MP

By Elyse Matson, MA CCC-SLP, SLP Therapy Resource

IDDSI stands for International Dysphagia Diet Standardization Initiative. The purpose of the initiative was to create standards across all environments so that the foods and liquids have the same texture or viscosity.

For example, when a patient arrives to your facility on nectar liquids, how do we determine if the hospital’s version of nectar is the same as ours?

The IDDSI framework consists of a continuum of 8 levels (0-7), where drinks are measured from Levels 0–4, while foods are measured from Levels 3–7.

There are specific testing methods to determine the levels, including a flow test with use of a 10 ml syringe and a fork test to determine food particle size and food softness.

Implementation

So should you implement IDDSI at your facility? There are several factors to consider. The first is, who is your menu vendor? The vendor supplies the menus to the kitchen and provides instructions/wording on which diets your facility uses and how to prepare the meals. It is up to this vendor to adopt IDDSI and provide the new language/instructions to the kitchen.

The next question is whether your local hospitals/referral sources are adopting IDDSI. This may create a need to address the diets sooner rather than later. We have created a conversion chart below to provide to your admitting nurses so they can convert the IDDSI diets back to your current diets.

Finally, you will need to work closely with your SLP, Dietary Department and IDT to determine if your facility is ready for this change. For further questions, please go to www.iddsi.org or reach out to Elyse Matson, SLP Resource (ematson@ensignservices.net).

By Lori O’Hara, MA, CCC-SLP, Therapy Resource — ADR/Appeals/Clinical Review

Setting the ARD

The purpose of the lookback period is to capture those conditions and characteristics that impact the patient’s treatment plan in such a way that they can 1) be reported to oversight agencies and 2) calculate a reimbursement rate.

Under PDPM, since the whole premise of the rate is that it is commensurate with how complex the patient is, it’s then essential that the lookback period capture as many of those things as possible. And it may be that capturing hospital activity is important!

If a patient received IV hydration or nutrition while in the hospital, it can impact our Nursing case mix. This makes sense — patients who were dependent on an enteral delivery of fluid or calories are quite fragile in the period after this treatment concludes. The lookback on this item is seven days and includes delivery while in the hospital.

So the IDT’s job is to decide what the right ARD is to capture all the important info. We may choose to set the ARD on day one, knowing that capturing the hospital intervention paints the most accurate picture of the patient’s complexity. Or, if an IV medication starts after admission on day 7, that might be the right date for a lookback to capture the clinical picture. Or, if the patient had fluids through the day of discharge and has wound treatments ordered on day five, then a lookback that captures part of the hospital activity and part of the post-admission activity may be what’s best.

The good news is that up through day eight, the ARD can be moved forward and backward as needed to make sure that we’ve captured all the complexities of the patient we’re taking care of.

Section GG Reconciliation

Mythbuster time! Therapy should not be the only source of data for Section GG. One of the sources, sure! But not the only one.

Data sources should include therapy evaluations, nursing documentation and the MDS Coordinator’s observation of CNA care. All of this data should be recorded in the record, and then the IDT’s job is to reconcile this through the Section GG UDA.

So what does “reconciliation” mean? It means looking at all the available data and deciding what really represents the “usual and baseline” performance through analysis and discussion.

Say you’re looking at toilet transfers. The Occupational Therapy evaluation says Mod Assist, the nurses’ notes say Partial/Moderate Assistance, and the MDS Nurse documents Partial/Moderate Assistance in her entry. Then Partial/Moderate Assistance seems like the perfect answer.

But what if the OT says Moderate Assist, one nursing entry says Moderate/Partial but one says Substantial/Maximal — and the MDS Coordinator’s note also says Substantial/Maximal? What’s the right answer?

That’s the reconciliation part. And there’s no CMS mandated formula — it’s your IDT looking at the data and the overall performance of the patient and deciding. Do you suspect the patient performs a little more independently with therapy, but that really they’re requiring more help? Then landing on the more dependent score is probably the right answer. Do you know that later in the day they become a lot heavier? Then again, their usual performance is probably the more dependent one.

The critical element is having as much data as you can (and sometimes that will be a very small amount, if therapy is starting the day of admission!) and making a reasoned decision based on the information you have. You want to be able to point to the data you had available and your IDT’s decision-making process to support your coding should you need to defend it later.