MDS Alert

Consider this proactive strategy to help residents access the resources they need.

Section Q gives surveyors a heads up about whether a facility is falling short in its efforts to help residents return to the community. So make sure you're coding this section correctly and be prepared to spring into action when the Return to Community Referral Care Area Assessment triggers.

Don't miss: "The trigger for the Return to Community Referral CAA is Q0600" with a code of 1, says Teresa Mota, RN, CALA, RAC-CT, senior program coordinator for Quality Partners of Rhode Island. The coding options for Q0600, which asks: "Has referral been made to the local contact agency?" include:

Code 0, no: determination has been made by the resident (or family or significant other, or guardian or legally authorized representative) and the care planning team that the designated local contact agency does not need to be contacted.

Code 1, no: determination has been made by the resident (or family or significant other, or guardian or legally authorized representative) and the care planning team that the designated local contact agency needs to be contacted but the referral has not been made.

Code 2, yes: if referral was made to the local contact agency.

"When the CAA (return to community referral) triggers based on Section Q coding, the facility will have a discussion with the resident and/or family, whichever is appropriate, about desired discharge plans," says Rena Shephard, MHA, RN, RAC-MT, C-NE, founding chair and executive editor of the American Association of Nurse Assessment Coordinators and president and CEO of RRS Healthcare Consulting Services in San Diego.

"The facility notifies the state-designated local agency within 10 days [for help with the referral]," says Shephard. "The local contact agency and facility staff -- but mainly the contact agency -- work collaboratively with the resident/family, etc. The referral is for any payer source."

CMS is supposed to post the list of contact agencies on its website, which the agency was reportedly working on doing at press time.

Meantime, Mota encourages people to take the proactive route and contact their state Medicaid agencies, which have been trained on Section Q requirements, to find out what programs are available in their state.

Don't reinvent the wheel: "If facilities already have relationships with their local contact agencies or have nursing home transition programs in place through programs such as 'Money Follows the Person,' or others, they can continue to follow the processes they have developed with these agencies," Mota counsels. Tip: Asking the family if they believe the resident will be able to come home can bring to light some issues, says Elisa Bovee, MS OTR/L, director of education for Harmony Healthcare International in Topsfield, Mass. Staff may have been asking these questions before but the MDS 3.0 "creates a forum for doing so." And that means staff need to prepare, she adds. "Coaching families that may have unrealistic expectations of taking home their family member may become a more frequent occurrence."

Resources: For information about a CMS brochure on transitioning to the community, see the MDS, Clinical & Coding News on page 119 of this issue. CMS has also provided an extensive list of community resources, including contact information, in a compilation of training aids (www.cms.gov/NursingHomeQualityInits/downloads/MDS30TrainingAids.pdf). Also review the

Return to Community Referral CAA-specific resource in Appendix C of the RAI User's Manual (page C-82).