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NACs, Need More Time? Four Areas to Gain Efficiencies

The nurse staffing shortage that simmered in long-term care—and throughout the entire healthcare field—for years finally boiled over in 2020 as a result of the COVID-19 pandemic, with nursing homes nationwide reporting sometimes crisis-level staffing problems, according to news reports and studies alike. There are few indications that the eventual end of the public health emergency will significantly reduce the staffing shortage any time soon. The pandemic’s emotional toll has resulted in burnout for many nurses, who have chosen to leave their jobs and, in some cases, to leave healthcare altogether. On top of that, the demand for nurses already outpaced nursing school enrollment before the pandemic started, according to the American Association of Colleges of Nursing.

Amid this staffing shortage, nurse assessment coordinators (NACs) may continue to face clinical demands on their time—making a fine-tuned Resident Assessment Instrument (RAI)/MDS process more critical than ever. Scott Heichel, RN, RAC-MT, RAC-CTA, DNS-CT, IPCO, QCP, ICC, director of clinical reimbursement for LeaderStat in Powell, OH, suggests that NACs review the following potential time sinks to find ways to gain efficiencies in the RAI process:

Time per MDS

“NACs should take a look at how much time they spend completing an individual MDS,” says Heichel. Coding an OBRA comprehensive assessment (excluding the care area assessments and care plan) requires an average of 80 minutes, according to the 2017 AANAC Nurse Assessment Coordinator Time Work Study and Salary Report. In comparison, it takes an estimated 51 minutes to code the 5-day PPS MDS, according to the Centers for Medicare & Medicaid Services (CMS).

“Therefore, depending on the quality of the supporting documentation, it shouldn’t take more than an hour or two to complete most MDS assessments,” says Heichel. “However, NACs are very detail-oriented and structured in how they approach MDS coding. Sometimes, a NAC may get hung up on one or two questions, and they go down a rabbit hole digging for the 100 percent accurate answer. Finding this information sucks up the majority of their day, and they end up taking six to eight hours to complete a single MDS. This bogs down the entire RAI process.”

Being laser-focused on one or two questions on one MDS doesn’t mean that the next MDS is on pause, he adds. “The next MDS is coming down the line no matter what, and NACs have tight deadlines to meet—completion deadlines, submission deadlines, end-of-the-month billing deadlines—and many other variables that they must worry about.”

NACs have to learn when to draw the line, says Heichel. “Accuracy takes a certain amount of time and energy, and doing the due diligence needed to accurately code the MDS is obviously very important. However, NACs must find a balance between meeting their responsibility to be accurate and the need to keep the RAI process moving.”

The question that NACs should ask themselves is: “Did I make a good faith effort to find the correct response?” suggests Heichel. “NACs should make their best effort to be accurate, but they have to figure out when to ‘cut the rope’ and move forward. Otherwise, they may spend so much time on one particular question that they end up constantly playing catch up on multiple other MDSs. This could not only reduce their efficiency and impact their job performance, it also could have survey or payment implications.”


The fact that too many meetings can reduce a NAC’s efficiency isn’t news to anyone, says Heichel. “Sometimes, providers have meetings out of habit. The participants rattle off some information, but essentially they are wasting time because nothing is gained from the meeting. In other meetings, participants have to sit around the table waiting for the meeting to start because someone is late. Or there may be side conversations occurring, preventing the meeting from staying on topic. That is all time that eats into the RAI process.”

However, it’s important to realize the positives that can come from a well-run meeting, says Heichel. “Robust, standardized meetings are a great way for NACs to gain valuable insights into potential clinical changes for their existing residents. Meetings also can help NACs keep a pulse on entries and discharges, and on the admission of new Medicare-covered residents. Pulling information out of meetings can make a NAC’s job easier and more efficient because the information they need is being shared readily.”

In fact, facilities where NACs attend no meetings at all may have difficulties as well, says Heichel. “I would question that because I’m not sure how a NAC would get all of the information they need to organize and plan their day—or to keep up with changes in a resident’s acuity.”

To find the balance needed for an efficient RAI process, NACs should look at all meetings they attend—daily, weekly, monthly, and quarterly—to determine whether each meeting fulfills at least one of two criteria, says Heichel. “First, is there a benefit for the NAC to be there? Will the NAC gain some direct, unfiltered knowledge that will help them manage some aspect of the RAI process? Or will having another meeting participant e-mail the NAC a high-level overview of what happened be sufficient?”

The second question is whether the team benefits from the NAC’s presence at the meeting, says Heichel. “Is the NAC bringing information to the table that helps other staff do their jobs? If there isn’t a benefit to either the NAC or the rest of the team from the NAC’s presence, then it’s time to re-evaluate their attendance. It’s critical to figure out which meetings are essential for the NAC, especially in a staffing shortage when they could be working the floor the next day.”

If there are too many essential meetings, it may be time for a facility-level or even corporate-level review, says Heichel. “Leadership may need to see if they can do anything to revamp the meeting process and make it go more smoothly.”


With the exception of the resident interviews, every question on the MDS needs to have enough supporting documentation in the medical record that anyone reading that documentation should be able to come to the same conclusion that the MDS assessor did, says Heichel. “However, multiple team members need to feed information into the medical record: floor nurses, nurse aides, outside consultants, wound care clinics, nurse practitioners, attending physicians, and others.”

Therefore, it’s no surprise that missing, inaccurate, or conflicting documentation can eat up a lot of a NAC’s time and throw a wrench into their productivity, says Heichel. “If NACs can’t trust the documentation that they are reading, they sometimes spend the majority of their day either trying to make sense of existing documentation or hunting down missing documentation.”

Addressing documentation problems typically will take a larger scale process fix than just the NAC’s practices, says Heichel. “For example, MDS section M (Skin Conditions) is a common documentation problem area. There are so many variables between who saw the resident and their opinion of the wound that, at the end of the day, the NAC may need to come together with other team members to figure out what is accurate in the documentation and what they will do as a team going forward to capture that information on the MDS.”

Other duties

NACs often have “other duties” that don’t necessarily require the skills of an MDS nurse, points out Heichel. “Therefore, these duties could be farmed out to someone else if they are trained properly so that the NAC has the time to focus on the priorities of the RAI process.”

Common other duties include the following, according to Heichel:

  • Insurance preauthorizations and updates. “NACs often are in charge of doing all of the authorizations for residents who are on insurance,” says Heichel. “They sometimes even work as the case manager, gathering weekly updates from multiple disciplines, scanning and faxing over the updates to the insurer, and waiting for a response. All of this is necessary for the appropriate staff member to do, but for the NAC, it’s simply eating into their productivity.”
  • Physician certifications/recertifications. “Providers that run a high number of skilled residents, either on the fee-for-service Medicare side or the managed Medicare side, all come with physician cert/recert requirements on a routine basis,” says Heichel. “At least two times in the first 14 days of the stay and then at least every 30 days after that, NACs often are filling out these forms, getting the required physician signatures, and monitoring the timing of every step of the process.” While NACs are often given this responsibility because they are highly involved with these residents, the physician cert/recert process could be handed off completely or partially, says Heichel. “For example, if needed, the NAC could enter the reason for skilled care on the cert/recert form during the weekly Medicare meeting so that it doesn’t take any extra time out of their day. Then, they could hand off the form to whichever staff member is in charge of the process to take on the often more time-consuming activity of tracking down the physician and getting the form signed. Wrapping the NAC’s participation into an existing process like that reduces the negative impact on the RAI process.”
  • Beneficiary notices. NACs are often responsible for distributing Notices of Medicare Noncoverage and Advance Beneficiary Notices (form CMS-R-131 for Part B residents and form CMS-10055 for Part A residents), as well handling as any beneficiary appeals, points out Heichel. “However, keeping these processes on track is very time-consuming. They may be handled more efficiently by someone other than the NAC.”

Each of these duties is extremely important, stresses Heichel. “They have to continue to move forward accurately and timely no matter who is doing them. However, it may be worthwhile to consider training another team member to handle some of these items at least on a temporary basis if not on a permanent basis. Having other staff members successfully perform these functions will free up the NAC to focus on the accuracy and timeliness of the MDS and the RAI process.”

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