Within the skilled nursing system, long-term care Residents are consistently monitored, which is no surprise. But there are various levels and ways that each Resident’s status is monitored and documented.
One of these methods is called the MDS.
The MDS (Minimum Data Set) is a portion of the federally mandated process for clinical assessment of all Residents living in a Medicare and Medicaid certified nursing home. Residents who are receiving treatment under a skilled benefit through Part A of Medicare require more frequent assessments, while Residents who are solely receiving care through Part B of Medicare are assessed quarterly.
Generally speaking, Residents who are receiving care through Part A of Medicare are either already on therapy services or at the very least have been screened by a therapist. So for the sake of this conversation, we’re talking about Residents receiving care through Medicare Part B.
In my experience, most therapy departments will automatically screen a Resident at the time of their Quarterly MDS Assessment. The quarterly MDS schedule provides an easy routine for therapy departments to follow, and prevents one or multiple therapists from having to spend the majority of one or more days screening every single Resident in the facility.
The intent of a therapy screen is to ensure that each Resident is being routinely monitored by the therapy department. Most departments have their own hard copy form, which typically looks like a checklist of various areas of function. The therapist is expected to review each item, and if any changes or deficits are noted, then an evaluation will likely be recommended.
The screening process is entirely hands-off. The therapist is not able to provide any treatment or assistance or make any clinical recommendations beyond “yes or no this individual needs therapy”.
Who does the screen varies from department to department. Some departments will designate specific therapists to perform every screen, some Rehab Directors will designate themselves to the role, and some departments will assign a screen to any therapist that happens to be available that day.
So what’s the big take-away here?
Why do I as an OT or COTA need to care about these screens (especially if I’m not the one doing them)? Well for one, your skills and services are just as relevant to the long-term Residents as they are to the short-term patients that come and go. Two, it is federally mandated that long-term Residents are monitored, and it would be a disservice to them for changes in their status to not be addressed. And three, a therapy screen is the perfect opportunity to advocate for the role of OT.
Resident’s balance seems worse? Advocate for OT! Resident isn’t eating as much at every meal? Advocate for OT! Resident shows a sad affect with less engagement in preferred activities? Advocate for OT! Resident is using a wheelchair instead of a walker? Advocate for OT! Resident can’t get in or out of bed independently anymore? Advocate for OT! And of course, any change in ADL status? Advocate for OT!
A screen is your opportunity to share what you’re seeing AND how OT can address these things, in more than just one capacity. It’s the gateway to program development, groups, rapport building, advocacy, and advancement of the profession. It’s the threshold to the door that will bring attention to the value of OT services in the long-term care setting. And that alone is enough of a reason.
The Memory Unit OT 
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