Use of admission MDS data to capture unrecognized cognitive impairment in heart failure: Implications for community care transitions

Background

Skilled Nursing residents who have cognitive impairment (CI) in heart failure(HF) have a significantly higher mortality rate. These residents’ ability to self-manage their complex care upon discharge is critical for positive health outcomes.

Method

We conducted a secondary data analysis of admission MDS records for 79 residents admitted for HF care from 2021 to 2022.

Results

Seventy-nine eligible admission MDS records were included in the study. Only one additional with DC diagnoses of CI in HF was captured upon discharge. Twenty-seven (35.1 %) records affirming CI in HF were omitted from the discharge diagnosis list or discharge summary.

Conclusion

This secondary data analysis of admission MDS records in two large mid-south metropolitan nursing facilities uncovered quality improvement opportunities, including improving facility interprofessional communication, opportunities to capture and improve diagnostic accuracy, the potential value of an evidence-based discharge planning program, opportunity for improved hand-offs back to community primary care providers.