MDS 3.0 RAI Manual

This website contains the MDS 3.0 RAI Manual v1.17.1 and MDS forms, effective October 1, 2019. This version of the MDS 3.0 RAI Manual incorporates clarifications to existing coding and transmission policy; it also addresses clarifications and scenarios concerning complex areas. Since the preliminary release of the manual on May 20, 2019, changes have been made to clarify which assessments swing bed providers must complete; the definition of the “interruption window” for interrupted Part A-covered stays; the coding of item I0200B; and changes related to group therapy policies, as well as other corrections. Please see the document titled “MDS 3.0 RAI Manual v1.17.1 Replacement Manual Pages and Change Tables_October 2019” posted in the Related Links section at the bottom of this page.

Care Transitions Intervention (CTI) Model

The Care Transitions Intervention® is also known as the CTI® and the Skill Transfer Model®. During a 4-week program, patients with complex care needs and family caregivers receive specific tools and work with a Transitions Coach®, to learn self-management skills that will ensure their needs are met during the transition from hospital to home. This is a low-cost, low-intensity evidence-based intervention comprised of a home visit and three phone calls.

INTERACT: Interventions to Reduce Acute Care Transfers

INTERACT (Interventions to Reduce Acute Care Transfers) is a quality improvement program that focuses on the management of acute change in resident condition. It includes clinical and educational tools and strategies for use in everyday practice in long-term care centers.

INTERACT is designed to improve the early identification, assessment, documentation, and communication about changes in the status of residents. The goal of INTERACT is to improve care and reduce the frequency of potentially avoidable transfers to the acute hospital.

Website requires login.