May 18, 2010 Feature

Skilled Nursing Facility Assessment Tool Focuses on Patient Communication

A revision of the tool used to assess Medicare beneficiaries in skilled nursing facilities (SNFs) places a new emphasis on the patient's communication abilities and needs as well as the patient's ability to direct his or her care within a facility.

The assessment tool, known as the MDS (Minimum Data Set), is pivotal to the SNF Medicare Prospective Payment System. The MDS is used to determine the patient's anticipated resource utilization. The assessment supports the clinical services provided to the patient as well as the SNF's reimbursement rate; it also serves as the basis for payment by many states' Medicaid programs.

Although MDS information is the basis for determination of the Medicare Part A reimbursement rate (first 100 days), this assessment tool is effective for as long as the patient is an SNF resident. On Oct. 1 the current version will be replaced by MDS 3.0, which will become the new standard for assessment of the Medicare beneficiaries in SNFs.

New Provisions 

The MDS 3.0 is the result of findings by the Centers for Medicare and Medicaid Services (CMS) that indicate a need to categorize more accurately certain types of SNF patients and serve them more appropriately. One of the most striking changes in the new MDS is the focus on residents with communication disorders and the need to improve the opportunity for the patient to direct his or her care provided within the SNF. This focus assures patient involvement and mandatory adherence to the patient's wishes.

Under the new system, SNF patient care will no longer be assessed and directed only by health care professionals who determine treatment based solely on objective, clinical findings. The MDS 3.0 requires a determination of the patient's ability to be a reliable informant (including the patient's ability to communicate) prior to completion of the first full assessment. If the patient is established as a reliable information source, the patient must then be interviewed regarding medical history, personal care, and activity preferences. Only when the patient cannot serve as a reliable information source may someone with knowledge of the patient provide the needed information by proxy.

Thus, the MDS 3.0 takes the need for prompt and accurate patient assessment to a new level, affording the opportunity to assure patient involvement in development of the Skilled Nursing Facility (Interdisciplinary) Plan of Care, which requires all members of the SNF care team to include patient goals and to state the intent to facilitate progress toward the patient's discharge from skilled nursing care.


The opportunity to include increased patient participation comes with challenges. Under the current system, few SNFs assess patient hearing and effective communication skills before any other physical condition; few hospital transfer sheets include clearly defined information aobut the patient's cognitive status; and patient information rarely includes a substantiated statement of whether the patient is a reliable informant. The MDS 3.0 brings to the SNF a new age of collaboration and integration of services. 

Under the current MDS, a series of observations and physician-ordered services must be completed to obtain answers. Often there is insufficient information because of cost concerns or absent referrals. With MDS 3.0, the SNF is expected to address the areas of communication and cognition immediately. The person who completes the first MDS after admission to the facility is expected to make an immediate determination regarding the patient's general cognitive status and the ability to provide reliable information, tasks that are often daunting for even the most experienced clinician. 

CMS has promised to offer extensive education for Medicare providers. It is clear that the SNF nursing staff (or an administrative representative) will be charged with determining the patient's ability to provide accurate information. This requirement indicates a need for those completing the MDS to understand basic information about communication, hearing loss, and the challenges of assessing residents who have communication and/or cognitive impairments.

The instructions for the new MDS refer to the inclusion of communication professionals throughout the MDS completion process:

  • The facility representative is to notify or consult a "speech or hearing specialist" if there are concerns regarding the use or function of a patient's hearing aid.  
  • The MDS instructions direct the MDS administrator, when assessing the patient's "speech," to "offer alternatives such as writing, pointing or using cue cards" when "the resident seems unable to communicate."
  • To determine the patient's ability to recall recent and past events, ability to think coherently, and preferences for customary routine activities, the MDS administrator must first determine if the patient is able to be understood (Section B Hearing, Speech, Vision). If the patient can be understood, the cognitive section (Section C) proceeds with the Brief Interview for Mental Status (BIMS), which "should be conducted if the resident can respond: verbally OR by writing out his or her answers." Administration of the personal preferences portion of the assessment (Section F) is also dependent on the results of the patient being understood (as determined in Section B).


The MDS 3.0 affords significant opportunity to speech-language pathologists and audiologists who serve SNF residents. Audiologists and SLPs are best positioned to meet the needs of those with communication disorders and are best suited to assist facilities in properly identifying those with communication disorders and preparing staff for the challenges of MDS 3.0 completion. To assure that SNF residents are assessed accurately and appropriately, communication professionals will be pivotal to the process of staff education, patient screening, and SNF admission processes. Audiologists and SLPs must become familiar with the components of the MDS 3.0 and help to prepare SNF staff who will be responsible for obtaining the admission information and completing the assessments.

The sections of particular interest to SLPs and audiologists are outlined in the sidebar at right. The instructions and the intent of each section (as written by CMS) suggest that all SNF employees involved in the MDS assessment process must be knowledgeable about communication disorders and how the MDS should be administered to patients with communication and/or cognitive disorders. When communication disorders are identified and documented, however, SLPs and audiologists are the only professionals trained to address them and their effects. To serve these patients most efficiently and with the highest quality of care, audiologists and SLPs should become familiar with the components of the MDS assessment, educate those responsible for its completion, and prepare to address the communication disorders that will be identified.  

Joanne M. Wisely, MA, CCC-SLP, is the senior director of regulatory administration for Genesis Rehab Services/Respiratory Health Services (Kennett Square, Pa.). She is the Pennsylvania representative for the ASHA State Medicare Administrative Contractor (SMAC) Network. Contact her at

cite as: Wisely, J. M. (2010, May 18). Skilled Nursing Facility Assessment Tool Focuses on Patient Communication. The ASHA Leader.

MDS 3.0 Sections Specific to Communication Disorders

Several new sections of Chapter 3 of the MDS 3.0 are of particular interest to audiologists and speech-language pathologists:

  • Section B: Hearing, Speech, and Vision—The intent of this section is to document the resident's ability to hear (with assistive hearing devices, if they are used), understand, and communicate with others and whether the resident experiences visual limitations or difficulties related to diseases common in older persons.
  • Section C: Cognitive Patterns—This section is intended to determine the resident's ability to remember both recent and long-past events (i.e., short-term and long-term memory) and to think coherently. These items are crucial factors in many care-planning decisions.
  • Section F: Preferences for Customary Routine and Activities—The intent of this section is to obtain information regarding the resident's preferences for his or her daily routine and activities. This is best accomplished when the information is obtained directly from the resident or through family or significant others, or through staff interviews if the resident or significant others cannot report preferences.

Other sections of the MDS that are relevant to SLPs and audiologists include:

  • Section G: Functional Status—The "Balance During Transition and Walking" subsection is relevant to audiologists. Medicare covers vestibular testing but does not cover Part B audiology rehabilitation services.
  • Section K: Swallowing/Nutritional Status—This section focuses on gathering information related to the resident's nutritional status. The resident should be the source for the first subsection; the medical record is the source for the remainder of the section.
  • Section O: Special Treatments, Procedures, and Programs—This section records the number of minutes (categorized by individual, concurrent, and group treatment) of speech-language pathology and audiology services administered in the last seven days.


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