MDS 3.0 Explained: Coding the Social Determinants of Health

Updates to MDS 3.0 coming in October include an increased focus on resident self-reporting, giving residents a stronger voice during the interview process and their care journey. Throughout the latest draft, CMS discusses the need to better understand and address how disparities in health outcomes require better data regarding social determinants of health (SDOH).

This article is an overview of what’s changing in MDS 3.0 to help address SDOH, based on draft v1.18.11 currently available on the CMS website.

Ethnicity and Race

By asking residents to self-report their ethnicity, CMS can gather data to form a greater understanding of how and/or if ethnicity impacts the care an individual receives. Residents, or a legally authorized representative, can report ethnicity based on a list of options. Similarly, residents are asked about their race. See A1005 for more information.

Language Preferences

Finding out a resident’s preferred way of communicating is essential to delivering quality care. Any friction in communicating a person’s health needs can cause frustration and lead to safety issues, social isolation, unmet needs, and poor health outcomes. American Sign Language is included in communication preferences. See A1110B for more information.

Transportation Barriers

Residents need access to reliable transportation to support their care before, during, and after their stay at a LTC facility. This section asks residents how access to transportation has impacted their ability to make appointments or get their medications. By understanding barriers to transportation, providers can understand how widespread these issues are and better coordinate care after a resident returns home. See A1250 for more information.

Providing Reconciled Medication Lists

Successfully discharging a resident from a LTC facility must include a clear transfer of their reconciled medication list to the next party involved in their care. In doing so, complications are avoided and care coordination is improved during their next transition. A properly reconciled medication list should include OTCs, oxygen, and other physical items they require as part of their care plan. See A2121 for more information.

Health Literacy

As with any barriers to communication, understanding how to follow care plans and medication instructions is essential for residents to be able to support their own health and well-being. As stated in MDS 3.0, poor health literacy is tied to poorer outcomes, residents receiving less preventive care, and higher medical costs. By gathering data around health literacy, providers can better coordinate care and discharge planning by ensuring extra clear details are given to residents with lower levels of literacy. See B1300 for more information.

Social Isolation

Part of gauging a resident’s health-related quality of life involves asking them about their actual or perceived lack of contact with others. Social isolation often increases with age and is a significant risk factor for physical and mental illness. By understanding a resident’s perceived level of isolation, care staff can make more attempts to engage them in social events and activities. MDS 3.0 clearly states that a resident’s care plan should include ways to enhance their quality of life and include activity planning. See D0700 for more information.

MDS Coding in Long-Term Care

Beyond gathering essential data regarding a resident and their health status, updates to MDS 3.0 offer residents more opportunities to have their perspective and personal health status recorded. By going the extra step, providers can gain important insights into the health of an individual beyond what’s been documented in their health records or what may initially appear on their treatment plan. 

With a significant body of research supporting the need to address social determinants of health across our population, these updates will provide individuals with opportunities to improve their own outcomes and provide a vast data set that will give us valuable insights into population-level health risks associated with elements such as ethnicity, social engagements, and language and transportation barriers.

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