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Speak Up! Improve Communication to Bolster the MDS Process

Effective communication is the glue holding the MDS process together, says Stacy Grondel, BSN, RN, RAC-MT, CMAC, QCP. director of reimbursement operations at QRM in Addison, TX. “The nurse assessment coordinator (NAC) who is a strong communicator can develop better working relationships with the interdisciplinary team and executive leadership—and establish an MDS process that produces consistently accurate, timely MDS assessments. In turn, this will lead to a less stressful, more fulfilling work experience for the NAC as well.”

Keys to improving communication include the following:

Include three points in all MDS process communications

Effective communication about the MDS process requires a sufficient level of detail, says Grondel. “When you’re communicating, always provide Who does What by When. Failure to provide those three pieces of information leaves gray areas of potential misunderstanding that could result in process failures.”

Grondel offers two contrasting examples:

  • During the daily standup meeting, the NAC says, “X needs to be completed today.”
  • During the daily standup meeting, the NAC says, “Susan, X needs to be completed by end-of-shift today.”

“In the first example, the NAC is not specifically addressing one person, so no one on the team may feel that they need to take responsibility for that task,” points out Grondel. “In the second example, the NAC has ensured that Susan knows that she is in charge, what she needs to do, and when it needs to be completed. There’s no room for confusion.”

Take a collaborative approach when possible

While some MDS process issues can be solved with effective communication, others require more creativity, says Grondel. “For example, obtaining adequate, accurate documentation to support both the MDS and the clinical process is an ongoing struggle, and departments sometimes try to pin blame on each other and not own the problem. It’s easy for the NAC to fear that ‘if I try to fix this, it will become my responsibility.’”

However, that’s not a solution-oriented attitude, suggests Grondel. “Instead, you want to approach the problem with the attitude of ‘How can I help improve this situation by involving the whole team and not getting stuck doing all the work myself? Or, what solutions will help all of us get the documentation that we need?’”

Documentation improvement solutions may involve training staff using specific examples of what the documentation should look like, or adding triggers into the software system to help staff know when to document, explains Grondel. “But whatever the issue is, you should lead by example and figure out how to elevate and empower your team to do what you need them to do.”

Don’t speak in anger or frustration

“Trying to communicate when you are angry or frustrated could result in your message going unheard,” says Grondel. “There may be so much emotion in the way that you deliver your message that that is what people focus on. So if you are angry or frustrated, you should take a breather. You want to use that time to reflect on exactly what message you want to get across to the other interdisciplinary team members, the director of nursing services (DNS), or the administrator. Focusing on your core message will allow you to present the facts and be clear in what you are trying to convey to them.”

Say it twice so there’s a record

The MDS process is not only complex, it involves the participation of a wide range of interdisciplinary team members, points out Grondel. “So, it’s smart to communicate in both verbal and written form. You can build rapport with a face-to-face conversation, but then provide that same information in writing. For example, you could send an e-mail and say, “I just wanted to follow up on our conversation and confirm that we need the Brief Interview for Mental Status (BIMS) completed and signed by end-of-shift Tuesday for these five MDSs that are due’ or whatever the case may be. That way, you can look back if you ever need to and establish that you did communicate about that issue with this person.”

Manage personal expectations

Communicating effectively can be more difficult when the NAC is having a stressful, unfulfilling work experience, points out Grondel. “One way to make your own work experience more positive and connect with the interdisciplinary team is to manage your expectations of how the MDS process should work.”

MDS section GG (Functional Abilities and Goals) offers a good example of the need to manage expectations, says Grondel. “Effective Oct. 1, 2023, section G (Functional Status) is no longer needed for MDS coding unless your state uses the Optional State Assessment (OSA) for Medicaid case-mix purposes. Obtaining accurate documentation from certified nursing assistants (CNAs) for section G was a constant source of stress over the years, so many NACs celebrated its discontinuation on OBRA assessments.”

However, section GG data collection may present the same issues and stress for the NAC if CNA documentation is the primary documentation source, notes Grondel. “You have to acknowledge and address the realities of the situation. If the CNAs are providing supportive documentation for section GG, you must build time into your schedule for continuous section GG documentation audits and CNA education. Whether you need to train twice a month, once a week, or daily, you should incorporate that time into your schedule as part of your day-to-day tasks. This training is not an add-on task—it’s essential for MDS accuracy. Building it into your schedule will reduce your stress and improve your interactions with both the interdisciplinary team and leadership.”

Enlist the administrator’s assistance to enforce accountability

Roughly eight months after the end of the COVID-19 public health emergency (PHE), the professional environment in many nursing homes remains stressful, says Grondel. “Your goal may be to communicate clearly with the interdisciplinary team and hold team members accountable for fulfilling their part of the MDS process, such as documentation. However, staff are often tasked with competing priorities. Getting the administrator or CEO of your facility to work with the DNS and other managers to take the lead on that accountability piece can boost staff compliance—and reduce the amount of stress that you experience when communicating with other team members.”

Unfortunately, many administrators still don’t have a clear understanding of what the NAC position entails and just how long it takes to complete the MDS, acknowledges Grondel. “So, you may have to educate executive leadership on what you do and why it is important to the financial and even survey health of your organization.”

One good starting point is AAPACN’s Nurse Assessment Coordinator FTE Calculator Tool—FY 2024, suggests Grondel. “This tool uses the average time that it takes to complete each MDS assessment type, plus non-assessment tasks (e.g., meetings and Medicare Advantage plan management and reporting), to calculate your full-time equivalent (FTE) workload for your facility. This calculation allows you to present your time requirements in a clear way that executive leadership can understand. For example, you can show that if you have three comprehensive MDS assessments due on one day, and each assessment takes an average of almost three hours to complete, that involves more than one eight-hour workday.”

The next step is to re-enforce the importance of an MDS that accurately reflects the resident’s clinical status and care, says Grondel. “How are the financial stability and operations of the building impacted by an accurate MDS? Clarifying these items may help the administrator to understand the time requirements and benefits of protecting the NAC from unnecessary tasks and meetings.”

Once the administrator understands the basic time/benefit calculation of what the NAC does, they also will be better positioned to see the importance of taking on that enforcement role for the MDS process, says Grondel. “They will be primed to be on your side and back you up. So, you should provide a straightforward outline of exactly what you need from the interdisciplinary team to produce an accurate, timely MDS.”

For example, if other team members are completing resident interview items (e.g., the PHQ-2 to 9), when do they need to have those interviews completed and signed in the MDS? asks Grondel. “The administrator can’t enforce accountability if the Who does What by When isn’t clear to both the administrator and the team members.”

Resources for Talking About the MDS and the Need for Accountability  

For help explaining the reach of the MDS, take a look at AAPACN’s MDS Trickle-Down Effect tool. In addition, review the AAPACN guide MDS Items Impacting Reimbursement for the Patient-Driven Payment Model (PDPM) and the Skilled Nursing Facility Quality Reporting Program (SNF QRP) in combination with table 2, Case-Mix Factors in the Skilled Nursing Facility Prospective Payment System, FY 2024,” in the SNF Payment Basics fact sheet from the Medicare Payment Advisory Commission (MedPAC), which broadly illustrates how those MDS items feed into the PDPM case-mix-adjusted payment components. A detailed breakdown can be found in AAPACN’s PDPM At-a-Glance tool.  

For assistance explaining why accountability is so critical to the MDS process, see the July 31, 2023 AAPACN article “Accurate PDPM Reimbursement: Four Areas of Focus to Shore Up MDS Documentation” and the Dec. 5, 2023, AAPACN article “How to Explain the Nurse Assessment Coordinator Role to Others.” And, learn insights for building a better relationship with the DNS in the Oct. 25, 2022, AAPACN article “Partner Up! Working With the DNS to Create a Shared Vision Reaps Rewards.”

Find a positive support system within the NAC community

“Sharing information and insights with other NACs can help you gain significant expertise about the MDS process and how to incorporate MDS requirements into facility processes and systems,” says Grondel. “However, a twist on a quote I once heard is applicable here: ‘Don’t rehearse your doubts with other doubters.’”

That basically means that the NAC needs the support of other NACs who are positive about the job and want to succeed at it, says Grondel. “When you are always talking to people who are negative and complain about the job, it feeds into your own doubts, and you often take on that attitude as well. Surround yourself with people in the NAC position who see the good in what you are all doing so that you can carry that positive attitude into your interactions with your interdisciplinary team and your facility leadership.”

Note: The AAPACN Connect communities offer several options for networking to find like-minded NACs for support nationwide and within individual states.

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