well. And while I'm not sure when that will be finished, I can tell you that they're being done right now.

    There was a further suggestion that we make a change in our current payment policy which now is designed to pay a default payment rate in a case where there's some facility that doesn't conduct the assessment that's necessary to compute the payment timely has not, for example, submitted it timely. The suggestion was made that we develop a method for correcting errors so that appropriate payments can be made. This is an issue that would have to be changed in regulations but I can tell you that it is under active consideration to be changed in the future.

    And finally there was a general suggestion that for critical access hospitals, home health agencies and skilled nursing facilities in rural areas that a new provider type be invented with a little less burdensome requirements and cost reimbursement. That of course is a statutory issue and so I can't report any progress.

    With that, let me stop and I'm sure you'd rather hear from analysts. Thank you.

    DR. WOOD: Tom, thank you. Before we go on to a demonstration, are there any quick questions that Committee members might have? Heidi?

    MS. MARGULIS: Thank you, Mr. Chairman. Mr. Hoyer, what do you hear most frequently from your constituents so to speak, the nursing home providers, in terms of what changes they would like to see or what problems they're having with the system?

    MR. HOYER: Well, I think the major comment is simply that it is a large new workload and it is an additional burden to staff already burdened with the care of patients. And they wanted us to make sure that every piece of paper we've asked them to fill out is one that's absolutely necessary.

    DR. WOOD: Judith.

    MS. RYAN: Mr. Hoyer, what is the position of the CMS with regard to requirement of the RAPS documentation? Why is it in assessment profiles?

    MR. HOYER: Well, we currently require them and I'm not sure what shape MDS will take so I'm afraid I can't tell you where we'll end up.

    MS. RYAN: So currently we're not only requiring the minimum data that was originally the intent of the law, but the documentation for the resident assessment profiles as well?

    MR. HOYER: That is correct. I hope you'll discover in the demonstration some of the reasons why we've done that.

    DR. WOOD: Jack, did you have a question?

    MR. ROVNER: Could you elaborate a little more when you said this was a highly automated process, I'd like a better understanding of exactly how it's automated.

    MR. HOYER: From the guy who can't even do Powerpoint. The MDS data collected on the form is entered by the nursing facility and transmitted to the State. There are in the programs that do that, automated items to look for completeness and consistency. There are -- when the State receives the data, there are programs that do things for the State as well and finally when we do, there are also automated programs. Beyond that, I'm unable to go into detail but I can tell you from having talked to the people giving me cost estimates for making changes, that I'm either being robbed or they're very complicated.

    MR. TOBY: Tom, there's a perception that the MDS assessment has sort of moved away from quality monitoring and care planning to a primary focus on payment. Is that an accurate perception?

    MR. HOYER: No, absolutely not. In fact, I'm glad you asked me that question because the notion to build payment systems on the data sets that are designed to assure proper patient care and to help us measure quality was in our view a way of increasing -- creating a stronger incentive for us and the facilities to care about just those things, the patient characteristics that come out of patient care. So no, I think payment is definitely -- the payment system piece of this is a downstream use of a document that's very essentially for quality.

    MR. TOBY: I'll call another question. As we -- as you move, you mentioned about MDS3 and of course number two is highly automated and you mentioned you don't even do Powerpoint -- I might mention that I kind of got you to use e-mail when I was running (indiscernible).

    MR. HOYER: And I'm eternally grateful.

    MR. TOBY: But obviously it would require a lot of computer changes and software changes as you move to three. The question I have is what would this mean down the pipe for providers in terms of filling out the form or as you vision it down the pipe, would it be less time for them filling out the form and if they -- if less time, obviously they would have more time to provide patient care on a facility so what does it mean for providers as you move down the pipe in looking at three?

    MR. HOYER: Well, I think it takes a kind of a two part answer. When we do these assessment instruments, we do provide on our website the software, the basic software necessary to enter them and send them without charge to the providers. Frequently they prefer to buy proprietary software that performs a wider variety of functions for them. So they may be incurring those costs if they wish. What I am thinking myself is that as HIPAA takes hold and we move down the road to automation, increasingly these tasks will all be automated and there won't be any items of data that are entered more than once. That requires me to look past the implementation of HIPAA but I think that really is the future and I think what we're experiencing now are growing pains.

    MR. TOBY: Thank you.

    DR. WOOD: Eric. That was it? Okay. We'll give Judy Sutherland the last question and then we'll go on to the demonstration.

    MS. SUTHERLAND: I don't know whether Mr. Hoyer, you're the right person to answer this or it will come out of the -- in the demonstration but can you explain what kind of feedback or reporting exists as a result of this collection of data?

    MR. HOYER: Well, I actually think that some of our panelists are far better versed in the quality indicator technical panelists than I am. What we basically have is sort of two sets of quality indicators now. The ones we've been working with for the last couple of years and also new enhanced quality indicators that we expect to roll out in the five state demonstration here very shortly if we haven't already done it. Beyond that, I guess I can't go into details from my own knowledge but I know members of the panel can do so.

    MS. SUTHERLAND: Thank you.

    DR. WOOD: Thanks again, Tom.

    MR. HOYER: Thank you.

    DR. WOOD: We're pleased to welcome two people who will help us to understand how this process actually works by showing us a bit of it. Not the entire effort because it would take a long time but Rena Shepherd who is the President of the American Association of Nurse Assessment Coordinators and Sheryl Rosenfield who is an independent nursing consultant are here to help demonstrate MDS. And before I ask them to get into that, would you please briefly let the Committee as well as the audience know a little bit about your background of why you have come to possess this unique set of qualifications to show us.

    MS. SHEPHERD: Good morning, I am Rena Shepherd and I am the President of the American Association of Nurse Assessment Coordinators and I'm also an independent nurse consultant in San Diego, California.

    That's a good question. How will I have the qualifications to be here to talk about this? Well, as a director of nursing in nursing homes for 14 years, I was sort of forced to become intimately familiar with all of the processes and the regulations involved. And over the years, I have developed a certain amount of expertise in working with facilities as well as learning an incredible amount from the folks at CMS for one thing and many other experts in the field. And my work with AMAK (phonetic) certainly has been very enlightening and it provides me with a lot of information about how the providers, how do the nurses and the clinicians out there in the facilities feel about the process.

    MS. ROSENFIELD: Good morning, I'm Sheryl Rosenfield. I'm the clinical director with a firm called Summit Solomon, we're out of New York, and I have come up through the ranks of the nursing home industry for over 30 years. I worked with Mr. Toby in the 70's in region 2, I was the director of the PRO's and came from there working in and out of nursing homes.

    I'm someone who has had grandparents in nursing homes before OBRA 87 and parents in nursing homes after OBRA 87 and I can tell you that the dramatic change and improvement in care has really made me someone who goes through the entire country speaking frequently about the need for the minimum data set, the need for including using the resident assessment protocols, because they have provided us with standards of care, they have provided a uniform way for the team to come together with the resident and the family to plan proactive care to identify the risks and hopefully to have positive outcomes. And when positive outcomes are not going to happen due to illness or otherwise, the MDS process, the RAP's and the care planning and some of the regulations have directed us in a way to provide care that is often forgotten by the rest of the public and very much needed as all of us are aging going forward.

    I think the MDS, and I'll say it now and I'll say it later, has been a dramatic improvement in helping staff, helping commissions bringing staff into nursing homes to see that one tree in the forest, that resident, and to really come together and say what do you need, how can we help you, how can we make it better and how can we proceed so I hope you'll enjoy some of our demonstration.

    MS. SHEPHERD: Oh, thank you. I don't have a voice that carries. That's much better. Let me just say and I don't know who to talk to so I'll just talk to everybody. Sheryl and I really are very pleased to have been invited to provide this demonstration to the community. We -- as a part –- just by way of a demonstration, I am about to interview Mrs. Sweet who's sitting over here in a wheelchair and but I would like to talk to you just a little bit about the process before we begin. This document and I think the Committee members may have one in your handouts. It may have been stamped with the word sample on it. This is what it looks like. Do you have it? Oh, good, you do. Okay.

    This document as you have heard has been a part of the nursing home process for over ten years and as Sheryl said so eloquently, I just want to second that emotion as they say, that this instrument truly has made a difference in care in nursing homes. And we'd like to be able to demonstrate how that works but if you take a look at the document, you can see that it's very complicated. And it does require some training to learn how to accurately code it and how to figure out, you know, how well she's walking or how well she's transferring. So I'm not going to even make an effort to teach you that for today although I'll be happy to some other time if you want me to.

    But if you would just take a look at some of the major headings on the form, particularly if you go to starting on page three, and you can see Section A is the identification and the background information and cognitive patterns. You can see that we're going to do an assessment of her memory and her skills for daily decision making. And it goes on to communication and hearing patterns in Section C and vision, moving behavior and that has to do with indicators of depression and anxiety and sad mood. So if you just look at all the headings, you can see all of the very important areas that this instrument is used to assess.

    The Section G, physical functioning and structural problems, that is a big section as far as quality of care goes because we can see from one MDS to the next if somebody has declined or improved, of course, and it's also a key section for payment as you can imagine because a lot of rehabilitation therapy goes on in nursing homes.

    So if you just take a look at the rest of the headings there, you'll see what it is that we're going to be talking about here in the interview.

    I do want to say that I'm not going to go through it item by item because as I'm sure you all know very well, it's not nearly as effective to ask a closed ended question. What works much better is to use an interview technique with open ended questions and find out what the resident has to say and then from what I learn from her, I will determine how to code the various sections on the MDS. So you're not going to hear, you know, yes and no, questions and answers and things like that.

    And the other thing that I want to mention is that this process is truly interdisciplinary. There is no regulatory requirement that any particular discipline sit down and fill out this form. But there is a regulatory requirement that we have an interdisciplinary process which is just so important to the quality of care in nursing homes. And I have to say that when I managed an acute rehab unit not too long ago, I thought before I went in to be their manager that acute rehab units had it down, the interdisciplinary process. You know what I found out? Nursing homes do it better. Because acute rehab units do a parallel thing that I sort of call multidisciplinary. Nursing homes do an interdisciplinary process where they have to come together. They do their assessments and they come together and they build a care plan together rather than parallel ones. So that was a real eye opener for me.

    So as the MDS nurse, by the time I get to the point of being ready to interview Mrs. Sweet, I have already completed a significant amount of research. Assuming that this is her admission assessment, she came into the facility with orders from her physician and some sort of history and physical. If she comes from the hospital, we would have that paperwork. If she comes from home, the physician would need to provide history and physical information as well. So I would have reviewed all of that including all of her medications and I would also have completed a thorough physical examination which we didn't think would be quite appropriate to do here.

    MRS. SWEET: Well, just get on with it. I'm late for a bingo game. I'm new at this facility and I really -- this is not very nice.

    MS. SHEPHERD: It'll be just a minute. Okay. Let me say one more thing to the group and that is that some of the things that I would have examined would have been her skin, head to toe, even in between her toes, her vision, balance, things like that and her lung sounds. Okay.

    Mrs. Sweet, is it okay if we stay here and talk? It's kind of private here.

    MRS. SWEET: What are you going to talk about?

    MS. SHEPHERD: Well, my name is Rena and I'm a nurse here in the facility and we're talking with this group of folks about what's called in nursing homes the MDS process. It's the assessment process.

    MRS. SWEET: I can't help you. I haven't had PMS in years. I'm really late for bingo.

    MS. SHEPHERD: Okay. Well, can we go and find bingo a little later? Can we just talk a little bit? You and me?

    MRS. SWEET: Is this going to take long?

    MS. SHEPHERD: Not very long. Can I pull up a chair?

    MRS. SWEET: Yes, I'm always seeing you here and I know we talked the other day but I really want to meet some other people. Are there men here?

    MS. SHEPHERD: Okay. And you know there are some men here.

    MRS. SWEET: Do they play bingo?

    MS. SHEPHERD: Some of them play bingo and you know, I can set you up with a recreation therapist when we get finished here and she can take a look at the calendar and when the men go.

    MRS. SWEET: Okay.

    MS. SHEPHERD: And what they prefer. Okay. So let's talk a little. Okay.

    MRS. SWEET: Don't call me Mrs. Sweet. Call me Joey. I like to be called Joey.

    MS. SHEPHERD: Okay.

    MRS. SWEET: If you're going to be one of the people taking care of me, you can call me Joey.

    MS. SHEPHERD: I am. Thank you for telling me that. That's really important for me to know that.

    Now some of these folks are going to be listening to our interview and taking some notes maybe. Is that okay with you?

    MRS. SWEET: Well, it looks like they have a lot to write down and I really want to get to the games.

    MS. SHEPHERD: Well, we'll hurry.

    MRS. SWEET: Okay.

    MS. SHEPHERD: Is it okay with you that they listen?

    MRS. SWEET: Yeah, that's fine.

    MS. SHEPHERD: Okay.

    MRS. SWEET: But call me Joey.

    MS. SHEPHERD: Okay. Everybody call her Joey. Okay.

    Joey, why don't you tell me a little bit about yourself and what your life was like before you came here?

    MRS. SWEET: Well, I was living alone by myself in a lovely apartment and my daughter doesn't think it's safe any more for me to live there. I have some diabetes and I wasn't taking the pills so great and then I had a fall and thank goodness, you know, the fall, nothing broke --

    MS. SHEPHERD: Thank goodness.

    MRS. SWEET: You can see nothing broke, thank goodness, but my daughter said, "Ma, you got to go to the nursing home. You just got to go to the nursing home, you know, they'll take care of you in the nursing home." So I'm not that happy being here but I'm here right now.

    MS. SHEPHERD: And you're okay with it for right now?

    MRS. SWEET: For right now. I'm here short term. I'm not going to become a patient or anything else. I'll stay for, you know --

MS. SHEPHERD: Okay.

    MRS. SWEET: Get a little organized on my medications and I need shots now and things like that. I'm not happy about it.

    MS. SHEPHERD: Those sound like really good goals. When you were at home, did your daughter come and see you every day?

    MRS. SWEET: No, she didn't come every day. She came a few days a week and then I got a sore on my ankle and I didn't take care of it, I didn't want to bother her, I didn't tell her, so now, you know, I have to have this doctor come and look at that and the nurses have been changing the dressings here and, you know, I have this sugar problem, diabetes, you know, and I wasn't doing the pills well so now they've put me on shots and I really can't manage that too well right now. I have to get, you know, I have to learn how to do it.

    MS. SHEPHERD: Sure. And you can do that here. That'll be something that we'll make it a point to work with you on.

    MRS. SWEET: And I was living alone for a lot of years. My last husband died seven years ago and so, you know, being alone, I like being alone. Actually it's easier being alone but I want to meet the men while I'm here anyway because you never know.

    MS. SHEPHERD: You never know, that's true.

    MRS. SWEET: You never know and I've been married a few times. All good men. All good mean. And you know my daughter felt this would be good for some socialization also.

    MS. SHEPHERD: Well, it sounds like you're a very social person.

    MRS. SWEET: Very social.

    MS. SHEPHERD: And our environment here, our activities program, I think we'll be able to meet your needs.

    MRS. SWEET: Well, I'm a little nervous in the situation so, you know, I may be, you know, whatever but that --

    MS. SHEPHERD: Well, I think it's very normal to feel nervous but we'll -- our staff will certainly help you with that. Joey, tell me how you used to spend your days at home? Just, you know, in the last few weeks or months?

    MRS. SWEET: Well, I like to stay up late at night, you know, watch my TV. I love my TV and I love my books and I love my Bible but I used to like to watch the Ted Koppel is it, Ted Koppel.

    MS. SHEPHERD: Right.

    MRS. SWEET: I like to fall asleep to hearing his voice and that hair. He's really one of my favorites.

    MS. SHEPHERD: He's cute, huh?

    MRS. SWEET: He's really very, very charming and he's really up there, you know. He's not as young as people think. And then I fall asleep listening to Ted and then I, you know, make sure I shut the TV off and then at night, you know, sometimes I need to get up and I can manage that if you know what I mean.

    MS. SHEPHERD: To go to the bathroom?

    MRS. SWEET: Well, you said it, I didn't. Yeah, I live in an apartment that I set up the whole space because I'm not, you know, good at the walking yet but I can get up and I can go, you know, to the bathroom.

    MS. SHEPHERD: Safely?

    MRS. SWEET: Safely, no problems although I did have my fall, you know, that's why I'm here.

    MS. SHEPHERD: During that walk to the bathroom. Speaking of going to the bathroom, have you had any problems at all with controlling your urine?

    MRS. SWEET: We're in a public setting but no, I'm fine. I'm fine.

    MS. SHEPHERD: Good.

    MRS. SWEET: I take pills for the other part of it and that works just fine and I do it every day and that's important when you're my age.

    MS. SHEPHERD: That's right.

    MRS. SWEET: Very important.

    MS. SHEPHERD: That's very important.

    MRS. SWEET: And I like to be social so I have the phone and I call friends and I call neighbors and I used to be very involved in a choir and the library people come and visit me. So I'm not alone during the day unless I want to be alone. I have lots of friends and neighbors.

    MS. SHEPHERD: Right. That's wonderful. That's really important.

    MRS. SWEET: But my daughter feels I should be here for now so, you know, I'm here for now.

    MS. SHEPHERD: Right. Okay. And what about your hearing? Do you have any problems with your hearing?

    MRS. SWEET: No problem. I'm -- do I have a problem hearing?

    MS. SHEPHERD: It doesn't seem to me that you do.

    MRS. SWEET: I don't have a problem hearing. And I have my glasses. Thank goodness for my glasses. I have no problems seeing. And in fact they want me to go and see the eye doctor while I'm here, too.

    MS. SHEPHERD: So when you have your glasses on, are you able to see okay to read this?

    MRS. SWEET: Absolutely and I love reading books and at night I'll read the Bible if I'm up late and I can't fall back after Ted is off. So I, you know, I'm good with that.

    MS. SHEPHERD: Good. Excellent. And so you said that your daughter would come over to see you, when she came to see you, did she help you at all?

    MRS. SWEET: Yes, she'd do my shopping every few days with me. We'd go out on Sundays. We'd go to some church sometimes and then, you know, go have lunch with the kids and I'd be out with everybody and that was good. And she would help me getting in and out of the tub every other day. So she comes by, she knows I need that. I don't want any strangers, you know, here it's a little hard with strangers, too, but you know, I'm not that happy about it, but I'm -- they're very nice here. Everybody has been wonderful to me.

    MS. SHEPHERD: Oh, good. Good.

    MRS. SWEET: Absolutely wonderful and they ask me, do I want it at night, do I want it in the morning, but I tell them, you know, I'd like to do it when I want to do it. And they've been very nice about that.

    MS. SHEPHERD: Excellent, because that's exactly what we want to be able to do for you. 

So it sounds like you've been really a very active lady. Have you had any problems being alone at night though?

    MRS. SWEET: No. As I said, I'll read my Bible or I'll put back the TV, you know, I'm fine, I don't mind it at all and I like to stay independent. THAT to me is the most important --

    MS. SHEPHERD: That is very important.

    MRS. SWEET: That's very important.

    MRS. SWEET: But if you're, you know, asking me about problems and all that stuff, the doc says now he wants me to go for therapy. I'm happy --

    MS. SHEPHERD: Sure.

    MRS. SWEET:  -- doing this and I have my walker. I mean what's the story with -- do I have to go to therapy?

    MS. SHEPHERD: Well, I think it may be a good idea since the physician thinks it's important. How about if we have the rehab therapist come and chat with you, take a look at your history and what you're able to do at this point and then the two of you can talk about what might be helpful to you.

    MRS. SWEET: I would like to be a little bit more independent and not just in this all the time but I don't want to, you know, I don't want to take any more risks and fall down again, honey.

    MS. SHEPHERD: Sure. Sure and that -- and the therapy department will be really happy to work with you on that. You know, we haven't talked about your eating yet.

    MRS. SWEET: Do I look like I have a problem? I have all my own teeth, no problems.

    MS. SHEPHERD: Okay.

    MRS. SWEET: But I do -- I didn't ask before, I do like to have a little nip at night every now and then. A little Harvey's. Can I get that here? Does my daughter have to bring it in?

    MS. SHEPHERD: Well --

    MRS. SWEET: If the doctor says okay, I have several work.

    MS. SHEPHERD: We will talk to the physician about it and if it's fine with him, it's fine with us.

    MRS. SWEET: Do they have cocktail parties here?

    MS. SHEPHERD: Not regularly, no.

    MRS. SWEET: There are some nursing homes that do have that though (indiscernible) she can go look.

    MS. SHEPHERD: Well, you know, if there were enough people that wanted to have a cocktail party and it was okay with their physicians, sure, we could do that.

    MRS. SWEET: Well then maybe I'll do that this week instead of bingo.

    MS. SHEPHERD: Well, That's another thing that we could just talk with your physician about.

    MRS. SWEET: And I'd also like those Weight Watcher deserts, those low calorie jello things. Do they have that food here for me?

    MS. SHEPHERD: Sure, I like those things, too. Sure, and the dietician will be happy to come and talk with you about the kinds of foods that you like and we certainly have those kind of deserts.

    MRS. SWEET: Because I do have the diabetes so I have to watch it a little. So she's going to help me?

    MS. SHEPHERD: Oh, absolutely, she'll be right on top of that.

    MRS. SWEET: I have a complaint though. Can I give you one? I mean I know I (indiscernible).

    MS. SHEPHERD: No, please tell me.

    MRS. SWEET: Have you been to the dining room lately?

    MS. SHEPHERD: Yes. What's the problem?

    MRS. SWEET: It's very noisy. Very -- it's not like eating in a restaurant.

    MS. SHEPHERD: What's the problem?

    MRS. SWEET: It's noisy, there are a lot of old people there that they're all asking for where's my this, where's my that, it's not always very calm.

    MS. SHEPHERD: Well, you know, I can see your point and I think we can do something about that. So what we'll do is when the dietician comes to talk with you, we'll talk to her about changing you to a different table or maybe even you're not in the right dining room.

    MRS. SWEET: I didn't want to raise an issue with you but, you know, it's not (indiscernible).

    MS. SHEPHERD: It's not an issue at all. It's not a problem. We want you to be in the right place with the right people because that, you know, that's part of socializing, too.

    MRS. SWEET: I'm eating with a bunch of old ladies who aren't very nice. I'd rather eat with the men if you know what I mean.

    MS. SHEPHERD: Okay. We'll see what we can do. I'm glad that you told me about that. Are there any other problems?

    MRS. SWEET: Well, my roommate, did you meet her?

    MS. SHEPHERD: I have met your roommate, yes.

    MRS. SWEET: She doesn't know where she is.

    MS. SHEPHERD: She, yeah --

    MRS. SWEET: She thinks she's in a hotel. I keep saying to her, "You're not in a hotel, honey, you're in a nursing home." And she keeps saying, "But they don't wear uniforms. There's no nurses here." And I keep saying, "No uniforms, who cares, they're coming in, they're getting you up, they're moving you around, you're in a nursing home."

    MS. SHEPHERD: Well, are you feeling that you would rather not be in the same room with her, is that what I'm hearing?

    MRS. SWEET: I would like my own room. She's moving my plants, she's touching my stuff, I want the privacy. I, you know, I didn't have a roommate for, you know, seven years since my husband died. And before that, there was a gap. It's very hard to share a room with an old lady. I'm sharing a room with an old lady.

    MS. SHEPHERD: Well, you know what we'll do, when the social worker comes to talk about some of the things that she needs to discuss with you, that will be at the top of the agenda.

    MRS. SWEET: Because I have my routine. I want my routine. I want my Ted Koppel at night. I want my Harveys. I want my desert. I want to get up. I don't want to disturb her either. I don't want to be unfair to her.

    MS. SHEPHERD: Sure. And I think that the social worker will be able to work it out so that both of you are happy.

    MRS. SWEET: So do you have any other questions for me? Do you want to know anything else because I really want to get out of here?

    MS. SHEPHERD: Okay. Just a couple more questions.

    MRS. SWEET: Okay.

    MS. SHEPHERD: Now I know what you're going to say but I got to ask this question anyway. Do you know where you are?

    MRS. SWEET: Do you know where you are? I know where I am.

    MS. SHEPHERD: What's the name of this place, do you know?

    MRS. SWEET: County Hills Nursing Home.

    MS. SHEPHERD: Absolutely right. And what's the date?

    MRS. SWEET: That I really don't know.

    MS. SHEPHERD: Neither do I. So what is this an indication of that neither one -- it's March, maybe together we can figure it out.

    MRS. SWEET: March 20th. Am I close?

    MS. SHEPHERD: Yeah.

    MRS. SWEET: And it's going to be the holidays pretty soon. I know that because the bunny rabbits are hanging up wherever.

    MS. SHEPHERD: That's right. You sound like you're pretty much on target.

    MRS. SWEET: I am aware of that. And I know what room I'm in. I'm on the first floor. And I know I don't like my roommate. I know my nurses' names.

    MS. SHEPHERD: Good, good, that's excellent.

    MRS. SWEET: They're very lovely. They're just too busy. They don't have enough time. That's the problem.

    MS. SHEPHERD: Do you feel that they're able to meet your needs?

    MRS. SWEET: Absolutely. The nurses are wonderful. They're little angels (indiscernible) both of them.

    MS. SHEPHERD: Okay. Message received. Well, it sounds like we've covered just about everything that I had in mind. Is there anything else that you'd like to talk with me about?

    MRS. SWEET: I'd like to meet with the team. I'd like to see how you fill out that form and you better not lose it. I'd like my daughter to come in to hear everything because I want her to listen what you're planning for me. And then I want to come up with a plan that I will go to therapy, I'm going to try it.

    MS. SHEPHERD: Excellent.

    MRS. SWEET: I don't know how long I'm going to stay here.

    MS. SHEPHERD: Okay. That's fair and that's -- what you described is exactly the plan that we have in mind that everybody will get together. A few more of the interdisciplinary team members as we call them, social worker, dietician, therapist, will come by and talk with you and then there will be a team meeting.

    MRS. SWEET: I do want to talk to the social worker because she can help me plan everything going home.

    MS. SHEPHERD: Absolutely.

    MRS. SWEET: And who's going to teach me about the shots and everything?

    MS. SHEPHERD: That would be the nurses. And at the care plan conference, all of the discharge planning information will be collected there at that meeting so everybody will know exactly what goals you need to meet and that we need to help you meet to be able to get you where you want to go.

    MRS. SWEET: That sounds wonderful. Thank you, darling. I'm ready to go now.

    MS. SHEPHERD: Okay.

    MRS. SWEET: Thank you.

    MS. SHEPHERD: Thank you.

    MS. ROSENFIELD: I hope we gave it a reasonable chance --

    MS. MARGULIS: I think you missed your calling.

    MS. ROSENFIELD: Yes, when we do it actually -- when we do a training like this with the nurses, we even get a little more visual but I do want to add in that a piece that sometimes does appear as a burden and really I think what we need to do is with good education programs and models and maybe some of that Internet education for those of you who don't want to learn on line, the training is what the nurses and the clinical team need in the nursing homes to make this process a better process and to make it work.

    From this interview my nurse would go and document and would sit down with the clinical team where they would identify potential strengths and some other issues and problems and where we'd go into the process known as triggering which would then set off additional questions, standards of care, in 18 functional areas. And the 18 functional areas are also known as the RAP's, the resident assessment protocols.

    So the MDS is only one piece of the resident assessment instrument. You have the MDS form, you have the triggers which will then make the team go further into asking what we used to call a greater assessment, the minimum data set and now we're going to go a little step further. And in analyzing what is the problem for the resident and then with the team, the resident and the resident's family, coming up with a plan of care that would help achieve positive outcomes. From that care plan meeting, the team is required to sit down and identify problems and strengths and then goals and in that survey process, we try to wrest measurable outcomes where everyone speaking and observing and watching the resident, we can see where their ADL's were on admission and then where they are, whether it be weeks or months later. So each of the individual problems I would have with the diabetes, there's no RAP for diabetes. We're looking at functional issues.

    But in the diabetes, we would want to manage it, we would want to have some education making me more knowledgeable about my illness and probably my diet and maybe some exercise and those kind of things.

    With the walking and being in a wheelchair, the goal would to get me possibly to agree to try therapy to get me up and to safely transfer from the wheelchair to a walker and then have a more independent lifestyle.

    And so it's this process that by regulation within the first two weeks in the nursing home, the clinical team with the resident and the caregivers, we all get together and come up with a plan and then we try to implement that plan. And then on a quarterly basis, a formal quarterly basis, we go back and measure function through the quarterly assessment process and that's where the team does get together usually more informally and we can measure how the resident is progressing and our goals reasonable, measurable, obtainable and everything else towards positive outcomes. So the RAP's have greatly improved care in the nursing home. It has taught us how to look at the nutritional issues. They're given enough screening so that if residents are on certain medications, I know that they are now at risk for falls or they're at risk for dehydration. We did not have this ten years ago.

    On continence and incontinence, something that we chuckle about but clearly 15 years ago in a nursing home, if someone came in wet, they stayed wet and the goal was to turn and change them. Now the goal is for longer periods of dryness. To help them achieve a quality of life and to have, you know, less dependency on staff and less risk as far as skin breakdown and also the dignity issues.

    So that process has been, you know, and Rena and I can go on and on for hours about it and we'd gladly take your questions. We think this works. We think that the burden -- the outcomes outweigh some of the burden and maybe if we can get some education going in the facilities and an understanding that it is a document that stands alone, we would insure and definitely deliver higher standards, better quality of care.

    MS. SHEPHERD: Let me just say one thing. And I won't get on my RAP soap box because you've already heard it. I just want to explain one thing about the RAP's and because, you know, we -- Sheryl and I do a lot of teaching together and separately around the country and I find that the RAP's are very misunderstood. That a lot of people who are actually working with the process in the facilities still think that the RAP's are just a restatement of what item on that MDS triggered. And what it really is is as Sheryl said, it's a further in-depth assessment so that once the trigger is in front of you and you see that it may be a problem, the RAP process helps you to analyze the possible causes of this possible problem and complications related to it and risk factors related to it. So it's a whole assessment process that comes out of the MDS. And it really is the piece that has brought us quality in nursing homes.

    MS. ROSENFIELD: So the OBRA 87 that the MDS brought us dieticians to the table, they brought us social workers to sit and talk with people and recreation people, not to just do bingo, but to give meaningful and purposeful activities to people.

    DR. WOODS: Rena and Sheryl, thank you and this was really quite a wonderful demonstration. I'm actually quite impressed by a couple of the comments that you made and for some of the Committee members who might not have been in Miami when we saw the demonstration of OASIS, there was I think a very important principle that's evident here and that is when you take a basic approach which includes an adequate amount of training that will improve the assessment of the individual in the case of home care for -- the case the resident here, and you couple that with then a reasonable measurement approach that will yield information that you can use to make improvements, you'll have better outcomes in the long term.

    I would say that we've seen the same thing by the way in acute care if you take the example of acute myocardial infarction or a heart attack in a cooperative cardiovascular project which is another one of CMS' cooperative projects with healthcare providers, and that circumstance is just to extend that if you take a standard approach, a standard assessment tool, and you structure it so that an ER or EMS provider starts asking the same basic questions, you get much better information that you can use to make decisions and so these I think are important principles for us to think about how we want to go forward.

    Particularly with what Mr. Hoyer had mentioned earlier and that is the idea of how we can do a better job of getting basic assessments, especially older Americans, that we can use to sustain their health and maintain their function. I would say that in terms of the medical profession, I would suggest to you that there are tremendous learning opportunities here because the management of older folks is completely different than the acute management of most diseases which is what most physicians are trained to do.

    Actually I have one quick question and we have a little bit of time, not much but a little bit, but based on how this is done, and the fact that you have it available, how much does a physician's separate physical examination add on say a quarterly basis in a nursing home for a resident who is there for basically custodial care? Is there anything that is added by that visit?

    MS. ROSENFIELD: Absolutely.

    MS. SHEPHERD: Absolutely because the position was --

    MS. ROSENFIELD: You take it first and then I'll take it.

    MS. SHEPHERD: Well, the, you know, I think that Sheryl mentioned several times, this is a functional assessment that we're doing.

    I know it's that voice. Yeah, as we mentioned several times, the MDS is a functional assessment and what that means is we're looking at very specific issues related to how well the resident is functioning. And we absolutely need input from a number of different areas including the medical staff so that we can address issues like the diabetes that are not a part of the MDS.

    DR. WOOD: And how would you -- I mean that's part of the reason for the question. So there's a disconnect then where you don't actually get easily all the information that you might need. I notice that there's some questions that are in the MDS but they don't seem like they'd make it as easy for people to begin to do that communication. Is there a way that we can improve that communication?

    MS. SHEPHERD: Well, it's true that the medical conditions are sort of listed on the MDS but they don't trigger anything at this point. That doesn't relieve of us of the responsibility, you know, by standard practice or by regulation of addressing those issues for further assessment and care planning.

    DR. WOOD: My point actually is from the perspective of doing the best care for people. If you had an integrated record where you had everything together and you could see it, then all of the providers I think would do better so as we think about improvements, to me the question is what should we do that would improve the utility of this particular data set that would accomplish that in the --

    MS. ROSENFIELD: Improvements would be training in medical schools so that physicians know that gerontology is a very important, you know, facet of medical care and with that, having had the privilege of speaking at the medical directors association last year, you know, it was thousands strong and I addressed the MDS and PPS to over 400 physicians in my session, the vast majority did not get involved. There was at one time and in OBRA 87, it says that the physician is part of the team. And then unfortunately because their time is limited, Medicare payment is, you know, always up in the air in those discussions and so they don't want to or cannot spend the time sitting in a room planning care. In an ideal situation and in many nursing homes, I do want to say that, many, many nursing homes, physicians are part of the team, they do sit in on the meetings, they do review the plan of care and so the physician from diagnosis to even helping -- many of the physicians know the residents longer than we do and so having that history is a very, very important piece of planning care and so I don't think it should be regulation, again education, in that we need the physicians in the nursing homes.

    DR. WOOD: And again I think that's where the training and the triggering become very important so that's -- the specific question was how could we help then in triggering that as time is quite constrained and physicians may not spend time there. And you know the problem that we don't have enough trained geriatricians or gerontologists.

    MS. SHEPHERD: Right.

    DR. WOOD: We're going to have to figure out a way that you can improve the likelihood that an internist or a family physician will get the right questions asked so that the information gets to you in terms of the assessment.

    MS. ROSENFIELD: And I do want to add the nurse practitioners who have now been added to the nursing home world have added a tremendous amount in improving the quality of care and being right there when, you know, orders need to be changed and then communicating to the doctor.

    MS. SHEPHERD: If I could just say one thing. As far as the MDS goes and, you know, having information all in one place, I think in an ideal world, every healthcare organization would have an electronic medical record that would, you know, be creating that kind of a database but of course I hesitate to make that recommendation here because I don't have a clue where the money would come from or how we would make that happen.

    MS. ROSENFIELD: And then some people couldn't read it so, you know, the one interdisciplinary approach is what the MDS advocates and that's what we need.

    DR. WOOD: Wait a minute. I will give us time for just a couple of questions before we need to make a break. Tony.

    MR. FAY: Thank you, Mr. Chairman. I've got three technical questions about the form itself. The first question addresses the five-day and 14-day periods for transmittal of data. I understand talking to some nursing facility directors if that data is not transmitted within those time frames, then your Medicare payment is reduced to the default amount.

    MS. SHEPHERD: No, that's not accurate. It's not, I'm sorry, it's not tied to the transmission. It's simply -- it's not simple if you don't know the process but it's tied to setting the assessment reference date timely. In other words, the assessment has to cover a very specific period of time but it doesn't have to be done that day. But it has to cover that period. So if it covers the wrong period of time, then for the days that are late, then it would be in a default.

    MS. ROSENFIELD: Billing is done retrospectively and what Medicare was trying to do with the MDS assessment is get a clinical assessment with important items first week, second week, and then, you know, by the third week. So we can look at the acuity so to speak. This is on the payment side of it. They have to set a reference date as Rena said, get a picture of the resident, and then they have a reasonable period of time to get it into the computer and then over to billing and then getting it billed. So you're, you know, there is a lot of confusion in the field about what are the rules. That's very true.

    MR. FAY: Okay. Thank you for clarifying that. My other two questions, I was curious about the fact that the signature boxes appear throughout this form as opposed to one overall signature box on the front and then the third question in item, one of the items, I think it's at the end, has the Medicare case mix assigned it and I was curious as to how that is determined.

    MS. ROSENFIELD: Well, the case mix assignment is when the completed MDS goes through the web groupa (phonetic) and people will fall into one of 44 payment categories. So that's that case mix. Those are the acuities for which payment is made. In many other states, this is also used for the Medicaid payment.

    As far as the signatures go, in recent years, well it's always been required that the person filling out the individual section would be responsible for the gathering of the information and the assessment and that's when Mr. Hoyer said earlier this morning that this should stand as a document by itself and so as with any sort of medical documentation, clinical documentation, you'd always sign off on what piece you were responsible for. And one person could do it and that person would be a registered nurse. Do you want to --

    MS. SHEPHERD: Yeah, let me add something to that. The reason that there are several different places for signatures is because there's one sheet, the face sheet portion, that only has to be completed once. That's an oversimplification but basically it only has to be completed once as long as the resident isn't formally discharged. And so the team who's involved in filling that out needs to sign that there. And then the rest of the form has to be signed as Sheryl said by the individuals who complete it. There's also a spot on those two forms for the RN coordinator to sign and that person has signed verifying that it's complete, not that it's accurate. So there are actually different reasons for it and it's not a redundancy. Does that help.

    MR. FAY: Thank you.

    DR. WOOD: Who had one? Eric, okay.

    DR. OLSEN: Yes, is -- for MDS2.0 or the new -- the proposed one that's being worked on, is that interactive so that as you do it, you can eliminate parts of it because you get feedback that this is -- that kind -- is it interactive between the computer?

    MS. ROSENFIELD: It has a logic trail and depending on, of course, where you use it, it is interactive. But this does have a logic trail so that if you answer certain items one way, you do not have to answer other items. Absolutely.

    DR. WOOD: I would thank you again. Quite well done. We will take a ten minute break and reconvene a little bit after 25 minutes past the hour.

    MS. SCHMIDT: And let me add that for the Committee members, I've got the sign up sheets for the site visits. They'll be up here. Please sign up during the break if you can for the trips today and if you're going any place tomorrow. Thanks.

(Recess)

    DR. WOOD: Order please. Can I invite the Committee members and the panelists to return to the table please so that we can begin. We have with us today several individuals who will give us their perspectives from the field and so in order for them to have time to do that, could we all get back to the table.

    Again, the structure that we have tried to use and we used effectively in Miami was to begin to understand what we were trying to accomplish with a specific area of regulation, get a beginning demonstration and then began to get perspectives from the field, that is people who use these instruments and who deal with the regulations in caring for beneficiaries. I'm particularly pleased to welcome starting at my far left, Mary Ousley, who's the executive vice president of the Sun Bridge Health Corporation. Around the corner, oh, actually Mia's right there and then having to keep track of whose -- I can't see -- I have to look really across, it's Vicki -- yeah, Vicki McAllister. Sorry, Vicki, who's the chief operating officer and administrator of the Care Center in (indiscernible). Then Mr. Steven, he's a state president from the Arizona ARP. Next is Sara Burger who is from the National Citizens Coalition for Nursing Home Reform in Washington.

    We're pleased to have all of you with us and I'm going to ask actually if Mary would lead off and I remind you about the timer which is in front of you, right in front of Ms. Long's computer. Otherwise I will rather unceremoniously break in to make sure that your colleagues have time to say their piece.

    MS. OUSLEY: Good morning, Mr. Chairman and members of the Committee. I certainly appreciate the opportunity to be here today to provide the perspective on the regulatory and the policy in our nation's healthcare delivery system. My goal today is to have my comments fit into the objectives of this Committee and that is to look at efficiency cost effectiveness and most importantly quality and what drives quality for our seniors and the disabled individuals of America.

    My day job as you said is executive vice president of Sun Bridge Health Care and I'm also the chair of the American Healthcare Association representing over 12,000 skilled nursing facilities and assisted living.

    But I really want to emphasize that above and beyond everything else, as I speak about minimum data sets today, I'm here to represent the patient, the resident, in our nursing facilities. For those that are there today needing care and for those of us, some of us are about the same age here, who are going to be needing it pretty soon. Especially as we focus on the minimum data set, the statutory and the mandatory, regulatory mandate of this very, very powerful tool. Excellent presentation by my colleagues that talked about the MDS as a screening tool, the triggers, the RAP's.

    And I sat there as they were doing that and I did a care plan in my mind for Joey and that's what's so powerful about this tool. I heard that she was alone, she was independent, she was social but social on her terms, she liked her TV, she liked her phone. I knew that roommate compatibility was going to be very important to her. I knew that this was not her choice to come into the nursing home. She wasn't mad at her daughter but she said again and again, I'm not real happy. This is not my choice. So I know that as I deliver the care for Joey, I have to make sure that choice is a very important part.

    And then there was the therapeutic parts. That's how you translate all of this information into the most powerful delivery of care. I have been in this profession for over 30 years and the most dramatic change in care has come about since 1987 and with the use of the resident assessment instrument and the MDS. MDS was I think a public policy development at its best, at its very best.

    I think today and I want you to listen carefully to my next sentence. Minimum data set, the resident assessment instrument, is the most powerful, powerful tool in healthcare today. I did not say in skilled nursing. I said in healthcare today. And I think we need to really keep that in mind. It is the most under utilized and the most misunderstood along with being one of the most powerful. The power of the instrument we've said it again and again, number one it is in the delivery of care services. Number two, it is in data.

    I have a grandson that just turned ten and when he was three, I went over to read a book to him and he said, "Mimi, if you'd wait just a moment until I download this program." I knew that my world had changed and I had to move into a different world. And Logan taught me that.

    This is the only uniform source of data collection that actually depicts the care needs of seniors of America and is -- gives us the ability to collect that in a uniform way that can talk to seniors of America, can direct health policy and I'm going to speak a little bit more to how it can direct hopefully the utilization of healthcare resources across the entire continuum of care. It provides a platform for quality, one, quality indicators which are for us. That's for the provider of care to help us look at where we might have problems and use the continuous quality improvement methodology to improve them. It provides the platform for quality measures which is the public disclosure model that tells the consumer and the beneficiary this is a good place to go. This is a good place for my mother to be.

    I'm so proud that in less than a month, this -- the first pilot project as Tom referred to, will roll forth with real consumer information coming off of this powerful database. Needless to say, I support the MDS. I have worked very closely with Tom Hoyer and many -- and (indiscernible) Fadalsi (phonetic) and the colleagues around the room on the entire policy and regulatory development of this powerful tool.

    But I do want to say that as the tool has slowly evolved to a system that links payment, care, and evaluation of that care, it does need some change. It one, needs to be updated. Two, it needs to be streamlined. And we need some simplification. The recommendations are pretty straightforward as to what I think we need to do to keep this tool all that it is for all of us. Number one, update it. We've had some tweaks since 1995. I met with CMS just last week and they said we think we'll have version 3.0 by 2004. No way. That is too late. We need it now. We need the dollars both in resources and we need the human resources devoted to this. We are missing the advances of medical technology, our RAP's are getting outdated. That's creating a lot of the burden. We need it streamlined, convene a panel immediately, of clinicians, reimbursement specialists, software vendors, pull us together and say we need 3.0 out there so that we can continue to use this product in a very powerful way.

    Streamline it. We need an accurate updated short study assessment and we need it out right now. With every resident, every patient does not fall into the same category. Short stay assessment.

    The system being used for payment methodology, the question has come up for RUG's and for Medicare. It only takes a 108 data elements to determine that RUG's category. 500 elements are on all of the pages before you. Come up with a system, a process right now where we can quantify moving into the -- using it for the payment methodology that again does not overburden the caregivers to do that. Again we need to do it now.

    Next, expand it across the continuum of care. Seniors are so confused in this nation about where to get their care. Use this very powerful tool across the entire continuum of long term care as it was originally intended to one, give seniors the information that they need about their care, their good care is being provided, and it should be if we are going to be cost effective and efficient. It should move the individual. It should help us as healthcare providers be able to know where is the best place for a senior to receive that care.

    The last again is that of quality. Using that data to keep the informed public and to make policy decisions off of that.

    What I meant to say really in closing is this and I ask your help in this. All of the Committee. Is to help us restore the stature to this very powerful tool and repair its tarnished reputation. As overly burdensome, all of the things that have happened that this has evolved over the years so that the providers of all of healthcare can understand what a powerful, powerful tool it is and restore it to where it should be.

    I want to say that I support it, I support its continuation, its update, its streamlining and I guess what I'm really asking you to do is really free the MDS. Free it and bring it out of this to really use it the way it was intended to deliver the care. Thank you very much. I look forward to your questions.

    DR. WOOD: Think you very much, Mary. Next, Ms. McAllister.

    MS. MCALLISTER: Good morning, everyone. My name is Vicki McAllister and I'm the administrator of record for a 225 bed facility and the chief operating officer of a 40-acre non-profit faith based retirement community, allocated on one campus. We have 51 assisted living units, 625 independent residence and 100 HUD apartments within Glendale, Arizona community.

    Kathy Murdo, LPN, is with me today and she is one of our three MDS coordinators and I can assure you she is much more prepared to answer any detailed questions about the instrument itself as she does this every single day and does it very well. Thank you, Kathy.

    I'd like to start off with a quick quote and "the day we forget we are in business because of the customer is the day we start going out of business." I have been working on long-term care since 1977, been a licensed administrator since 1981, and working with sub-acute Medicare, ventilator, rehab, dementia and long-term care residents. Currently, our facility is part of phase one of appellative care demonstration project in collaboration with the Arizona Chapter of the Alzheimer's Association. I have especially enjoyed this.

    High standards of care and quality, I would hope my friends, colleagues and especially the residents and families at Glencroft would say about me. However, the demands of my time are many. Leadership development, collaboration support and especially proactive processes within an environment where staff are empowered to make decisions and be accountable for quality outcomes are very important to me as a leader and I think all leaders, should be all leaders.

    Facilitating change within my employment, professional association and local trade association are vehicles to effect that quality of care and standards of care improvement and support for my fellow peers during a very, very difficult time of scrutiny within our profession. Many colleagues I have known have left the industry or changed careers. But those of us who have stayed on have found vehicles to effect change and find support during this difficult time.

    And that support has been my active involvement within our local chapter and national board and professional certification of the American College of Healthcare Administrators and I'm also active within the Arizona Association of Homes and Housing for the Aged. These organizations and also OKA (phonetic) are working very, very well together to effect change.

    Streamlining regulations was never more important than it is right now. And I don't need to remind all of you about the statistics that are out there that you read about every day. But I'm going to summarize four of them for you quickly. The competition for employees. The licensed nursing shortage nationwide is unprecedented. In Arizona, Arizona has fewer registered nurses than the national average and a 26.7 turnover rate compared to the U.S. average of 15 percent. Supply and demand economics prevail with the shortage of nursing assistants as well.

    To add controversy to the equation, some consumer groups and policy makers think by mandating staffing ratios in this time of extreme shortage will solve most of the problem despite the realities of the market trends and I wholeheartedly disagree with that recommendation.

    One-third of Arizona's skill care nursing facilities are operating under Chapter 11 bankruptcy. Ten percent have closed due to financial non-viability and ten Valley hospitals have closed their skilled nursing units. And this is not unlike the national trends.

    The national liability insurance increase crisis across the United States has been in the news this past six to 12 months, 50 to a 1,000 percent increases or $70,000 to $600,000 increases or non-renewed policies. How can businesses operate without liability insurance? Two companies, St. Paul and General Staff, have stopped writing new insurance coverage. Rising health insurance for employees, there's a ten to a 40 percent increase in the last two years.

    And lastly, our reimbursement for providing care to our residents has not and probably won't keep up with these increases in cost. Very difficult issues to deal with and wrestle with every day.

    But back to streamlining regulations. Streamlining regulations through AHSA's (phonetic) recommendations to submit quarterly MDS for Medicare only assessments is something that was submitted previously to this Committee and I support that. This recommendation will help to decrease staff workload and time without compromising quality because the quarterly assessment contains all the data elements required to calculate the appropriate payment rate and less time consuming to complete than a full MDS. Presently, at Glencroft, we do a full five-day MDS assessment which is not mandatory. But takes approximately an hour and a half per resident to do a full MDS. So with this recommendation, if this would take place, we would be able to do a quarterly assessment which would take approximately 45 minutes to do so.

    This proposed change would substitute the full MDS and allow us to save time. And we would also propose to do the same on day 30, on day 60, but continue the full MDS on day 14 and 90 as mandated by regulation.

    We also support the recommendation that AHSA has of CMS issuance of a revised user manual in one comprehensive document so that all requests for information be contained in one area rather than multiple sets needed for clarification.

    Lastly, a good resident assessment is crucial to the provision of good care and I think all of our previous speakers have talked about that and I wholeheartedly support the use of the MDS. But streamlining to a quarterly assessment rather than the 30 and 90 day full assessment can only improve efficiency giving nursing personnel an opportunity to decrease the paper requirements and thereby visiting more residents during their workday and this is what's important to staff.

    Often we can do more for less. Again, often we can do more for less. But the simple reality is that now we have to do more for less. And with less. Due to our extraordinary increases in healthcare liability and healthcare insurance costs, simple economics of supply and demand of nursing personnel and overall regulatory licensure compliance expectations that we face every single day. I would like nothing better to increase the number of nursing assistants within our facility but this is cost prohibitive because these other costs continue to increase.

    I truly admire the advisory board panel here today for the participative collaborative environment that you have conveyed. Perhaps if more of this could take place in the future together, all constituency groups would find our common ground on these matters before us and quality resident outcomes would prevail. We wouldn't still be working in this profession if we did not want quality improvement processes and did not want positive outcomes of care. And it's only through leadership development and collaborative proactive participative processes again with all these constituency groups and within our healthcare settings where we model the systems and processes to demand accountability and quality process improvements within our settings. Quality attracts quality. Let me say that one more time. Quality attracts quality and it starts with us.

    I'd like to end with just one other quick quote which I think summarizes that responsibility and accountability that is before us and I would challenge our group to see other opportunities to work collaboratively together such as the work force shortage issues.

"We all need to take responsibility for those who follow us. Do it not to be thanked, do it not to take the credit, do it because you want to and as a gesture of the repayment for those who have done it to you and for you."

    Thanks, everyone.

    DR. WOOD: Thank you very much. Next, I'd like to invite Mr. Steven to make his comments and then we'll finish with Ms. Burger. If you want to, if you're still revising, that'd be fine.

    MS. BURGER: Thank you for that transfer, I think it was the way it originally was done and I think our presentations will fit a little better together.

    The National Citizens Coalition for Nursing Home Reform for those of you who are not familiar with the organization is a non-profit membership organization that has had as its reason for being to improve long-term care systems and quality of care and life for residents in nursing homes.

    For almost 27 years, we have been trying to bring the, and successfully bring, the consumer voice to policy discussions. And in fact, we have been working with all of these people for so many years, it certainly feels like family to us and hopefully we -- the residents have been beneficiaries of some of that.

    I'll just make four points here today. The first is that the MDS is only a minimum of data that was named minimum for a reason and it is also at the same time the powerhouse driving good care.

    The second point I want to make is that the MDS generates important data for beneficiaries in choosing and monitoring nursing homes.

    The third point, long-term care ombudsman and local and state ombudsman, advocates and families, use the MDS and the RAI system, the whole system with the RAP's to help facilities improve care. To work with them as part of the team.

    And finally, the real issue is not regulatory relief, but adequate staffing to do the assessments and implement the care that is so desperately needed by these residents.

    Go back to the first one about the -- it's the minimum information necessary. And also the powerhouse regarding good care practices. The information on the MDS was selectably and carefully arrived at by a coalition, a public group, that collaboratively worked representing all the stakeholders. It was a long process and a very fruitful one. The beneficiaries, the professionals, the provider organizations, the regulators, payors, and the workers all met together to devise what would be in this instrument.

    Now I have to tell you we were very pleased as a consumer organization that the piece called customary daily routine was kept in the instrument as a balance to the purely clinical and functional information that you've heard about so far and if you look on I think it's the second page of your MDS, you'll see that there. And the reason we were so interested in having this then is because this tells the individual details of a person's life. The kinds of things that you heard in our theater in the round this morning. They are so important for a person to have known for their care plan to be appropriate. Imagine for a moment that you're demented, think how much more important that information is.

    For instance, if a person comes into a nursing home and is bathed in the morning because he's demented and is wet in the morning, he can't let everybody know that he needs to go to the bathroom, and that person then sleeps through breakfast, that begins to make it so that that person may for instance if he is sleeping through breakfast, lose weight and you'd think well what's the problem here. But if you look at that customary daily routine, you may find out that this person always took a bath before they went to bed. And in his demented state, because he took a bath before he went to bed, he felt that signaled going to sleep. So as a result, he was sleeping through his best meal of the day and losing weight. The details count.

    When I talk to family members, I say go into the nursing home and ask -- the first thing you should ask the DON, what do you think of the MDS? And if the person says, this is the answer I want them to say, it's only the minimum, then I know they're going into probably a pretty good nursing home because that's really crucial to the approach to care.

    At the same time, the MDS does drive good care. There is this national database that you've heard about and what's being done. We have a collected overtime. Think from a consumer point of view, the issue of pain. What could be more central to resident well being than the issue of pain? The old MDS did not collect very good information. The new one, the 2.0, collects much better. It collects both the frequency and the intensity. Brown University took that data, collected on 2.2 million residents and looked at it, this is surrounding the time April 1st, 1999, looked at it over a six-month period and what did they find? They found that 14 percent, 300,000 folks, were not having their pain adequately addressed. And when I say pain, they were looking at daily moderate pain or excruciating pain. Think what that means to a resident.

    What else did they find? Looking at over six months, they found that 40 percent of those were still experiencing moderate daily pain or excruciating pain. That's 125,000 residents suffering every day. Did something need to be done? Of course, but the fact is this database gave us the information. What happened? There were an absolute flurry of articles about how to treat pain in older people. There was a flurry of articles in journals about how to assess residents who cannot tell you that they are having pain except by their behavior. It also put quality indicators for pain on the top most list of everyone.

    It also made consumer information available. You can go on to the Brown University website and find out in your state how the pain is assessed and how it is treated so people have a basis to go by. And certainly by the fall, I think we'll see a QI on the nursing home compare which is a website that certainly most consumers and their families use.

    Finally, because we still have this database, we hope Brown University and by -- they were supported by the Robert Wood Johnson Foundation so it was a nice partnership, we hope they'll look at this and see two things. One, that there's a lot more pain identified over time because we're getting better at it. And two, that we'll see a lot more treatment of pain so that we know that people are not languishing in pain.

    As you've heard before and I won't go into it again, the beneficiaries will have this information on the website because this -- Tom Scully, the administrator of CMS feels that the quality indicators which are generated from the -- in the MDS instrument information, will provide consumers with ways of choosing and monitoring nursing homes and secondly, that the nursing facilities will be able to use that information to improve care. So we have supported that greatly.

    My third point is that ombudsman advocates and families are using the MDS and then they say well how come they're using it? Well, we actually teach them. We have a little book here that we teach these people about the system and how it works. And we tell them that the MDS collects the facts, that the RAP's, and they learn about the RAP's, too, is the analysis of those facts and then the care plan includes the strategies and as the care plan where the resident and their families will be involved, they are part of the interdisciplinary team and that's where you get -- you saw the example this morning with Joey. So we use that.

    DR. WOOD: Ms. Burger, could you wrap up please?

    MS. BURGER: Yes, I'd be glad to. Finally, the real issue is not regulatory relief but sufficient staff to complete the RAI process. Registered professional nurse is responsible for a great deal and yet we have had a recent report to Congress, the second one, Appropriateness of Minimum Nurse Staffing Ratios in Nursing Homes Report to Congress, Phase Two, Final Volume, and that suggests throughout that we need increased staffing across the line. I do believe we need minimum staffing ratios but we only need them if it's accompanied by payment for those staff which must come and then there's accountability for where those funds go.

    MDS has been an exceptional tool, a powerful tool, it protects residents by giving individualized resident care, quality assurance systems, consumer information, and a national and an international research to improve practice. CMS has done a good job. I hope they continue.

    DR. WOOD: Thank you. Mr. Steven.

    MR. STEVEN: As a representative of AARP Arizona, I appreciate the opportunity of being invited to share with the Advisory Committee on regulatory reform AARP's position regarding the need for a long-term care comprehensive standardized resident assessment document like the minimum data set or as it's commonly referred to, MDS2.0.

    AARP believes that a uniformly applied comprehensive standardized patient assessment document is an essential tool to deliver the quality care for the individual resident.

    In an article I read recently, it pointed out that when long-term care facilities used facility specific non-standardized assessment forms, it was difficult to make comparisons of residents and facility characteristics. Changes in resident's conditions could not be tracked readily over time, clinical outcomes were difficult to measure and compare. In short, prior to the MDS, documents to measure true quality outcomes was at best a hit and miss proposition.

    As we've heard, the original MDS1.0 was implemented in 1990 and it's far from perfect and we all knew that. The revised version of MDS2.0 was implemented in 1996 and while it represented a significant step forward, it too is not perfect and needs to be revised.

    AARP believes changes are both necessary and inevitable and should be ongoing for all future editions of MDS. That's what continuous quality improvement is all about. It is critical, however, that these changes your Committee looks at and other committees look at do not do anything that would weaken the ability to improve the quality of care either here in Arizona or around the country to the residents that are served.

    We understand your Committee has been charged with evaluating systems to reduce regulatory burden it places on providers. AARP would strongly encourage a simultaneous approach that would also result in improved care outcomes for individual residents receiving care in a long-term care setting. Improved care outcomes for the residents in long-term care has to be the first priority as these systems are updated and improved.

    It is our belief that there are six specific areas you ought to look at to do this kind of improvement and if implemented, they would not only reduce paperwork burden and regulatory compliance demands, but they would improve resident outcomes.

    Key among the areas to look at, as you heard Ms. Burger talk about is staffing improvement. We need to incorporate into the MDS future versions what we know adequate staffing levels can do to improve quality outcome for residents. For example, this report that Ms. Burger reported on clearly makes it known that if you choose as a facility to take more residents that require more need, then you need to have a tool which helps you determine quickly on line realtime what kind of staffing should be provided in order to do that.

    This staffing information needs to be integrated into the document and automatically available and facilities, if they choose, to take these higher risk patients need to be held accountable then for providing that kind of care and level of care.

    Clearly, there's a financial payment issue that must be addressed if the staffing standard were adopted. But this isn't the forum, this isn't the time and this isn't the place to deal with that. But it must be dealt with at the time we put the staffing levels where they need to be.

    Additionally, there are critical -- a few other critical areas to look at. In the next MDS revisions, we need to address case mix adjustments for all essential QI's. Currently 20 quality indicators are not risk adjusted and need to be. And that's not fair for the resident outcomes we're trying to achieve. We need better information in those vital areas.

    There needs to be an integrated, automated analysis of resident level detail behind the quality indicators. Currently, we spend a lot of time on an individual manual basis trying to do this function and we need to free up that staff to be able to do it, to focus on the resident care needs instead.

    Future MDS's need to incorporate predictive software utilizing the data collected and this perhaps is the most exciting part to me of what this data gathering can accomplish. For example, given the current MDS data at hand, 87 percent of patient falls and 80 percent of pressure sores can be predicted in advance before any problems occur. And therefore we don't try and solve a problem after it's occurred. We are creating care plans which anticipate and avoid future possibilities. The liability exposure that is threatening to cripple the financial stability of the industry could be significantly reduced if we used this kind of software, resident outcomes would be improved and staffing could focus on the business at hand of really taking care of the residents, rather than spending their time in the paperwork area.

    MDS data systems need to produce clinical information to the actual caregiver in a realtime format in a usable form so they can take more immediate action in improving and addressing resident needs.

    And finally, as we've heard from several individuals, the consumer must have access to current facility specific up to date information not necessarily individually specific information but facility specific information and comparative information that is based on the MDS data that has been gathered so that they can assess whether the nursing home being recommended or that they are considering for themselves or a loved one or themselves is appropriate. This information needs to be presented in easily understandable format which while may be statistically valid, doesn't require a degree in systems assessment to understand.

    Thank you for the opportunity to speak with you today and should you have any additional questions regarding my comments, I'll be glad to try and answer them for you. Thank you.

    DR. WOOD: Thank you. The panel members, we would like to stay here for a few moments while we give the Committee the opportunity to ask specific questions. So let me invite the Committee to begin with questions. Jeff.

    MR. BLOOM: Thank you, Mr. Chairman. I'd like to ask Ms. and some of the other panel members, Ms. Burger, you mentioned that the MDS is the minimum data set. What other things would you like to see incorporated into it to elevate it a little higher than the absolute minimum data set that we have. What things do you feel that would be important to be included in it?

    MS. BURGER: That's a good question and I think when I said that I didn't mean that there should be more than what was actually transmitted from the facilities to the central office. But that it is a minimum and therefore there's a lot more that needs to be done. Then I think you heard that in an interview, that needs to be taken into consideration when you're planning care. So I didn't mean to lead you astray on that. But I think it's a good question to get it out that this is the minimum and it is the piece that we need to have publicly available.

    MR. BLOOM: So what specifically things would you --

    MS. BURGER: Oh, what would you -- I mean -- all right, I'm sorry. I think there are levels of care needs that need to be looked at. I certainly think the one of the places that we have fallen down hardest is on collecting appropriate information in designing care for those who have dementing illnesses. That's 60 percent of our population. Some say I work for the Alzheimer's Association. I don't.

    But I do think that we need a great deal more information known about the individual daily lives and the appropriate care that can help those folks to live as productive lives as possible and as drug free as possible. So that would be one place I would --

    MS. OUSLEY: If I could address that for just one second. When you use the minimum data set at the facility level and you use that, again that minimum data set is that screening level and then you go on to your resident assessment protocols, what that minimum screen is telling you is that you really do need to look further in certain areas. You tie that to the regulation that Mr. Hoyer referred to that we must insure the highest practical level of mental, physical, psychosocial well being for residents. Then that tells the facility that you -- and really good facilities really do this, that I gathered all of this information here but there's still a piece missing for this individual resident. I need maybe a deeper assessment. I need something else so really I mean I think that maybe not consistently in every single facility in the nation do we do that as well as we should but again this process guides you down that line to accomplish that.

    DR. WOOD: (indiscernible), then Heidi.

    MS. RYAN: I am so struck that in many ways this dialogue has pointed out the existence within long-term care of a functional assessment process which goes well beyond the medical diagnosis and the dimensions of the illness or an episode of care. And instruct that long-term care is so defined by its dependence on the entry level caregiver, by the fact that there is not a reimbursement system or a set of public policies that have been discussed sufficiently, much less say enacted in terms of payment and the resource needs in this arena and the conclusion of the most recent IOM look at quality since OBRA has concluded in one of the statements that I don't even think is bolded but I really read with a lot of passion and that is there simply is not the capacity in the system to address and respond to these needs.

    But it seems to me that the recommendations that have been discussed today have been supportive of the need for this minimum data set would suggest that it would be most useful to have it cross the continuum because some of the confusion in the administrative burden right now comes with when do you discharge a patient from a long term care to an acute care setting? When is a patient really discharged? When is a patient really transferred? When are the cycles for measuring need to be put in place?

    Secondly, it's a strategic question about how much of it needs to be used for payment purposes. Thirdly, it's the whole complexity that CMS is trying to address by developing a data system for this whole range of care and we don't have clarity in the MDS itself that we need to achieve, meaning we need the 03 out now, not two years from now. And there are a couple of things that are really lifted up here for me and that is we say educate and the education is going to solve this and I'm not sure it is.

    I think the clarity around the requirements as quickly as possible will help and then probably a strategy that is information system based much like what these last sets of recommendations were. Do it across the continuum and be very clear that the tools, the information is given to the front line caregiver such that the CNA has the information to use in the care plan and can enter it. So this is a –- we're trying to address the most complex level of care with perhaps least sophistication around the information systems and then we don't have it across the continuum which we need so I hear patterns emerging out of these comments but we also are seeing it in the part of healthcare that is least well funded.

    DR. WOOD: Heidi.

    MS. MARGULIS: This is a follow-up to something that Judy said and I guess it goes to Mr. Hoyer and that is what are the obstacles preventing the MDS, I think about Microsoft, MDS3 from coming out and 03 versus 04?

    MR. HOYER: I think other than the time it takes to do it and the money it takes to fund it, there aren't any obstacles as -- I believe --

    MS. OUSLEY: Fix that.

    MR. HOYER: I suspect that some of the newer terms delays in working on it have been because our resources have been at least refocused temporarily on the administrator's quality initiative which is beginning now so I expect them to shift back to MDS3 now that they've gotten that. We have a very energetic administrator and he tends to pursue it all right now. I suspect he'll be interested in MDS3 as well.

    MS. RYAN: May I have a follow-up?

    DR. WOOD: Why sure, you're (indiscernible).

    MS. RYAN: There were a number of comments that Mr. Steven made, this would also go to Mr. Hoyer, that interested me and I was wondering if you might comment on in terms of where you are, especially the one that called for predictive software using the data that's collected?

    MR. HOYER: Well, I think we have a strong interest in making the data more useful by having more effective software. Again, that takes some time and money to develop. I'm not sure we have the kind of research resources that we need to really go there at this point. But it remains one of our objectives and it's actually tied to what I talked about earlier, the requirement from the benefit and -- Beneficial Proven Protective Act. What we really are trying to look long term at, you know, and economical and effective data systems that go across provider's sites and achieve program objectives. So I think we have a lot of work to do but certainly it's on the agenda.

    DR. CROSBY: All of the panelists mentioned staffing is a critical issue and while we can perhaps improve and streamline the MDS through some recommendations, because it's so critical I'm wondering if you all in the trenches have any other ideas that regulatory change could be made to improve staffing problems?

    MS. OUSLEY: Realizing that the opening comments were pretty clear about the entire charge to this Committee, as we've referred to the new staffing study that's coming out, it's really since 1990 this profession has been grossly underfunded. The staffing that came out two years ago said that at a minimum, we need staffing of between 2.75 to 2.9 and the study that will be released this week says that there's a $7.6 billion shortfall in funding to nursing facilities to meet that mandate today. And I really think that is the accountability and the responsibility of all of us to step up and say that a nursing assistant cannot take care adequately of 13 residents and an RN cannot do assessments for