The Minimum Data Set (MDS) has been a driving force in many areas of the long-term care sector of healthcare for nearly 30 years. Beginning as an assessment tool to drive the care plan process, and evolving into a tool that is now used for reimbursement and for the quality measures/survey processes, the MDS is scrutinized from a multitude of outside agencies for its accuracy.
Amazingly, providers continue to lack multidisciplinary understanding of this vital process. Often the MDS Coordinator is the only person on staff who knows the scheduling and payment guidelines. Many administrators, directors of nursing and even consultants are unaware of the coding rules and what portions drive the Quality Measures. It’s widely noted that a change of staff in the MDS nurse can cause large monetary shifts in reimbursement and also in favorable QMs.
The MDS Coordinator position is as specialized a position as one can have without additional formal training in the LTC industry. There are rules for Medicare, Managed Care, Case Mix, Quality Measures, and OBRA/Care Planning that all have to be followed and coordinated. There is an exception to almost every rule and that exception may only apply in one strange instance that only happens every once in a while. There are more than seven different manuals [RAI Manual, Quality Measures Manual, Medicare Benefit Manual, Managed Medicare Benefit Manual, SNF QRP Manual, SNF VBP Manual, Five Star Manual] for MDS Nurses to adhere to for instructions, interpretations and rules outside of the volumes of general LTC regulations. Some states have Case Mix rules in addition to all of those!
It often takes over six months of training for an MDS nurse to become “independent” in performing their job. It takes over a year for them to comprehend the myriad of intertwined rules. Mistakes often occur during this time period that cause negative survey outcomes and/or lessened payment reimbursement. This increases stress and resulting in additional staff turnover more often than not.
Next year, with the implementation of the Patient Driven Payment Model (PDPM) there should be some relief of MDS workload, yet it will likely be the next evolution of the MDS coordinator role. With payment shifting from therapy focus to clinical acuity focus, where will the documentation and assessment come from to ensure providers continue to be paid at optimal rates?
Providers will need hands-on assessments and detailed documentation to support the medical condition changes that drive reimbursement payment and provide the skilled level of care. Changes of condition and lack of progress towards planned goals will require immediate identification to ensure an interim assessment or significant change is properly identified and documented to continue accurate payment. Many providers will fail to capture these critical assessments and documentation if understaffed direct care nurses are expected to be the sole method by which the assessments and documentation are completed. There is already widespread noncompliance with the current assessments that have been developed as “check the box” forms because of the increased workloads due to higher acuity patients and decreased availability of licensed nurses to employ.
In several social media settings, there is a trending dissatisfaction from MDS nurses because of the high stress from heavy workloads and additional nurse manager duties such as on-call and floor rotations. But the biggest problem is feeling undervalued and under-appreciated by direct supervisors who don’t understand the MDS position themselves. With the shortage we have in licensed nurse staffing nationwide and the ever-shifting rules and workload, experienced MDS nurses are becoming a rare commodity. We cannot afford to squander their talents.
What investment should be made in this position? What support should be given to MDS nurses? If the MDS coordinator is suddenly off work due to medical illness, an emergency, LOA, vacation, or (heaven forbid) resignation, what is the backup plan?
Here are some tips to help find ways to reinstate MDS into the clinical team while still preserving the integrity of the MDS position:
- On-Call: If the MDS nurse must be in an on-call rotation, attempt to reduce frequency whenever possible. Always try to prevent on-call assignments during the last week and/or the first week of the month due to the MDS billing process.
- Cross Train: Develop a program to cross train other nurse managers in MDS duties. Possibly divide some of the MDS areas per nurse manager in order to have a backup for scheduling, MDS completion, and Care Plan completion (at a minimum). This can help relieve stress from the MDS Nurse who may feel unable to take time off or be away from the building.
- QM Programs: Pick an item per week or per month for the interdisciplinary team to learn about so QMs can be managed proactively. Identifying potential negative triggers during daily clinical reviews will often assist in the prevention of having to capture them on an MDS.
- MDS Appreciation: Recognize the little things every day that add up to the big things! Give kudos for being on top of the schedule, for meeting or exceeding budgets, for catching clinical concerns before negative outcomes occur. [There is a Nurse Assessment Coordinator Day — Make sure to celebrate it!)
- Open Communication: With the changes in the Medicare payment system with PDPM, there is a lot of angst about how providers will implement it and be able to provide staff for the changes. Discuss plans with the IDT and ask for ideas from the MDS nurses. They are the experts today and they will have some great ideas for how to tackle this as a team.
- Training: This is an investment in the MDS nurses and in the entire facility team! Ensure that the training source is vetted so as not to pay for information before the rules are finalized, but have a plan to start training as soon as possible! Start with ICD-10 coding, clinical assessments skills, and areas that aren’t based off of the RAI Guidelines or payment rules that are not yet published.
- Outside Support: There are many resources for MDS support from outside agencies. Corporate consultants, consulting firms (private sector and government funded, and Quality Improvement Organizations), associations, certification programs, and social media support groups. Find support for the MDS Nurses and the IDT team to ensure compliance and maximization of facility reimbursement.
- Encourage Personal Time: Minimize offsite work from the MDS Nurses. Many feel overwhelmed by their workload and take work home (including care plans, remote MDS completion, etc). This not only increases the risk for inaccuracies in the medical record and the potential for HR conflicts, it takes away from much needed personal/family time and then often adds to stress and resentment in the work place. Even if the MDS Nurse “volunteers,” discourage offsite work whenever possible in order to foster personal relaxation.
- Team Building: This is probably one of the most important items! Often due to a heavy workload and a lack of understanding of the position, the MDS Nurse becomes an outsider to the nursing team. MDS are not antisocial desk nurses (or at least they shouldn’t be!!) Schedule team building events on a regular basis to encourage interdisciplinary relationships.
- Monitor Workload: Keep an eye on census patterns and overall duties assigned to your MDS Nurse(s). Often census has a rapid rise and fall and while that puts a crunch on everyone, the MDS schedules lag from a few days up to two weeks and then don’t always match up. The reduction of hours for MDS to complete assessments may result in noncompliance and reimbursement issues. Additionally, if there is a large increase in MDS workload, look at duties that might be temporarily reassigned, such as dining room duty, room rounds, etc. These “extra” duties can take away precious MDS time.
This next year’s PDPM implementation will be as significant to MDS Coordinators as OBRA 1988 and MDS 3.0 2010!! Invest in your future by learning and supporting the RAI Process and MDS role. Make it one of your Top 10 “To Do’s”!
Rosanna L. Benbow, RN, CCM, CIC, DNS-CT, RAC-CT, is owner/consultant at Leading Transitions Post Acute Care and Staffing.