MDS Alert

Hint: Use ‘disentangling’ to make complex questions easier.

The Resident Mood Interview (PHQ-9^©) can yield loads of information about your residents’ well-being and overall health. But this interview is also one of the most difficult — and the most essential — to complete accurately.

Why the Resident Mood Interview is Crucial

“For MDS 3.0, the importance of coding accuracy for Mood indicators continues to be significant, as well as relevant to quality care, care planning, and reimbursement,” wrote Peter Mastrangelo in a recent Harmony Healthcare International blog posting. “Mood distress is often underdiagnosed and undertreated in the long term care setting, yet it is associated with significant morbidity.”

Mood disorder is associated with both psychological and physical distress, noted Debra Saliba, MD, MPH, director of the UCLA/Jewish Home Borun Center for Gerontological Research, in a CMS instructional session. Mood problems can lead to poor outcomes in rehab, interference in diabetes therapy, poorer functional status overall, poorer health outcomes, and much more.

Remember: If you’re coding the presence of mood distress symptoms in PHQ-9^©, whether the staff version or the resident version, “you’re not making a diagnosis of depression,” Saliba noted. “That still is up to the primary care provider (PCP) and/or the mental health specialists at your facility to actually look at these signs and symptoms and say yes, this is related to a mood disorder, or no, these signs and symptoms are something else.”

Despite the importance of the resident mood interview, you can run into some seemingly unmanageable roadblocks while conducting the PHQ-9^©. Here are some tips to overcome the most common interview problems.

Keep the Conversation on Track

“Some residents like to talk about what’s going on and they may stray from the topic a bit,” Saliba noted. Steer residents back to the interview questions by acknowledging the response and guiding the conversation back to the topic.

According to CMS, you can use the following phrases:

• “That’s interesting, now I need to know …”
• “Let’s get back to …”
• “I understand, can you tell me about …”

Don’t Be Afraid to Ask for Clarification

Clarify and validate your understanding of what the resident is telling you. CMS suggests that you use these types of phrases:

• “I think I hear you saying that …”
• “Let’s see if I understood you correctly.”
• You said … Is that right?”

Use the ‘Unfolding’ Technique

You can use “unfolding” if the resident has difficulty selecting a frequency, Saliba recommended. Start by offering a single frequency response. You can pick a mid-point and then have the resident move up or down. Then, follow up with a sequence of more specific questions.

Example: Ask the resident, “Would you say [symptom] bothered you more than half the days in the past two weeks?” If the resident says “yes,” show the cue card and ask whether it bothered her nearly every day, or on half or more days, CMS instructs. If the resident says “no,” show the cue card and ask whether it bothered her several days or never or one day.

Probe to Get the Answer

“Probing” comes in handy when the resident gives you a noncommittal response like “not really.” Give residents gentle encouragement to report any symptoms, CMS says. You can probe by asking neutral or nondirective questions or statements, such as:

• “What do you mean?”
• “Tell me what you have in mind.”
• “Tell me more about that.”
• “Please be more specific.”
• “Give me an example.”

Use Echoing to Summarize Long Answers

Sometimes residents give long answers, so echoing is a way to summarize their answers to narrow it to the response choices on PHQ-9^©. Then, ask which response option best applies.

Scenario: For item D0200E, Poor Appetite or Overeating, the resident response was: “The food is always cold and it just doesn’t taste like it does at home. The doctor won’t let me have any salt …”

Your response could be: “You’re telling me the food isn’t what you eat at home and you can’t add salt. How often would you say that you were bothered by poor appetite or overeating during the last two weeks?”

Employ ‘Disentangling’ Method to Break
Down Responses

“Disentangling” involves separating an item into shorter parts, and then providing the patient with an opportunity to respond after each part, CMS says.

Example: For item D0200C, Trouble Falling or Staying Asleep, or Sleeping Too Much, you could “disentangle” the item into the following separate questions:

• “How often are you having problems falling asleep?”
• “How often are you having problems staying asleep?”
• “How often do you feel you are sleeping too much?”