Article contributed by AAPACN Solution Provider MDS Consultants
By Kristine Martinez BSN, RN, RAC-CT, RAC-CTA, QCP, DNS-CT
It is a bit odd that when asked what you do for a living most MDS coordinators struggle to come up with an answer. Who struggles to explain what they do every day? The reality is that MDS coordinators fully understand what this multifaceted job entails but are at a loss how to put it into words for someone who isn’t out there doing it every day. Being able to answer this question quickly, completely and in such a way that is easy to grasp has a myriad of critical upsides.
What does MDS Stand for?
MDS stands for Minimum Data Set, which is truly not ‘minimal.’ The MDS is an interdisciplinary assessment for nursing home residents (who may be long term residents and/or receiving rehab) that helps capture each resident’s health needs, functional abilities, cognitive status, and psychosocial status for a variety of purposes. The MDS Coordinator is typically a Registered Nurse due to the nature of the data collection and care planning as well as the federal requirement that an RN signs for the completion of the MDS. The MDS Coordinator is responsible for overseeing the Assessment Process, also known as the RAI Process. This explains why most prefer to be called a Resident Assessment Coordinator (RAC) or Nurse Assessment Coordinator (NAC) instead of a Minimum Data Set Nurse. Other terms that may be appropriate for the manager of this position are MDS System Manager and Clinical Reimbursement Specialist. Regardless of the term used, completing the MDS is just the beginning of the role.
Where did the MDS come from?
The Omnibus Budget Reconciliation Act (OBRA) of 1987 is considered the birth of the MDS. The MDS comes with instructions called the Resident Assessment Instrument or the RAI manual. Through the RAI manual and MDS, OBRA established the requirement for a nationwide, comprehensive, standardized, reproducible assessment of each resident’s functional status. Over time, this data collection has expanded to include health, cognitive, and psychosocial evaluations as well as incorporated evaluations of resident preferences. This federally mandated assessment is used to compare quality among Nursing Homes nationwide; it also allows for comparison of quality among Nursing Homes within each state. When a Resident Assessment Coordinator (RAC) completes an MDS assessment and submits it to the federal government, the data collected is used to help improve the quality of care and quality of life for residents in nursing homes.
How does the MDS system work for the resident?
When the MDS was first introduced 30 years ago, it was a basic functional assessment. While the MDS continues to be a detailed functional assessment, it has evolved into much more. A comprehensive MDS is required for each resident at least annually. This is an evaluation of a resident’s ability to communicate and see, cognition, mood, behaviors, personal preferences for cares and activities, functional abilities, continence status, current diagnosis, health conditions, nutritional status, dental status, skin condition, care needs, restraint and alarm use, and goals. With the collection and synthesis of this information, the RAC develops a comprehensive care plan that staff utilizes daily to provide care that supports the resident’s goals and quality of life. An abbreviated assessment is conducted on at least a quarterly basis to evaluate the resident’s status; this allows for evaluation of the resident’s current needs and abilities as compared to the prior assessment. Quarterly comparisons allow the interdisciplinary team (IDT) to determine if changes need to be made to each resident’s care plan.
What are Care Area Assessments or CAAs?
Completion of the comprehensive MDS triggers Care Area Assessments, which are the critical link between the MDS and the Care Planning Process. The Care Area Assessments consist of 20 areas of concern that are common for nursing home residents that may require a more in-depth clinical assessment based on each resident’s unique health needs, functional abilities, cognitive status, and psychosocial status. The RAC uses the clinical record, resident interviews, the resident’s medical history, causes, contributing factors, lab values, physician consults, complete physical assessment, and any other pertinent information to investigate each relevant care area. The RAC then integrates this information using clinical judgment, critical thinking skills, and evidence-based nursing practice to arrive at conclusions about the resident’s status, needs, problems, and strengths to create an effective care plan.
The CAAs create the Care Plan for a resident
The care plan is designed and created to meet each resident’s unique wants, needs, and goals as they relate to their health needs, functional abilities, individual cognitive and psychosocial needs, and safety. When each resident’s preferences and goals are the center of the care plan, the approach to the resident’s care becomes holistic. Holistic care requires the support of the interdisciplinary team to ensure that the care plan promotes the resident’s highest quality of life and highest practicable level of function. Often the RAC oversees updates to the care plan as the resident’s needs and goals change. In doing so, the RAC facilitates coordination of care and services between the various IDT members and direct care staff.
Why is the MDS so important for payment and quality measures?
The MDS is used for reimbursement from Medicare, Medicaid, and some insurances. Medicare, Medicaid, and insurance reimbursement are critical to business sustainability and long-term facility solvency. Reimbursement from Medicare and Medicaid as well as private insurance requires that precise MDS data is collected, coded, and submitted to Centers for Medicare and Medicaid (CMS) per federal guidelines.
The same MDS information is utilized to create statistics for publicly reported quality measures as well. Quality data gathered in MDS process reflect facility performance and ability to manage resident risk for skin breakdown, restraint use, falls, psychotropic medication use, behaviors, depression, infections, use of indwelling catheters, weight loss, incontinence, and functional abilities. Accurate, timely data collection in the resident health record is critical to ensure that both facets – reimbursement and quality measures – are reproducible by an auditor who reviews a resident’s health record.
Finally, the MDS is also used to set nationwide thresholds for quality care metrics. MDS data informs quality initiatives such as the 5-Star Program in Care Compare (the online comparison site created to inform the general public about facility quality); Value-Based Purchasing (a Medicare payment incentive program); and the Quality Reporting Programs (the system of comparison of facility care metrics). Facility acuity and census information from the MDS impacts expected staffing ratios set by CMS. State surveyors pull information from the MDS that is specific to the facility during the facility comprehensive survey. The RAC must have a working knowledge of the programs mentioned above, and an understanding of how MDS data impacts each one.
Who can become a MDS Coordinator or RAC?
The ideal candidate to become a RAC is a nurse with excellent assessment and documentation skills. Successful RACs are curious, detail-oriented, comfortable with utilization of the nursing process, and willing to use critical thinking to advocate for each resident through holistic care planning. A career as a RAC involves working with the IDT and direct care staff to foster collaboration with all departments for the welfare of the resident. As an administrative nurse, a RAC is a leader and an educator who is interested promoting staff engagement in care planning as well as care delivery to support resident preferences. Collaborating with the interdisciplinary team (IDT) and direct care staff, the RAC can foster implementation of care planning approaches that improve and sustain each resident’s health, safety, and participation in their daily cares as well as activities they find meaningful. The RAC becomes the ‘right-hand man’ to both the administrator and the Director of Nursing Services in managing changes in resident health and care needs that have an impact on reimbursement and quality measures. The RAC learns to utilize resources such as the RAI manual, Medicare Benefit Policy Manual, MDS 3.0 Quality Measures Manual, Claims -Based Quality Measures Manual, and the 5-Star Users Guide. Participation in continuing education for accurate MDS completion, ICD10 coding rules, and quality measures management promotes confidence and competence in overseeing the many MDS facets related to the success of the long term care facility. The competent RAC has some form of formal training, and it usually takes a new RAC about a year to feel comfortable in the role.
Is there a Certification Program for this position?
The RAC may earn certification through a national organization, such as the RAC-CT through AAPACN. Experienced RACs may choose to pursue advanced training to become a specialist in clinical reimbursement. An additional credential a RAC-CT certified nurse may consider includes the RAC-CTA, which is an advanced certification that incorporates advanced principles of clinical reimbursement, Medicare compliance, RAI/MDS process integrity, leadership, ICD-10 CM accuracy, quality measure improvement strategies, and managing medical reviews. However, the most important role that the Resident Assessment Coordinator has is as a resident advocate.
How to answer the question, “What do you do?”
So, when a RAC gets asked, “What do you do for a living?” The response should be, “I am a nurse with a specialty in resident assessment coordination. I conduct assessments that help improve the quality of care for residents in my facility and nursing homes nationwide. I ensure that the care plan has a holistic approach and is centered around the resident’s wants, needs, and goals for care. I have a working knowledge and monitor quality measures and quality initiatives. I am a resource within my facility on Medicare and Medicaid reimbursement. Most importantly, I am an advocate for resident centered care and quality of life.”
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