Do you anticipate significant changes in capturing depression end-splits for the nursing CMGs with the October 1st change to PHQ-2 to 9 from PHQ-9?



You’re not alone in contemplating the impact of the coming changes to capturing the depression end-splits; this is certainly a concern for many providers. As you know, if the total severity score for the Patient Health Questionnaire (PHQ) is equal to or greater than 10, the depression end-split can be captured, impacting the nursing case mix groups (CMG) for Special Care High, Special Care Low, and Clinically Complex. However, this October 1st changes bring an adjustment in which the resident responses to the first two items (PHQ-2) will determine if the full nine question interview (PHQ-9) is completed.


I’d like to direct your attention to Appendix D of the RAI User’s Manual where interview techniques “disentangling” and “unfolding” are reviewed. The text instructs us to break the question apart if necessary. “If the resident has difficulty understanding, requests clarification, or seems hesitant, you can employ unfolding or disentangling techniques.”

  1. Unfolding refers to the use of a general question about the symptom followed by a sequence of more specific questions if the symptom is reported as present. This approach walks the resident through the steps needed to think through the question.
    1. RAI V1.18.11 (draft), pg D7: If the resident has difficulty selecting a frequency response, start by offering a single frequency response and follow with a sequence of more specific questions. This is known as unfolding.
  2. Disentangling refers to separating items with several parts into manageable pieces. The type of items that lend themselves to this approach are those that include a list and phrases such as “and” or “or.” The resident is given a chance to respond to each piece separately. If a resident responds positively to more than one component of a complex item, obtain a frequency rating for each positive response and score that item using the frequency of the component that occurred most often.
    1. RAI V1.18.11 (draft), pg D-9: If the resident has difficulty with longer items, separate the item into shorter parts, and provide a chance to respond after each part. This method, known as disentangling, is helpful if a resident has moderate cognitive impairment but can respond to simple, direct questions.

For more tips in administering the Resident Mood Interview (PHQ-2 to 9), see Steps for Assessment and Interview Tips and Techniques in the RAI Draft User’s Manual V1.18.11 pg D 4-9. CMS also has a Video on Interviewing Vulnerable Elders.

Stacy Baker, OTR/L, RAC-CT, CHC
Director of Audit Services

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