This post is part of the MDS 2023 Countdown series.  Disclaimer. Current as of May 13, 2023

What You Can Expect to See

This new Section Q update presents a key change to the wording: GOAL vs expectation. The Cambridge American Dictionary defines expectation as “the feeling or belief that something will or should happen,” while goal is defined as “an aim or purpose.”

In the clinical setting, we are trained to create goals that are attainable. Asking the resident for a personalized goal similarly allows the resident to think about how they intend to achieve their goal(s) and in what timeline.

This change in language is not surprising, as long-term care advocates have been using the terms patient centered and personalized care over the last several years. Goals ultimately allow the resident to think for themselves and feel heard, providing more choices in care and the least restrictive environment for each individual.

What Is Changing

On page Q-11 of the Draft RAI manual projected for October 2023, we now have a clear definition for “Active Discharge Planning”:

“DEFINITION: ACTIVE DISCHARGE PLANNING  An active discharge plan means a plan that is being currently implemented. In other words, the resident’s care plan has current goals to make specific arrangements for discharge, staff are taking active steps to accomplish discharge, and there is a target discharge date for the near future. If there is not an active discharge plan, residents should be asked if they want to talk to someone about community living (Q0500B) and then referred to the LCA accordingly. Furthermore, referrals to the LCA are recommended as part of many residents’ discharge plans. Such referrals are a helpful source of information for residents and facilities in informing the discharge planning process.”

While always helpful to have instructions in black and white (or red and white in this case), NAC’s should be aware and read closely:

specific arrangements for discharge should be noted in the resident’s care plan

You should also:

  • document (in a timely manner) any attempt to secure discharge arrangements
  • discuss the importance of documentation with your team (including therapy, social services, even activities and dietary – their input is invaluable)

Another change we see in Section Q is Q0500. Q0500A provides additional criteria for answering the question:

“Does the resident (or family or significant other or guardian or legally authorized representative only if resident is unable to understand or respond) want to be asked about returning to the community on all assessments? (Rather than on comprehensive assessments alone.)”

If the resident is unable to understand the question they are being asked, the resident’s family, significant other, legal guardian or other legally authorized representative should be asked. Q0500B has been replaced by Q0500C, with a more specific set of answers, making it easier to read and code the item set correctly

Recommendations from MDS Consultants

  • A resident’s discharge goal needs to be addressed in the resident’s care plan
  • Specific arrangements should be care planned for discharge
  • Discharge planning should involve the resident’s IDT

Do not wait! The time to prepare is now.

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