Helping the assessors
Short staffing, training issues and turnover can add up and make coordinators’ lives more difficult when it comes to the time spent collecting data.
Minimum Data Set coordinators serve vital functions in today's skilled nursing facilities — their ability to dig deep is so critical that one software executive likens it to navigating the Andromeda galaxy.
But Andromeda has a measly 1 trillion stars to map. MDS 3.0 forms, says Jason Jones, have more than 43 quattuordecillion possible field combinations. (That's the number 43 followed by 45 zeroes, clarifies Jones, the chief technology officer of software supplier Simple LTC.)
Those data fields, of course, aren't just generating regulatory compliance. They dictate patient care plans, feed into the Five-Star Quality Rating System and hold growing importance in the face of value-based payments and other reimbursement changes.
So, what should be done with all that data, and just as important, how do you support the person tasked with making sure it's accurate and appropriate?
“It's critical for MDS coordinators to know what to focus on,” Jones says. “Otherwise, they fall victim to information overload, and reimbursement and quality suffer. The good news about MDS is that its data allows emerging technologies like machine learning and artificial intelligence to help MDS coordinators do their jobs.”
And they need help.
According to a biennial survey of MDS coordinators released by the American Association of Nurse Assessment Coordinators this spring, the average completion time for a single assessment has topped five hours.
Full-time coordinators spent an average of 80 minutes on the OBRA comprehensive assessment, 54 minutes on care planning and 171 minutes on care area assessments, according to the nearly 700 survey takers. Overall, MDS completion resulted in an average of 8.9 triggered care areas per resident.
Contributing more pressure: The increased time requirements of completing Section GG, which was added this year and has led to about 13.5 extra minutes to the 5-day Medicare PPS scheduled assessment.
“That 13 minutes in isolation does not seem significant,” says Jessie McGill, RN, RAC-MT, the study's co-author and a curriculum development specialist for AANAC. “But when you multiply it for each patient who is admitted on Medicare and those who are readmitted and depending on your Medicare census, that makes a big difference in how you spend your time.”
Karen Reed, a former MDS nurse and senior clinical educator for Ability Network, says time is the number one thing most coordinators need. She blames issues such as short staffing, high-acuity residents, training issues and turnover for making data collection so time-consuming.
“With more and more requirements each year added to the MDS, they can't simply keep working longer hours, bogged down by manual processes,” Reed says.
McGill says creating a smart workflow is key to cutting wasted time. Coordinators often spend precious minutes of their days emailing or physically chasing down material from colleagues in other departments, including pharmacy and therapy.
Software, she adds, can be a boon — or add more challenges if it's not done right.
“Tools have to be simple so MDS coordinators can use them effectively,” Jones says. “Otherwise, the job remains complicated and all that beautiful data goes to waste.”
Seamless transitions needed
Ewa Bigner, RN-RACT, is a senior clinical reimbursement specialist with Adventist Care Centers in Florida. She says the MDS coordinators she consults with develop a “vision” on how best to navigate software over time.
But consistency is critical. Coming into a new facility with different technology or changing systems restarts a two- to three-month learning curve, costing coordinators precious time.
“Most end-users learn quickly and require minimal follow-up instructions post-implementation phase,” says Bigner, whose 15 facilities use Netsmart's Vision EHR. However, “we like to periodically re-evaluate and assess their knowledge and provide training on individual cases.”
Vision allows interdisciplinary teams to respond to real time interviews and complete MDS assessments using comprehensive clinical data, explains Hannah Patterson, Netsmart's director of long-term care.
With daily charting, EHR entries are automatically populated into the MDS, including sections B, C, D, E, G, GG, I and O.
Kelton Swartz, Cerner's senior strategist for core clinical programs and capabilities, says populating up to 70% of the MDS with data drawn directly from therapy and pharmacy departments gives coordinators more time to review data, rather than just compile it.
Cerner's systems include embedded scrubbers that review entries across categories and look for potential errors from all departments.
Logic-based programs are blended with consulting expertise to identify items that might present as red flags to surveyors. They pop up on the dashboard, outlining the risk, suggesting double-checks or allowing the user to bypass the message.
When changes are made, Swartz says that the system tracks the correlating electronic health record data as justification.
“It gives them a second set of eyes,” Swartz says. “That has saved priceless dollars and prioritizes reimbursement and different outcome measures that help set up the care plan.”
Bigger demands ahead
MatrixCare Business Analyst Ray Alameda says Section GG is the tip of the reporting iceberg.
Claims data is being collected this year for the rollout of three new quality reporting measures: successful discharge to community, Medicare spending per beneficiary and potentially preventable readmissions.
“These new measures and those that will be enabled in the future set additional importance on how some MDS questions are completed,” he says. “A dash on the MDS has never had a bigger impact than it does today.”
At Ability, leaders work with MDS team members to create solutions. Last year, that led to a new Five-Star dashboard for Ability's Carewatch product. John Sheridan, vice president of business development, says the new component was a response to requests for analysis of ratings using current data versus months-old information on Nursing Home Compare.
Improved interoperability also remains a goal. McGill recounts a complaint by one coordinator whose partner hospital stopped sending 25 pages of printouts with new admits — but instead left nursing home staff to scroll through 200-plus EHR pages to find patient information.
Alameda says a better system would synchronize the exchange of information both across and within facilities.
That's a big concern for Andrew Porch, founder and CEO of Team TSI, which provides
analysis incorporating MDS and other data sets to create a “full-circle” of information.
Porch says some clients are stymied by data collection companies that hold patient data hostage and by hospitals that don't relay full treatment information back to skilled nursing facilities at readmission. Given the emphasis on rehospitalization, facilities need to know what happens to their residents when they're away.
They also need systems that allow them to see what-if scenarios that consider coding variables and reimbursement links.
“Our clients are asking, ‘What are the connective dots?' ‘If I do this, then what is the impact?'” Porch explains.
Though some old stereotypes would characterize coordinators as paper pushers, the job has evolved. The AANAC survey showed they spend an average of 11.6 hours each week in committee and other meetings, with Medicare management accounting for another 14.6 hours.
In some facilities, many are also still expected to perform nursing duties or have the added responsibilities of state-level pre-assessment work or pre-authorization and pre-certification work for managed care patients.
“They should be allowed to focus primarily on the MDS and not these other tasks,” says Joel VanEaton, BSN, RN, RAC-MT, RAC-CT, a consultant with Care Centers Management who serves as an MDS education coordinator for Extended Care Products.
Reed says she's also hearing frustration in understanding ever-changing rules and being held accountable for them “without adequate training.”
Kelly Danielson, clinical product management for MatrixCare, says having the right tools and quality communication between coordinators and leaders in nursing, therapy and social services also leads to better performance.
Continuing education, vendor resources and recognition of increasing time demands are other ways of supporting them.
“Is the MDS coordinator in an environment that is supportive of their role? Are they recognized for the value and importance of the job they are doing?” Danielson asks.
Maria Arellano, MS, RN, PMC-III, Clinical Product Manager for American HealthTech, calls the coordinator role “one of the toughest jobs in a SNF.”
“Trying to facilitate the RAI process across multiple departments involving a high volume of residents can be daunting,” she says. “You have lots of responsibility, but many times you may not have the authority over the individuals you need to support your work.”
A former MDS coordinator, VanEaton sometimes steps back into that role on a short-term basis at one of the eight facilities he advises.
He says the move toward value-based payments, the focus on outcomes and many of the recent regulatory changes have lifted the veil on the coordinator's job. Increased visibility, he says, can help underscore the value of the position and provide better opportunities for them to improve assessments.
“If you're not out of your office and moving around the building, then you're not going to make a good MDS coordinator, he says.”