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One year. When asked how long it takes a new nurse assessment coordinator (NAC) to fully learn the job, I say at least one year. The nuances of the Resident Assessment Instrument (RAI) and Minimum Data Set (MDS) are substantial. The instructions for coding the MDS, the RAI User’s Manual, are over 1300 pages—but that is not the only manual the NAC needs to be knowledgeable about. In addition to the regulatory requirements of the MDS, there are also survey implications, the impact on MDS 3.0 Quality Measures, SNF quality reporting, Medicare requirements, state Medicaid reimbursement, and more—each of which has at least one manual the NAC must properly apply. The volume and complexity of information NACs must master can make orientation a challenge. However, the right orientation plan can pave the way to a long, satisfying MDS career. For those tasked with orienting a new NAC, here are five tips that will help guide the process:
1. Incorporate Day One Introductions
Too often, a new NAC will start working in his or her office alone, or with only the other nurses in the MDS department. To be successful as a NAC, it is critical to remove those silos and establish an interdisciplinary team (IDT) approach to the MDS process as soon as possible. Ideally, on the NAC’s first day in the office, all IDT members will have a scheduled time to meet with the NAC and explain their role in the facility and their experience with the MDS. This process will introduce the NAC to key members of the IDT, many of whom are involved in completing portions of the MDS. This introduction is also important to allow the NAC to identify the level of experience each IDT member has with the MDS. Consider this example:
The dietary manager started two months ago and received her MDS training from the previous manager, but she is not confident she is doing everything correctly yet and has expressed the desire for more training and oversight. On the other hand, the social services director has been in the position for five years and completed a state training on MDS interviews two years ago. She also schedules and leads most care plan meetings. She is very confident in her MDS experience and believes she is completing interviews and coding the MDS correctly.
While this introduction does not explore the quality of the training the IDT member has, it does provide a foundation of the knowledge, experience, and comfort level the team member has with MDS process. This will guide future trainings and support for the entire MDS team. The team will need to learn, grow, and work together to ensure a timely and accurate RAI process.
2. Allow Time for Application and Practice
The NAC is not expected to memorize the 1300-plus pages of the RAI User’s Manual; however, the expectation is that the NAC will recognize where to locate the information when a question arises. During the first week, the NAC should start learning the MDS in detail, which means going line-by-line through the MDS and covering the RAI User’s Manual instructions. Attempting to complete training for all items A-Z in one sitting is not optimal. Instead, it is recommended to allow time for the NAC to apply and practice skills as they are learned. In practice, this might look like:
Once training is completed for sections B and C, the NAC can complete these sections on several assessments, as needed. The trainer and the NAC will review supporting documentation during the 7-day look-back window for section B, while applying the RAI definitions for each item. It is key for the new NAC to understand that he or she must follow the RAI definitions to ensure accurate and reproducible coding conclusions. Section C will involve a scripted interview; a key training point here is the timing of the interview, preferably the day before or the day of the ARD. The trainer also needs to explain how to assess the resident for signs and symptoms of mental status changes while the BIMs is being completed – which is part of the instructions for the CAM (Confusion Assessment Method) assessment at MDS item C1310.
This process of learning and practicing skills should continue throughout the NAC’s orientation. The trainer will add a few sections at a time and then allow the NAC to apply this information and practice coding these sections, along with the previously learned sections. This process should continue until all MDS items have been trained.
Often, there are sections that are assigned to specific IDT members. For example, section K is often coded by the dietary manager, and the behavioral symptoms section is often coded by social services. While regulations require that an RN coordinate and verify the completion of the MDS and Care Area Assessments, there is no regulatory requirement addressing who completes each section of the MDS. The team member assigned to each section must have the competencies needed to code the section accurately. When it comes to orienting a new NAC, the sections completed by IDT members can be trained last—but they still must be trained. Ultimately, the NAC will be responsible for monitoring accuracy and on-going education regarding the RAI process. The NAC may also need to be the back-up for coding these sections when the primary person is unavailable.
3. Build on Previous Lessons
The MDS directly affects many other topics—reimbursement, Quality Measures (QMs), surveys, and more. When training more complex items, it is important to tie concepts back to previously learned items and reinforce that education. This helps the new NAC internalize the connection between the MDS and other outcomes. Consider how a single item can affect multiple topics:
For Medicare reimbursement under the Patient-Driven Payment Model (PDPM), one of the key components is the accuracy of diagnoses in section I and coding MDS item I0020B. The primary diagnosis for the Medicare stay, which is reflected at I0020B, must meet the requirements for that diagnosis as learned during the training for section I—it must be a physician-documented diagnosis in the last 60 days and be active with a direct relationship to the resident’s status in the 7-day look-back period. When training on this section, highlight the impact that inaccurate coding of the diagnoses would have.
For a NAC to develop a comprehensive understanding of the impact the MDS has on reimbursement, a solid understanding of MDS coding instructions must be established. The NAC is also responsible for ethically following reimbursement rules and completing each MDS with integrity. This means that the MDS must accurately reflect the resident’s status at the time of the assessment, which will in turn generate the appropriate reimbursement and quality outcomes based on supporting documentation.
4. Audit and Re-educate
Orienting a new NAC requires ongoing attention, reinforcement, and re-education. To train effectively, a facility must validate that the training has been applied appropriately. This is best accomplished by auditing assessments the NAC has completed, preferably starting after the third week. The trainer should focus on auditing the coding that the NAC has previously been trained on and providing feedback on what was done well and what needs improvement. The coding instructions are very complex, especially when coding for a unique situation. The auditor will want to pay special attention to these situations to ensure the NAC is properly applying the coding instructions, coding tips, and the RAI examples.
For example, consider that activities of daily living (ADLs) are coded in section G using the Rule of 3:
The NAC pulled a report from the nurse aide documentation software which showed the resident transferred independently for all episodes and coded section G “0. Independent.” However, during the audit, the trainer identified that the resident had a fall on the last day of the look-back period and the nurse charted that the resident was transferred off the floor using a mechanical lift and total assist by staff. The trainer re-educated the NAC, reinforcing that nurse aide documentation may not be the sole documentation used to code section G. Prior to coding section G, the NAC must review documentation from nursing and therapy services, and also interview the resident and staff to establish a full and complete understanding of the ADL function during the look-back period. Using the nursing documentation of total assist with one transfer and all other transfers being independent, the trainer and the NAC modified the MDS coding to reflect “1. Supervision” with transfers.
5. Ensure Knowledge of Source Documents
Another key aspect of training is ensuring the NAC understands how to use the source documents to support how the assessment was coded. The RAI User’s Manual is the source document for coding MDS items. In case of an audit, whether internal or external, it is important that the NAC be able to justify a coding decision by citing to its authoritative guidance.
If a state auditor questioned ADL coding on a resident, it would be inappropriate for the NAC to state, “my trainer told me to code this way.” The NAC needs to be able to reference the RAI User’s Manual to explain how the Rule of 3 and other coding tips or examples were used to come to the coding conclusion.
Structuring the NAC’s training around knowledge and application of source documents not only sets them up for success, but also removes the dependency on the trainer. It can be very easy for a new NAC to develop the bad habit of asking the trainer the answer while never going to the source document. The goal is to guide the NAC to be able to answer their own questions by using the source documents—often validating their conclusion with the trainer until confidence builds. As a trainer, it is important to never just answer questions; look it up together, guide the NAC to the answer’s location in the RAI User’s Manual, and discuss the correct coding conclusion.
Conclusion
A successful orientation and training prepares the new NAC with key knowledge, builds their confidence, and lays the foundation for a great career. This phase of preparation is crucial to the NAC’s success, which then impacts everything from turnover, to interdepartmental communication, to overall resident outcomes.
For more resources on creating a great orientation, check out AAPACN’s new 10-Week Nurse Assessment Coordinator Orientation Guide Tool.
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