Dr. Levine is a nationally recognized expert in wound care and pressure ulceration. and has published and spoken widely on this topic. He is a Board Member of the National Pressure Ulcer Advisory Panel (NPUAP). Dr. Levine's Pocket Guide to Pressure Ulcers co-authored by Elizabeth Ayello RN and published by the New Jersey Hospital Association is in its 4th printing and has sold over 30,000 copies.

Hear ye!  Hear Ye!  RAPs are out!  CATs and CAAs are in!

I chuckle as I write this blog post knowing that few of my regular readers will understand, and have probably clicked off by now.  But the few of you who remain know how important this topic is to long-term care.

Dr. Jeffrey M Levine On October 30, 2009 CMS finally released the RAI Users Manual V 3.0 which contains the long awaited MDS 3.0.  These mandatory assessment tools will go into effect in all Medicare certified skilled nursing facilities on October 1, 2010.  They are accompanied by a new, more complex RUGs IV Payment System which adds several new categories and significantly increases payments weighted toward clinically complex residents.

You may already know that RAI stands for “Resident Assessment Instrument,” and that this tool is mandated for all residents of Medicare certified skilled nursing facilities by the Nursing Home Reform Amendments, or OBRA-87.  The RAI is the cornerstone upon which is built the processes of care planning, reimbursement, and quality improvement in the nursing home.  The current RAI Version 2.0 has been in use for the past 15 years, and the revised version will go into effect very soon.

Changes in the new RAI are numerous.  Many assessment areas have undergone major revisions including cognitive patterns, depression, behavior, and falls.  A new assessment section was added for pain.  MDS 3.0 has adapted resident interviews for some sections to increase the resident’s voice in the care planning process.  The skin component (Section M), which deals with pressure ulcers, is significantly expanded and will force most facilities to completely revamp their skin tracking programs.

The old RAI used Resident Assessment Protocols (RAPs) as a link between the Minimum Data Set (MDS) and the care plan.  The RAPs are now discarded in favor of an expanded system which includes the Care Assessment Triggers (CATs) and Clinical Assessment Areas (CAAs).  The CATs will serve the same purpose as RAPs, guiding the interdisciplinary team toward a comprehensive assessment.

The CAAs serve as extended resident assessment areas, and facilities are instructed to choose current clinical protocols, tools, and resources for this process which must be identifiable on request by CMS.  According to the RAI User’s Manual, CAAs are “decision facilitators.” The rationale for these architectural changes in the RAI lies in the criticism that MDS 2.0 did not employ standardized assessments which compromised its reliability and accuracy.

Has your facility started on the learning curve for MDS 3.0?  If not, time is quickly ticking to October 1, 2010 and you have a long way to go.

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The  RAI User’s Manual V 3.0 can be downloaded here

A reference for this post was Rahman AN et al, The Nursing Home Minimum Data Set Assessment Instrument:  Manifest Functions and Unintended Consequences. The Gerontologist, 49(6), 727-735.



  • Richelle
    10/13/2010, 5:30 am  Reply

    I am a student at the University of Kansas Medical Center working on a pressure ulcer prevention project in long term care areas. I was hoping you could help shed some light on what triggers a pressure ulcer prevention care plan. Is there a certain list of items/risk factors that would identify that a patient was at risk for a pressure ulcer and then provide interventions. I have read a little about care area triggers and care area assessments but I have not found a specific list of the actual triggers. Thank you so much for your time.

    • 10/13/2010, 9:09 am

      Good question Karen. I would start with the risk-assessment section of MDS 3.0, Section M. You can download this section at my post:

      You will find that along with the commonly accepted risk-assessment tools such as Braden and Norton scales, there is clinical assessment which is more of a bedside technique employing other factors such as severe anemia, hypoxia, and other underlying illnesses. MDS 3.0 does a good job advancing this concept.

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Dr. Jeffrey M. Levine has authored numerous articles on topics related to healthcare of the elderly. These include medical history, prevention and treatment of chronic wounds such as pressure ulcers, elder neglect and abuse, and physical restraints. He has also edited a book on legal and regulatory aspects of nursing homes.