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Interviewing to Increase Resident Voice in MDS 3.0 Assessments
Excerpts from the Long-Term Care
Facility Resident Assessment Instrument User’s Manual, Version 3.0,
Centers for Medicare and Medicaid Services, CMS, November 2009:
All residents
capable of any communication should be asked to provide information
regarding what they consider to be the most important facets of their
lives. There are several MDS 3.0 sections that require direct interview
of the resident as the primary source of information (mood, preferences,
pain). Self-report is the single most reliable indicator of these
topics. Staff should actively seek information from the resident
regarding these specific topic areas; however, resident
interview/inquiry should become part of a supportive care environment
that helps residents fulfill their choices over aspects of their lives.
In addition, a
simple performance-based assessment of cognitive function can quickly
clarify a resident’s cognitive status. The majority of residents, even
those with moderate to severe cognitive impairment, are able to answer
some simple questions about these topics.
Even simple scripted interviews like those in MDS
3.0 involve a dynamic, collaborative process. There are some basic
approaches that can make interviews simpler and more effective.
Introduce yourself
to the resident.
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Be sure
the resident can hear what you are saying.
Do not
mumble or rush. Articulate words clearly.
Ask the
resident if he or she uses or owns a hearing aid or other
communication device.
Help him
or her get the aid or device in place before starting the
interview.
The
assessor may need to offer an assistive device (headphones).
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Ask
whether the resident would like an interpreter
(language or signing)
if the
resident does not appear to be fluent in English or continues to
have difficulty understanding. Interpreters are people who
translate oral or written language from one language to another.
If an interpreter is used during resident interviews, he or she
should not attempt to determine the intent behind what is being
translated, the outcome of the interview, or the meaning or
significance of the interviewee’s responses. The resident should
determine meaning based solely on his or her interpretation of
what is being translated. |
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Find a
quiet, private area where you are not likely to be interrupted
or overheard. This is important for several reasons:
Background
noise should be minimized.
Some items
are personal, and the resident will be more comfortable
answering in private. The interviewer is in a better position to
respond to issues that arise.
Decrease
available distractions. |
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Sit where
the resident can see you clearly and you can see his or her
expressions.
Have your
face well lighted.
Minimize
glare.
Ask the
resident where you should sit so that he or she can see you
best. Some residents have decreased central vision or limited
ability to turn their heads.
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Establish
rapport and respect.
The steps
you have already taken to ensure comfort go a long way toward
establishing rapport and demonstrating respect.
You can also engage the resident in
general conversation to help establish rapport.
If the resident asks a particular
question or makes a request, try to address the request or
question before proceeding with the interview.
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Explain the purpose of the questions
to the resident.
Start by introducing the topic and
explain that you are going to ask a series of questions.
You can tell the resident that these
questions are designed to be asked of everyone to make sure that
nothing is missed.
Highlight what you will ask.
End by explaining that their answers
will help the care team develop a care plan that is appropriate
for the resident.
Suggested explanations and
introductions are included in specific item instructions. |
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Say and show the item responses.
It is helpful to many older adults to
both hear and read the response options.
As you verbally review the response
options, show the resident the items written in large, clear
print on a piece of paper or card.
Residents may respond to questions
verbally, by pointing to their answers on the visual aid or by
writing out their answers. |
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Ask the questions as they appear in
the questionnaire.
Use a nonjudgmental approach to
questioning.
Don’t be afraid of what the resident
might say; you are there to hear it.
Actively listen; these questions can
provide insights beyond the direct answer.
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Break the question apart if necessary.
If the resident has difficulty
understanding, requests clarification, or seems hesitant, you
can employ unfolding or disentangling techniques. (Do not,
however, use these techniques for the memory test).
Unfolding
refers to the use of a general
question about the symptom followed by a sequence of more
specific questions if the symptom is reported as present. This
approach walks the resident through the steps needed to think
through the question.
Example: Read the
item (or part of the item) to the resident, then say, “Do you
have this at all?” If yes, then, “Do you have it every day?” If
no, then, “Did you have it at least half the days in the past 2
weeks?”
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Disentangling
refers to separating items with several parts into manageable
pieces.
The type of items
that lend themselves to this approach are those that include a
list and phrases such as “and” or “or.” The resident is given a
chance to respond to each piece separately. If a resident
responds positively to more than one component of a complex
item, obtain a frequency rating for each positive response and
score that item using the frequency of the component that
occurred most often.
Example: An item asks
about “Poor appetite or overeating.” Disentangle this item by
asking, “Poor appetite?”; pause for a response and then ask, “Or
overeating?” If neither part is rated positively by the
resident, mark no. If either or both are rated positively, then
mark yes. |
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Clarify using
echoing.
If the resident
appears to understand but is having difficulty selecting an
answer, try clarifying their response by first echoing what they
told you and then repeating the related response options.
Echoing means simply
restating part of the resident’s response. This is often
extremely helpful during clinical interviews. If the resident
provides a related response but does not use the provided
response scale or fails to directly answer the question, then
help clarify the best response by repeating the resident’s own
comment and then asking the related response options again. This
interview approach frequently helps the resident clarify which
response option he or she prefers.
Repeat the response
options as needed. Some residents might need to have response
choices repeated for each item on a given list.
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Move on to another
question if the resident is unable to answer.
Even if the interview
item cannot be completed the time spent is not wasted. The
observation of resident behaviors and attention during the
interview attempt provide important insights into delirium,
cognition, mood, etc.
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Break up the
interview if the resident becomes tired or needs to leave for
rehabilitation, etc.
Try to complete the
current item set and then offer to come back at another time to
complete the remaining interview sections.
It is particularly
important to complete the performance-based cognitive items in
one sitting.
Do not try to talk a
resident out of an answer. If the resident expresses strong
emotions, be nonjudgmental, and listen.
Record the resident’s
response, not what you believe they should have said.
If the resident
becomes deeply sorrowful or agitated, sympathetically respond to
his or her feelings.
Allowing emotional
expression—even when it is uncomfortable for you as the
interviewer—recognizes its validity and provides cathartic
support to residents.
If the resident
remains agitated or overly emotional and does not want to
continue, respond to their need. This is more important than
finishing the interview at that moment. You can complete this
and other sections at a later point in time.
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Resident
preferences may be influenced by many factors in a resident’s
physical, psychological and environmental state, and can be
challenging to truly discern.
Residents should be
encouraged to articulate their desires and not be strictly
limited by their physical limitations and perceived
environmental restrictions.
When a resident is
unable to communicate information about his or her preferences,
a family member, close friend, or other representative must be
used to complete preference questions. In this case, it is
important to emphasize that this person should try to answer
based on what the resident would prefer. The resident’s
preferences while in the nursing home and the resident’s current
responses when the particular item is offered or provided should
form the basis for these responses.
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Psychosocial
Care Plans
Activities Care Plans
Coding
Manual for MDS 3.0
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