This measure is based on data from the MDS 3.0 assessment of short-stay nursing facility residents and reports the percentage of those short-stay residents who can self-report and who are on a scheduled pain medication regimen at admission (5-day PPS MDS assessment) and who report lower levels of pain on their discharge MDS 3.0 assessment or their 14-day PPS MDS assessment (whichever comes first) when compared with the 5-day PPS MDS assessment.
Measure Specs
General Information
Numerator
The numerator is the number of short-stay residents who have a 14-day PPS assessment or discharge assessment (whichever comes first), who can self-report,(MDS 3.0 item J200=1) and who are on a scheduled pain medication regimen (MDS 3.0 item J0100A = 1), reporting a defined reduction in pain when compared to their earlier assessment (a 5-day PPS assessment). Reduced pain is indicated, when compared to the prior assessment, there is a decrease in pain frequency (MDS 3.0 item J0400) or a decrease in pain intensity (as reported in MDS 3.0 item J0600A = 0–10, with 10 being the worst pain you can imagine, or a decrease in the verbal description of pain (MDS 3.0 item J0600B = 1–4, with 4 being very severe, horrible pain).
Denominator
The denominator is the total of all short-stay residents in the nursing facility who have a 5-day PPS MDS 3.0 assessment and either a 14-day PPS MDS 3.0 assessment or a discharge MDS 3.0 assessment (whichever comes first); who have been on a scheduled pain medication regimen (MDS 3.0 item J0100A = 1) and who do not meet the exclusion criteria.
Exclusions
A resident is excluded from the denominator if there are missing data in the relevant MDS questions.
If the short-stay facility has fewer than 20 residents in the sample, they are excluded from public reporting because of small sample size.
Public Comments