The recently released version of the Minimum Data Set (MDS) Resident Assessment Instrument (RAI) manual contains “substantial revisions,” according to a statement issued by the Centers for Medicare & Medicaid Services (CMS).

Changes include standardized assessment items that need to be collected across post-acute care settings, allowing for comparison of quality and outcomes within and across all such settings. These revisions set standardized assessment language so that providers look beyond what the resident tells them.

In the latest revision, not only is standardized language incorporated for Section GG — used to measure the functional status of residents — but also Section A, which is used for collecting clinical information. The discharge process and medication reconciliation are updated as well, while transportation and social isolation assessments are new to the manual.

In keeping with the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act), the MDS changes offer residents more ownership and autonomy to follow their care over time and across multiple settings. In practice, this means providers will have to develop ways of ensuring and documenting that residents and families understand the services being provided Language in the manual was changed to be gender neutral as well.

It will be left to each state to determine how it will incorporate these changes. Some states, such as Wisconsin, Ohio, and Illinois, have already taken clear steps to do so. A completely separate and optional state assessment package will be released in late April or early May.

Once providers analyze the implications for their organizations, they are encouraged to work with their software vendors to incorporate the necessary updates into their systems before the October 1, 2023, the effective date for the MDS RAI manual revisions. 

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