Mds Hc Form PDF Details

Navigating the complexity of healthcare and support services requires accurate and detailed assessment forms to ensure that individuals receive the care and support they need. Among these essential tools in Massachusetts is the Minimum Data Set – Home Care (MDS-HC), introduced in a significant overhaul by the Executive Office of Health and Human Services, Division of Medical Assistance. As of February 2003, chronic disease and rehabilitation hospitals have been mandated to transition to this form and the accompanying Request for Services (RFS-1), moving away from the previous Long Term Care Assessment form. This shift aims to streamline the referral process for long-term care services, encompassing nursing-facility and adult-day-health services among others. The MDS-HC form must be completed meticulously by an assessment coordinator, a role designated to a registered nurse to guarantee the form’s accuracy and completeness, although certain sections can also be filled out by a licensed social worker. The assessment’s breadth covers various essential aspects of a patient’s care needs, from cognitive and communication patterns to social functioning and informal support services, underlining the importance of a comprehensive approach to patient care planning and implementation. The inclusion of meticulous documentation on the patient’s condition, coupled with ICD-9-CM codes for diagnoses, lays a robust foundation for determining clinical eligibility for MassHealth's long-term-care services. Furthermore, the directive for chronic disease and rehabilitation hospitals to adhere to the updated documentation requirements by February 1, 2003, emphasizes the state’s commitment to enhancing communication lines between providers and the Division, thereby facilitating a smoother and more efficient process in addressing the long-term care needs of Massachusetts’ residents.

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Form NameMds Hc Form
Form Length9 pages
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Avg. time to fill out2 min 15 sec
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COMMONWEALTH OF MASSACHUSETTS

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

DIVISION OF MEDICAL ASSISTANCE

600 Washington Street Boston, MA 02111 www.mass.gov/dma

MassHealth

Chronic Disease and

Rehabilitation Hospital Bulletin 83

January 2003

TO: Chronic Disease and Rehabilitation Hospitals Participating in MassHealth

FROM: Wendy E. Warring, Commissioner

RE:

Changes in Clinical Assessment Forms

 

 

 

 

Background

The Division determines clinical eligibility for MassHealth long-term-care

 

services based upon documentation submitted by the provider. The Long

 

Term Care Assessment form has been replaced by two new forms in

 

order to facilitate communication between providers and the Division.

 

 

 

New Forms

Attached to this bulletin are copies of the two new forms required for

 

approving referrals for long-term-care services, including, but not limited

 

to, nursing-facility and adult-day-health services.

 

• Request for Services (RFS-1) (formerly called the MassHealth

 

Long Term Care Assessment form)

 

• Minimum Data Set – Home Care (MDS-HC)

 

Chronic disease and rehabilitation hospitals must begin using these new

 

forms by February 1, 2003. Please discard all previous versions of the Long

 

Term Care Assessment form.

 

 

 

Who May Complete

The MDS-HC must be completed by an assessment coordinator. The

the MDS-HC

assessment coordinator must be a registered nurse who certifies the

 

accuracy and completeness of the MDS-HC.

 

The following sections of the MDS-HC may be completed by a licensed

 

social worker (LSW, LCSW, or LICSW).

 

AA – Name and Identification Numbers

 

BB – Personal Items

 

CC – Referral Items

 

B – Cognitive Patterns

 

C – Communication/Hearing Patterns

 

E – Mood and Behavior Patterns

 

F – Social Functioning

 

G – Informal Support Services

 

O – Environmental Assessment

 

 

 

 

CONTINUED ON BACK

MassHealth

Chronic Disease and

Rehabilitation Hospital Bulletin 83

January 2003

Page 2

Who May Complete

Each person who completes a portion of the MDS-HC must sign and

the MDS-HC

certify the sections he or she completes in Section R – Assessment

(cont.)

Information (Other Signatures, Title, Sections, Date).

 

 

Qualifications for

The registered nurse or social worker must be licensed by the

Completing the Forms

Massachusetts Board of Registration.

 

 

ICD-9-CM Codes

The MDS-HC assessment requires the use of the ICD-9-CM codes for

 

medical diagnoses.

 

 

Trainings

The Division holds periodic trainings for providers. You will receive notice

 

of trainings when they are scheduled.

 

 

Supplies of the Forms

You may photocopy the forms as needed. To obtain supplies of the

 

forms, use the information below to mail or fax your request. Include your

 

provider number, address, telephone number, the exact title of the form,

 

and the desired quantity.

 

MassHealth Forms Distribution

 

P.O. Box 9101

 

Somerville, MA 02145

 

Fax: 703-917-4087

 

 

Questions

If you have any questions about this bulletin, please contact MassHealth

 

Provider Services at 617-628-4141 or 1-800-325-5231.

 

 

 

 
(With hearing appliance if used)

MINIMUM DATA SET - HOME CARE (MDS-HC)©

•Unless otherwise noted, score for last 3 days

•Examples of exceptions include IADLs/Continence/Services/Treatments where status scored over last 7 days

SECTION AA. NAME AND IDENTIFICATION NUMBERS

1.

NAME OF

 

 

 

 

 

 

 

 

 

 

 

 

 

CLIENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a. (Last/Family Name)

 

 

 

b. (First Name)

 

c. (Middle Initial)

2.

CASE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

RECORD

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NO.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

GOVERN-

a. Pension (Social Security) Number

 

 

 

 

MENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PENSION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AND HEALTH

b.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health

insurance

 

number

(or

other comparable insurance number)

 

INSURANCE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NUMBERS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION BB. PERSONAL ITEMS (Complete at Intake Only)

1.

GENDER

1. Male

2. Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.

BIRTHDATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Month

Day

 

Year

 

 

 

3.

RACE/

(Check all that apply)

 

 

 

 

 

 

 

 

 

 

 

 

 

ETHNICITY

RACE

 

 

 

 

 

 

Native Hawaiian or other Pacific

 

 

*

 

 

 

 

 

 

 

 

American Indian/Alaskan

 

 

 

 

Islander

 

 

d.

 

 

 

 

 

 

 

 

 

 

 

White

 

 

 

 

 

Native

 

 

a.

 

 

e.

 

 

Asian

 

 

b.

ETHNICITY:

 

 

 

 

 

Black or African American

c.

Hispanic or Latino

f.

4.

MARITAL

1. Never married

3. Widowed

5. Divorced

 

 

STATUS

2. Married

4. Separated

6. Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.LANGUAGE Primary Language

*

0. English

1. Spanish

2. French

3. Other

 

 

 

 

6.

EDUCATION

1. No schooling

 

5. Technical or trade school

 

 

(Highest

2. 8th grade/less

 

6. Some college

 

 

Level

3. 9-11 grades

 

7. Bachelor's degree

 

 

Completed)

4. High school

 

8. Graduate degree

 

7.RESPONSI- (Code for responsibility/advanced directives)

BILITY/

0. No

1. Yes

 

ADVANCED

 

 

 

DIRECTIVES a. Client has a legal guardian

 

 

 

 

 

b. Client has advanced medical directives in place (for example, a do not hospitalize order)

SECTION CC. REFERRAL ITEMS (Complete at Intake Only)

1.DATE CASE

OPENED/

 

REOPENED

 

 

 

 

 

 

 

 

 

 

 

 

Month

 

Day

 

 

Year

 

 

 

 

 

 

2.

REASON

1. Post hospital care

 

 

4. Eligibility for home care

 

 

FOR

2. Community chronic care

 

 

5. Day care

 

 

REFERRAL

3. Home placement screen

 

 

6. Other

 

3.

GOALS OF

(Code for client/family understanding of goals of care)

 

 

CARE

0. No

1. Yes

 

 

 

 

 

 

 

a. Skilled nursing treatments

 

 

d. Client/family education

 

 

 

b. Monitoring to avoid clinical

 

 

e. Family respite

 

 

 

 

 

 

 

 

 

 

 

 

 

complications

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c. Rehabilitation

 

 

 

 

f. Palliative care

 

 

 

 

 

 

 

 

4.TIME SINCE Time since discharge from last in-patient setting (Code for most

LAST recent instance in LAST 180 DAYS)

HOSPITAL

0. No hospitalization within 180 days

3. Within 15 to 30 days

 

 

STAY

1. Within last week

4. More than 30 days ago

 

 

 

2. Within 8 to 14 days

 

 

 

 

 

 

 

5. WHERE

1. Private home/apt. with no home care services

 

 

LIVED AT

2. Private home/apt. with home care services

 

 

TIME OF

3. Board and care/assisted living/group home

 

 

REFERRAL

4. Nursing home

 

 

 

 

5. Other

 

 

 

6. WHO LIVED

1. Lived alone

 

 

 

WITH AT

2. Lived with spouse only

 

 

 

REFERRAL

3. Lived with spouse and other(s)

 

 

 

 

4. Lived with child (not spouse)

 

 

 

 

5. Lived with other(s) (not spouse or children)

 

 

 

6. Lived in group setting with non-relative(s)

 

 

 

 

 

 

 

7.PRIOR NH Resided in a nursing home at anytime during 5 YEARS prior to case

PLACEMENT opening

 

0. No

1. Yes

8.RESIDENTIAL Moved to current residence within last two years

HISTORY

0. No

1. Yes

SECTION A. ASSESSMENT INFORMATION

1.ASSESSMENT Date of assessment

REFERENCE

DATE

Month

Day

Year

2.REASONS Type of assessment

FOR 1. Initial assessment

ASSESS- 2. Follow-up assessment

MENT 3. Routine assessment at fixed intervals

4.Review within 30-day period prior to discharge from the program

5.Review at return from hospital

6.Change in status

7.Other

SECTION B. COGNITIVE PATTERNS

1.MEMORY (Code for recall of what was learned or known)

RECALL

0. Memory OK

1. Memory problem

ABILITY

a. Short-term memory OK — seems/appears to recall after 5 minutes

 

 

b. Procedural memory OK—Can perform all or almost all steps in a

 

multitask sequence without cues for initiation

2.

COGNITIVE

a. How well client made decisions about organizing the day (e.g., when

 

SKILLS FOR

to get up or have meals, which clothes to wear or activities to do)

 

DAILY

0.

INDEPENDENT—Decisions consistent/reasonable/safe

 

 

DECISION-

 

 

MAKING

1.

MODIFIED INDEPENDENCE—Some difficulty in new situations

 

 

 

 

only

 

 

 

 

2.

MINIMALLY IMPAIRED—In specific situations, decisions become

 

 

 

 

poor or unsafe and cues/supervision necessary at those times

 

 

 

3.

MODERATELY IMPAIRED—Decisions consistently poor or un-

 

 

 

 

safe, cues/supervision required at all times

 

 

 

4.

SEVERELY IMPAIRED—Never/rarely made decisions

 

 

 

 

 

 

 

b. Worsening of decision making as compared to status of 90 DAYS

 

 

AGO (or since last assessment if less than 90 days)

 

 

0. No

1. Yes

3.INDICATORS a. Sudden or new onset/change in mental function over LAST 7 DAYS

OF DELIRIUM (including ability to pay attention, awareness of surroundings, being

coherent, unpredictable variation over course of day)

0. No

1. Yes

b. In the LAST 90 DAYS (or since last assessment if less than 90

days), client has become agitated or disoriented such that his or

her safety is endangered or client requires protection by others

0. No

1. Yes

SECTION C. COMMUNICATION/HEARING PATTERNS

1. HEARING

0.HEARS ADEQUATELY—Normal talk, TV, phone, doorbell

1.MINIMAL DIFFICULTY—When not in quiet setting

2.HEARS IN SPECIAL SITUATIONS ONLY—Speaker has to adjust tonal quality and speak distinctly

3.HIGHLY IMPAIRED —Absence of useful hearing

2.MAKING (Expressing information content—however able)

SELF

0. UNDERSTOOD—Expresses ideas without difficulty

UNDERSTOOD

 

1. USUALLY UNDERSTOOD—Difficulty finding words or finishing thoughts

(Expression)

BUT if given time, little or no prompting required

2. OFTEN UNDERSTOOD—Difficulty finding words or finishing thoughts,

 

prompting usuallly required

 

3. SOMETIMES UNDERSTOOD—Ability is limited to making concrete

 

requests

 

4. RARELY/NEVERUNDERSTOOD

3.ABILITY TO (Understands verbal information—however able)

UNDER-

0. UNDERSTANDS—Clear comprehension

STAND

1. USUALLY UNDERSTANDS—Misses some part/intent of message,

OTHERS

BUT comprehends most conversation with little or no prompting

 

(Comprehen-

2. OFTEN UNDERSTANDS—Misses some part/intent of message;with

sion)

prompting can often comprehend conversation

3. SOMETIMES UNDERSTANDS—Responds adequately to simple, di-

 

 

rect communication

 

4. RARELY/NEVERUNDERSTANDS

4.

COMMUNICA-

Worsening in communication (making self understood or understand-

 

 

TION

ing others) as compared to status of 90 DAYS AGO (or since last

 

 

DECLINE

assessment if less than 90 days)

 

 

 

 

 

0. No

1. Yes

 

SECTION D. VISION PATTERNS

1.VISION (Ability to see in adequate light and with glasses if used)

0.ADEQUATE—Sees fine detail, including regular print in newspapers/ books

1.IMPAIRED—Sees large print, but not regular print in newspapers/ books

2.MODERATELY IMPAIRED—Limited vision; not able to see newspa- per headlines, but can identify objects

3.HIGHLY IMPAIRED—Object identification in question, but eyes ap- pear to follow objects

4.SEVERELY IMPAIRED—No vision or sees only light, colors, or shapes; eyes do not appear to follow objects

2.VISUAL Saw halos or rings around lights, curtains over eyes, or flashes of LIMITATION/ lights

 

DIFFICUL-

0. No

1. Yes

 

 

 

 

 

TIES

 

 

 

 

3.

VISION

Worsening of vision as compared to status of 90 DAYS AGO (or since

 

DECLINE

last assessment if less than 90 days)

 

 

 

 

0. No

1. Yes

 

 

 

MDS-HC Version 2.0 — July 21, 1999

MDS-HC - Pg 1

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