During the pandemic, priorities shifted. They had to. The safety and care of the residents was the number one priority, and it required all hands on deck. Nurse assessment coordinators (NACs) found themselves working the floor, filling nurse aide shifts, and assisting with mass testing efforts. Even the Centers for Medicare & Medicaid Services (CMS) provided exceptions to the rules—including waiving the MDS completion and submission timeframes for a period during the public health emergency.
In June 2021, the American Association of Post-Acute Care Nursing (AAPACN) surveyed NACs regarding compensation, challenges, and time spent on MDS-related tasks. The pandemic’s effects were clearly reflected in many of the findings, and what was most telling was the stark decrease in time spent completing the care area assessments (CAAs). The 2021 AAPACN Nurse Assessment Coordinator Work Time Study and Salary Report found that the average number of minutes spent on CAAs per comprehensive assessment declined to 46 minutes, compared to 171 minutes in 2017. This is likely not surprising to many long-term care professionals, since the RAI process took a backseat to direct resident care during the pandemic. The waiver for MDS completion and submission may have also had an impact on CAA completion. Although this waiver was terminated on May 10, 2021, while it was in place many assessments were completed after the resident had discharged from the facility, making the completion of a well-analyzed CAA unnecessary. However, when the time is right, leadership in skilled nursing facilities should reassess the MDS workload to ensure NACs have adequate time to complete the MDS and CAAs that will drive resident-centered care plans.
While some facilities are beginning to recover and finally adjusting into a new normal, other facilities are still in crisis mode, as both the pandemic and staff shortages continue to wreak havoc in many areas. So, while right now may not be the right time to reassess priorities for all facilities, when that time comes, here are five tips to reassess how many hours are necessary to successfully work in the NAC position:
- Identify how many hours are needed to complete the comprehensive assessment for each resident, which includes the MDS, CAAs, and developing or revising the care plan. This part of the process is best completed by the NAC, or in collaboration with the NAC, to determine the average amount of time it takes them to complete this assessment.
The 2021 AAPACN work study report showed that it takes NACs, on average, 187 minutes to complete a comprehensive assessment. Compared to previous reports, this new completion time seems low. It reflects a decrease from over 300 minutes in both the 2015 and 2017 AAPACN NAC work study reports, largely due to the drastic reduction reported in time spent completing CAAs in 2021. Although these averages can help estimate the time needed, it is also important to identify how long it takes an individual NAC, as the average number of minutes varied greatly based on years of NAC experience and years of long-term care experience. But experience does not always mean quicker—NACs with four or more years of long-term care experience spent approximately 45% more time on CAAs than NACs with less than one year of long-term care experience. This may indicate that there are differences in the quality of the CAAs being completed, or it may suggest a lack of training in appropriate CAA completion for new NACs compared to those with more experience.
- Identify how many hours are needed to complete each of the non-comprehensive assessment types (e.g., tracking records, OBRA assessments, PPS assessments). This part of the process is also best completed by the NAC, or in collaboration with the NAC, to determine the amount of time, on average, the NAC needs to complete these assessment types.
Completion time for many assessments has remained consistent in 2021, compared to the 2015 AAPACN work study report, including assessments such as tracking records and OBRA quarterly assessments. However, as items have been added to the Medicare PPS assessments, the completion time for these assessments has increased over time. In 2015, the PPS 5-Day assessment took an average of 49 minutes to complete, but has expanded to 70 minutes, on average, in 2021.
However, an accurate determination of the hours needed in each facility depends greatly on how much time the NAC in that facility needs for MDS completion. In addition to individual variations, the NAC must consider all state requirements. For example, some states are now collecting PDPM data on OBRA assessments when not combined with a 5-Day, which may increase completion time for those assessments. Moreover, some states require additional assessments, such as Optional State Assessments (OSAs). Each of these factors can affect the time to complete non-comprehensive assessments.
- Identify the hours per month required for meetings and other additional duties.
The role of the NAC entails much more than just MDS completion and submission. The NAC often monitors and reports on changes in Quality Measures, Five-Star, or other trending data. The NAC is often involved in meetings that review residents at risk, weight loss, behaviors, or wound care, as these may signal the need to monitor for a Significant Change in Status Assessment. Additionally, the NAC often leads meetings on management of Medicare residents and the triple check meeting. All of this time must be accounted for when determining how many full-time equivalent (FTE) hours the NAC needs.
Also, consider any additional duties assigned to the NAC. These may include manager on duty, restorative nurse duties, COVID-19 testing or screening, management of physician certifications, or issuance of beneficiary notices, just to name a few.
- Run a report to determine how many assessments per type were completed within the time frame being assessed.
Often, a three-month time frame is used for analysis of NAC FTE hours due to fluctuations in census that may occur during a shorter time period. Once the time period is selected, run a report to identify how many assessments, per type, were completed. While there are often reports available in the facility’s MDS software, the Reason For Assessment Report (RFA) in CASPER will show all submitted assessments during a selected time period. Please note that any assessments not submitted to CASPER, such as for Medicare Advantage plans, would need to be calculated separately.
- Enter information into an FTE Calculator.
AAPACN created a NAC FTE calculator, available free for members, to calculate NAC FTE needs. This Excel tool provides instructions on one tab and the calculator on the next tab. Once all fields are completed, the tool will calculate the recommended FTE need. One FTE is equal to one 40-hour per week NAC. So, if the calculator shows the need is 1.5 FTE, then that equates to one full time NAC and a part time NAC working 20 hours per week.
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