Dianne E. Tobias Janice L. Feinberg William G. Troutman Resident assessment and medication monitoring to optimize outcomes through prevention, detection, and resolution of medication-related problems lie at the heart of nursing facility-based pharmaceutical care. Consultant pharmacists have long desired a tool to more tightly integrate these fundamental processes. Now they have it. The MDS-Med Guide is a unique clinical tool for consultant pharmacists and other health professionals to promote the integration of resident assessment data with monitoring of medication therapy in the federally mandated resident assessment process. The MDS-Med Guide is intended to assist in the clinical decision-making process of evaluating complex medication regimens of nursing facility residents, monitoring the therapeutic outcomes of medication therapy, and identifying and preventing potential medication-related problems. This article describes the MDS-Med Guide, the methodology used in its development, and suggestions for use in clinical practice. Resident Assessment Comprehensive resident assessment has been a federal requirement in all Medicare- and Medicaid-certified nursing facilities since 1991. The Resident Assessment Instrument (RAI) is a revolutionary health care tool that provides a comprehensive, standardized, reproducible assessment of each nursing facility resident’s cognitive, behavioral, functional, and medical status. The RAI is used to develop outcome-oriented resident care plans to maximize quality of care and residents’ quality of life through early recognition of problems and risk factors that can be avoided, managed, or reversed. RAI Framework MDS + Triggers + RAPS Comprehensive Assessment The RAI consists of the Minimum Data Set (MDS), Triggers, Resident Assessment Protocols (RAPs), and Utilization Guidelines. The MDS contains more than 400 data elements: demographic variables; clinical items, including an extensive array of diagnoses, syndromes, signs and symptoms, and treatments; and "indicators" describing behavior, mood, cognition, psychosocial well-being, and involvement in activities. The MDS is divided into sections that correspond to areas of physical, functional, and psychosocial status (Table 1). The MDS identifies actual or potential problem areas for each resident and forms the foundation of the comprehensive resident assessment. Triggers are specific responses for MDS items that identify residents who have or are at risk for developing specific problems and require further evaluation using RAPs. RAPs are structured, problem-oriented frameworks for organizing MDS and other clinically relevant resident-specific information that identify medical and functional problems and form a basis for individualized care planning. The RAPs provide further assessment of "triggered" areas and help staff look for causal or confounding factors, some of which may be reversible. There are 18 RAPs, which cover the majority of areas addressed in a typical nursing facility resident’s care plan (Table 2). Utilization Guidelines are instructions concerning when and how to use the RAI. Problem Identification Process Pathway Clinicians are generally taught a problem identification process as part of their professional education. For example, the nursing profession’s problem identification model is called “the nursing process”; pharmacy’s model is called “the pharmaceutical care process.” All good problem identification models have similar steps: assessment, decision-making, care planning, implementation, and evaluation.The RAI provides a structured, standardized approach for applying a problem identification process in nursing facilities. Assessment (MDS/Other) Decision-making (RAPs/Other) Care Plan Development Care Plan Implementation Evaluation Table 1. MDS Sections Section A. Identification and Background Information Section B. Cognitive Patterns Section C. Communication/Hearing Patterns Section D. Vision Patterns Section E. Mood and Behavior Patterns Section F. Psychosocial Well-Being Section G. Physical Functioning and Structural Problems Section H. Continence in Last 14 Days Section I. Disease Diagnoses Section J. Health Conditions Section K. Oral/Nutritional Status Section L. Oral/Dental Status Section M. Skin Condition Section N. Activity Pursuit Patterns Section O. Medications Section P. Special Treatments and Procedures Section Q. Discharge Potential and Overall Status Section R. Assessment Information Section T. Therapy Supplement for Medicare PPS Table 2. Resident Assessment Protocols RAP No. RAP Title 1 Delirium 2 Cognitive Loss 3 Visual Function 4 Communication 5 ADL Functional/Rehabilitation Potential 6 Urinary Incontinence and Indwelling Catheter 7 Psychosocial Well-being 8 Mood State 9 Behavior Problem 10 Activities 11 Falls 12 Nutritional Status 13 Feeding Tubes 14 Dehydration/Fluid Maintenance 15 Dental Care 16 Pressure Ulcers 17 Psychotropic Drug Use 18 Physical Restraints Importance of MDS Data The significance of the MDS to long-term care pharmacy cannot be overstated. The MDS is the basis for resident classification under the Medicare prospective payment system (PPS). State Medicaid programs use MDS data to determine case-mix reimbursement rates. State regulatory agencies use MDS data to target the facility survey process to problem areas. The Health Care Financing Administration (HCFA) has developed nursing home Quality Indicators (QIs), derived from items on the MDS, that indicate either the presence or absence of potentially poor care practices or outcomes in nursing facilities. On July 1, 1999, HCFA incorporated QIs into the nursing facility survey process. Many of these QIs are designed to evaluate the use of medications in the facility; others can be impacted by drug therapy. In addition, the MDS and QIs may also be used by managed care organizations to determine reimbursement levels and assess quality. For these reasons it is critical that long-term care pharmacy begin integrating MDS data into its systems and processes, and linking clinical services to these established resident-specific and facility-specific quality and outcome data. To advance the process of data integration, the ASCP Research and Education Foundation has developed the MDS-Med Guide. Goals of the MDS-Med Guide The MDS-Med Guide was developed to: Foster pharmacist involvement in the resident assessment and care planning process Aid in the evaluation of medications as a cause or aggravating factor contributing to a resident’s physical, cognitive, or functional decline Facilitate incorporation of medication information into the resident’s plan of care Promote the integration of MDS data with the therapeutic monitoring of medication therapy Assist pharmacists in evaluating and monitoring complex medication regimens of nursing facility residents to identify, resolve, and prevent medication-related problems Facilitate incorporation of resident assessment data into the pharmaceutical care plan. The MDS-Med Guide is a tool—not a definitive reference for medication side effects or adverse drug reactions—and it is not designed and should not be used as a rigid screen. The MDS-Med Guide was designed for the geriatric nursing facility resident with chronic diseases and conditions; acute or self-limiting conditions were not considered. The MDS-Med Guide relates specific MDS items, which may reflect potential positive and negative outcomes of medication therapy, to specific medications and medication classes. The consultant pharmacist can use this information when performing initial medication assessments and drug regimen reviews; when developing pharmaceutical care plans to establish and monitor progress toward achieving desired therapeutic goals; and to identify, resolve, and prevent medication-related problems. To use the MDS-Med Guide, the pharmacist must have expertise in geriatric pharmacotherapy and be thoroughly familiar with the resident assessment process and the components of the RAI: the MDS, Triggers, RAPs, and Utilization Guidelines. For complete information, see the Long Term Care Facility Resident Assessment Instrument User’s Manual, published by HCFA and available from various distributors. Enhancing and Expanding the Role of the Pharmacist Increased involvement in resident assessment and care planning through the use of the MDS-Med Guide will enable pharmacists to see a resident’s medication regimen not in isolation, but rather as one component contributing to the physical, functional, and psychosocial status of the resident. This integrated approach is needed to effectively identify, resolve, and prevent medication-related problems. The MDS-Med Guide will also increase awareness and appreciation of the effect of medications on a resident’s physical, functional, and psychosocial status. Many MDS items use functional terminology familiar to nursing and other long-term care health professionals involved in care planning to describe the behavior, mood, cognition, psychosocial well-being, functional ability, and involvement in activities assessed as part of the resident assessment process. The MDS-Med Guide correlates this functional language to potential therapeutic and adverse effects of medications. This correlation will assist the pharmacist in incorporating the "language of resident assessment" into their problem identification process, clinical decision-making, and patient care recommendations. The ability to communicate in the common language of resident assessment will enhance the effectiveness of the pharmacist’s recommendations and facilitate incorporation of medication-related issues into the resident’s plan of care. Structure of the MDS-Med Guide The MDS-Med Guide is available in three formats: pocket guide, wall chart, and query software. The content and format of the MDS-Med Guide dramatically illustrate the scope and potential effect of medications on the cognitive, behavioral, functional, and medical status of nursing facility residents. The pharmacist’s experience and knowledge of geriatric pharmacotherapy provides the important and necessary expertise required to use the MDS-Med Guide appropriately. The MDS-Med Guide Pocket Guide and Wall Chart present both MDS-medication and RAP-medication data in a grid format. Medications/medication classes are listed vertically, and MDS items or RAP titles are arranged horizontally. MDS items and RAP titles are cross-indexed with medications/medication classes by color-coded cells. The medications/medication classes in the MDS-Med Guide represent those commonly prescribed for geriatric nursing facility residents with chronic diseases or conditions; topical agents and antineoplastic medications are not included. The medications/medication classes are listed in the MDS-Med Guide in the following manner (Table 3): Pharmacologic Class   Therapeutic Category     Medication Class or Specific Medication The basis for the organization of medications/medication classes is the table of contents of the Handbook of Clinical Drug Data, 8th Edition;1 the list was adapted with permission. The user must be familiar with this format in order to efficiently use the MDS-Med Guide. Table 3. Organization of Medications/Medication Classes in MDS-Med Guide Analgesic and Anti-Inflammatory Cardiovascular   Antiarrhythmics   Antihypertensives   Hypolipidemics   Vasodilators Central Nervous System   Anticonvulsants   Antidepressants   Antipsychotics   Anxiolytics/hypnotics   Neurodegenerative disease   Antiparkinson Gastrointestinal   Acid-peptics   Antiemetics   Gastrointestinal motility   Miscellaneous gastrointestinal Hematologic   Coagulants and anticoagulants   Hematopoietics Hormonal   Antidiabetic   Other hormonal   Thyroid/antithyroid Renal and Electrolytes   Diuretics   Electrolytes   Antigout Respiratory   Antihistamines and Antiallergics   Bronchodilators   Cough and cold Antimicrobial   Antifungal   Antimycobacterial   Antiviral MDS Grid The MDS Grid (Figure 1) contains MDS Sections and relevant subsections, MDS item numbers, and MDS item descriptions from the MDS Version 2.0 Full Assessment. MDS item numbers mandated for quarterly assessment are indicated by an asterisk. If the MDS item is a RAP trigger, the applicable RAP number(s) appears in parentheses. The following MDS Sections are not included in the MDS Grid: Section A. Identification and Background Information; Section O. Medications; Section P. Special Treatments and Procedures; Section Q. Discharge Potential and Overall Status; Section R. Assessment Information; Section T. Therapy Supplement for Medicare PPS. In addition, the MDS Grid does not include every item in the MDS; items with little or no applicability to the monitoring of medication therapy are not included. The MDS Grid identifies medications/medication classes that have the potential, over time, to improve or cause a decline in the disease, condition, sign, symptom, or function described by the MDS item. MDS items are cross-indexed with medication/medication class by red, green, or blue color-coded cells: A green cell indicates that the medication/medication class has the potential to improve or is therapeutic for the disease, condition, sign, or symptom described by the MDS item. A red cell indicates that the medication/medication class has the potential to cause a decline or cause or worsen the disease, condition, sign, or symptom described by the MDS item. A blue cell indicates that the medication/medication class has the potential to either improve or cause a decline in the MDS item. Assigning Green, Red, and Blue Cells In developing the MDS-Med Guide, all medications of a class were, if possible, grouped together for purposes of assigning red and green cells. However, in many cases the assignment of red cells dictated that medications from the same class be listed individually because of different adverse effect profiles. The MDS-Med Guide does not present every documented adverse effect of every medication/medication class listed. The absence of a red cell does not mean a medication/medication class can be excluded as a possible cause of an adverse effect. This is especially true when the addition of the medication or a change in its dosage is closely related in time to the emergence of the adverse effect. Similarly, the association of a medication/medication class and adverse or therapeutic effect does not constitute evidence of a true cause-and-effect relationship. Illness of any sort is highly individualized, and residents may experience medication-related benefits or adverse effects in more or fewer MDS items than indicated. It is possible, and perhaps likely, that more than one medication in a resident’s regimen may contribute to an adverse effect or improvement in resident status. The potential effect of multiple medication therapy was not considered in the development of the MDS-Med Guide. MDS Item Data Sets MDS items were identified that correlate with: (1) presenting features and functional signs and symptoms associated with diagnoses frequently encountered in nursing facility residents that may be improved with medication therapy; and (2) possible signs and symptoms of common or serious adverse medication effects.a These MDS items were grouped into data sets for possible therapeutic effect and possible adverse effect (Appendix 1). The correlations for possible therapeutic effect were determined through a review of gerontology nursing texts.2–5 For each diagnosis, the presenting features and functional signs and symptoms identified were then reviewed with therapeutics texts to determine which medications/medication classes might contribute to improvement of a given set of presenting features, signs, and symptoms.6, 7 The correlations for possible adverse effect were determined based on a review of side effects reference texts and review articles.1, 8–28 The MDS item data sets identified for a particular adverse drug effect (e.g., confusion) or clinical condition (e.g., heart failure) were made as inclusive as possible; not all medications/medication classes will necessarily affect all MDS items in a data set. Figure 2 presents a schematic of MDS item data set development. How Were Green Cells Assigned? Medications/medication classes that are considered therapeutic for a disease or condition, or that may improve a sign or symptom, are coded green for all items in the applicable MDS item data set. If a medication/medication class is known to be therapeutic only for certain signs or symptoms, only those MDS items were coded green. In most cases, all items in the MDS item data set were coded green for all therapeutic medications/medication classes because it is often difficult to delineate which symptoms benefit from which medications. For example, various antipsychotic agents are indicated for the treatment of schizophrenia/psychosis. These medications are coded green for the disease diagnosis schizophrenia (MDS Item I1gg) and for the MDS data set that correlates with signs or symptoms of schizophrenia/psychosis: B4; B5a-f; B6; E1a,d-l,n-p; E3; E4a-e; E5; F1a-f; I1gg; J1e,i; N1; N2 (Table 4). How Were Red Cells Assigned? Medications/medication classes known to cause an adverse effect were coded red for all items in the applicable MDS item data set. For example, various medications may cause diarrhea. These medications are coded red for the bowel elimination pattern, diarrhea (MDS Item H2c), and for the MDS data set that correlates with signs or symptoms of diarrhea: H2c; J1a,c (Table 5). How Were Blue Cells Assigned? A blue cell indicates that the medication/medication class has the potential to either improve or worsen the disease, condition, sign, or symptom described by the MDS item. MDS items are coded blue for medications/medication classes that were independently coded red and green for an MDS item based on the therapeutic effect, adverse effects, or MDS item data sets. Table 4. MDS Item Therapeutic Data Set (Green Cells) for Schizophrenia/Psychosis MDS Items: B4; B5a-f; B6; E1a,d-l,n-p; E3; E4a-e; E5; F1a-f; I1gg; J1e,i; N1; N2 MDS Section MDS Item B. Cognitive Patterns 4. Cognitive skills for daily decision-making 5. Indicators of delirium-Periodic disordered thinking/awareness a. Easily distracted b. Altered perception/awareness c. Episodes of disorganized speech d. Periods of restlessness e. Periods of lethargy f. Mental function varies over course of day 6. Change in cognitive status E. Mood and Behavior Patterns 1. Indicators of depression, anxiety, sad mood a. Negative statements d. Persistent anger e. Self deprecation f. Unrealistic fears g. Statements that something terrible is about to happen h. Repetitive health complaints i. Repetitive non-health complaints j. Unpleasant mood in a.m. k. Insomnia/changed sleep pattern l. Sad/pained/worried expression n. Repetitive physical movements o. Withdrawal from activities p. Reduced social interaction 3. Change in mood 4. Behavioral Symptoms a. Wandering b. Verbally abusive c. Physically abusive d. Inappropriate behavior e. Resists care 5. Change in behavioral symptoms F. Psychosocial Well-Being 1. Sense of initiative, involvement a. Interacting with other b. Planned structured activities c. Self-initiated tasks d. Establishes own goals e. Involved in life of facility f. Accepts invitations to groups I. Disease Diagnosis 1. Diseases gg. Schizophrenia J. Health Conditions 1. Problem conditions e. Delusions i. Hallucinations N. Activity Pursuit Patterns 1. Time awake 2. Time involved in activities

RAP Grid

• Section I—The Problem gives general information about how a condition affects the nursing home population and often describes the focus or objectives of the protocol.
• Section II—The Triggers identify MDS item responses that alert staff to a resident’s possible problems, needs, or strengths.
• Section III—The Guidelines present comprehensive information for evaluating factors that may cause, contribute to, or exacerbate the triggered condition, including medications; and suggested approaches for additional assessment.
• Section IV—The RAP Key has two parts: a list of the MDS items that triggered the RAP, and a summary of all MDS items relevant to the analysis in the RAP Guidelines.

The MDS-Med Guide RAP Grid (Figure 3) identifies medications/ medication classes that have the potential to contribute to or aggravate a RAP problem. RAP titles are cross-indexed with medication/medication class by red cells. A red cell indicates that the medication/medication class may cause or aggravate the problem addressed by the RAP. The RAP Grid contains only red cells because it focuses exclusively on the potential negative effects of medications on a resident’s problem.

How Were Red Cells Assigned?

In addition, correlations were made between the RAPs and signs and symptoms of potential adverse medication effects from the MDS item data sets. If there is a correlation between the signs and symptoms of an adverse medication effect and a RAP problem, all medications/medication classes in the applicable data set are coded red for that RAP (Appendix 1).

The Feeding Tubes and Physical Restraints RAPs do not list or discuss specific medications/medication classes in the RAP Guidelines, and no MDS item data set correlations were made; therefore, there are no red cells for the Feeding Tubes and Physical Restraints RAPs.

How to Use the MDS-Med Guide

The appropriate use of the MDS-Med Guide requires a thorough understanding of the resident assessment process and resident assessment instrument, how the MDS-Med Guide grids were developed, and expertise in geriatric pharmacotherapy. Before using the MDS-Med Guide, pharmacists should become familiar with the resident assessment process and procedures, the role of the MDS coordinator, and the MDS software system and capabilities in the different facilities they serve. The MDS-Med Guide will be most valuable when incorporated into the pharmaceutical care process. For information on how to establish a pharmaceutical care practice and implement the pharmaceutical care process, see Cipolle RJ, Strand LM, Morley PC. Pharmaceutical care practice. New York: McGraw-Hill; 1998.

At least initially, pharmacists may want to target residents to receive formalized pharmaceutical care planning based on high risk for medication-related problems,²⁹ high risk for RAP problems, or RAP problem areas of concern to specific facilities (e.g., falls, nutrition, pressure ulcers).

Assessment of Medication Regimens

Use information in the RAP Grid to identify: (1) potential problem areas where medications may be a cause or contributing factor; (2) residents at high risk for developing a RAP problem; and (3) medications/medication classes that may be implicated in a triggered RAP.

This information should be incorporated into the pharmaceutical care plan, and the pharmacist’s assessment of this information should be shared with the MDS coordinator and interdisciplinary team for incorporation into the resident’s care plan. Specific interventions may include:

• Assessment of the benefits versus risks of continued therapy
• Appropriate recommendations to the prescriber for changes in therapy to reduce the risk of medication- related problems, prevent further functional decline, or achieve therapeutic goals
• Appropriate recommendations to the interdisciplinary team for actions to be incorporated into the resident’s plan of care to reduce the risk of medication-related problems
• Providing resident-specific MDS-medication and RAP-medication information to the interdisciplinary team for incorporation into the resident’s plan of care.

To begin, evaluate the resident’s medication regimen against the MDS and RAP Grids:

For each medication/medication class:
• List MDS items that may decline over time (red cells, blue cells).
• List MDS items that may improve over time (green cells, blue cells).
• Note the MDS Sections each medication/medication class has the potential to effect, both positively and negatively, rather than just single MDS items, as most medications will affect more than one item in an MDS Section.
• List RAPs (problem areas) that may be affected (red cells).

For each MDS item:
• List medications/medication classes that may cause a decline over time (red cells, blue cells).
• List medications/medication classes that may cause improvement over time (green cells, blue cells).
• Review the relevant MDS Section in the RAI User’s Manual.

This process allows the pharmacist to see the potential cumulative effect of medications on MDS items/Sections.

For each RAP:
• List medications/medication classes that may cause or contribute to the RAP problem (red cells).
• Review the relevant RAP in the RAI User’s Manual.

This process allows the pharmacist to see the potential cumulative effect of medications on RAP problem areas and can be used to identify residents who may be at higher risk for developing a RAP problem. The data may initially appear overwhelming, but in a short time the pharmacist should become familiar with the MDS and be able to easily organize the information by MDS Section. The MDS-Med Guide Query Software automates this process and provides data in five report formats: Med/MDS, MDS/Med, Med/RAP, RAP/Med, Triggered RAPs/Med.

To monitor a resident over time:
• For new residents, obtain baseline data for MDS items from admission assessment.
• For current residents, review the last full and subsequent quarterly assessments.
• Note which MDS items are included in the quarterly assessment, and incorporate the monitoring of these MDS items into the pharmaceutical care plan.
• Note changes in MDS items over time, and evaluate the changes with respect to initiation of therapy or changes in medication regimen.

It may be useful to develop MDS item monitoring forms for specific diseases or conditions for which medications should provide a therapeutic benefit (e.g., depression, congestive heart failure), medications/medication classes known to be problematic in nursing facility residents, or residents at high risk for specific RAP problem areas. The use of forms should facilitate the monitoring of MDS items over time and aid in clinical decision-making.

Assessment of Medications as a Cause or Contributing Factor When a RAP is Triggered

• Review the current care plan and RAP Summary Sheet.
• List all medications/medication classes the resident is currently taking or has recently taken that may be implicated in the RAP problem (RAP Grid red cells).
• Review the RAP in the RAI User’s Manual.
• Review RAP Triggers, listing all medications/medication classes that the resident is currently taking or has recently taken that may cause a decline in the MDS item(s) that triggered the RAP.
• Evaluate these medications/ medication classes as a potential cause or aggravating factor contributing to the resident’s RAP problem.
• Share information and recommendations with the interdisciplinary team for incorporation into the resident’s care plan.

Problem Identification and Clinical Decision-Making

With the information provided in the MDS-Med Guide, the pharmacist can begin to see how a resident’s medications, both individually and cumulatively, may affect various areas of functioning, then incorporate this information into the problem identification process and clinical decision-making. For example, if a resident is receiving a medication that is coded red for an MDS item and that MDS item has declined over time (i.e., since the last assessment), further investigation may be warranted to determine if the medication may have caused or contributed to the decline. This determination is a complex task requiring—in addition to knowledge of the potential effects of the medication—knowledge of the resident’s condition; disease progression, generally and in the individual resident specifically; and typical and atypical manifestations of the resident’s diseases or conditions.

Problem identification may include the following assessment pathway:
• What is the time course with respect to initiation of therapy or changes in medication regimen?
• Have the signs and symptoms occurred or worsened since the medication was initiated or the dose increased or decreased?
• Are there patient-specific variables in this resident that would make development of a medication-related problem more likely?
• Is there an underlying problem?
• If the last assessment did not show a decline in the MDS item and the most recent assessment did, what has changed in the interim?

After assessment, problem identification, and clinical decision-making, the pharmacist is ready to design and implement a pharmaceutical care plan. The pharmaceutical care plan includes therapeutic goals, monitoring parameters (including MDS items and RAP information), appropriate monitoring intervals, specific interventions, expected outcomes of intervention, schedule for follow-up, and actual outcomes during follow-up evaluation. For more information on pharmaceutical care planning, see Cipolle RJ, Strand LM, Morley PC. Pharmaceutical care practice. New York: McGraw-Hill; 1998.

Conclusion

The development of the MDS-Med Guide Version 1.0 established a methodology for correlating medications to MDS items and RAPs through the identification of data sets and the assigning of therapeutic or adverse effect potential to medications/medication classes commonly used in geriatric nursing facility residents. The next step is the incorporation of the MDS-Med Guide into practice and validity testing.

The MDS-Med Guide is a powerful clinical tool that can revolutionize the way consultant pharmacists practice. Increased involvement in resident assessment and care planning through the use of the MDS-Med Guide will shift the pharmacist’s focus from the medication regimen in isolation to the medication regimen as one component contributing to a resident’s physical, functional, and psychosocial status.

The MDS-Med Guide enables pharmacists to see how a resident’s medications, both individually and cumulatively, may impact on various areas of functioning, and to incorporate the "language of resident assessment" into their problem solving process, clinical decision-making, and recommendations.

Re-engineering one’s practice is a daunting task, but it can be done—one patient at a time. The MDS-Med Guide is the clinical tool to advance this process.

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