Persistent staffing shortages combined with regulatory headwinds have put even more pressure on nursing home MDS coordinators, a specialty position that itself has not been immune to the job turnover felt across the sector.
And their role to ensure that facilities get the reimbursement they earn and the right care is provided may be more vital than ever with proposed Medicare cuts on the horizon.
Some operators, like Milwaukee-based North Shore Healthcare, have looked for ways to make their MDS process easier and more efficient by keeping their MDS coordinators focused on assessments and by providing them more regional support.
But as staffing challenges have forced operators to rely on MDS coordinators more for patient care, that can sometimes be easier said than done, leaving them to choose between maximizing reimbursement and patient care.
“It’s unfortunate because they are RNs (registered nurses) so they do get hauled away too often and we try to protect that,” North Shore Owner and Partner David Mills told Skilled Nursing News. “Long story short, automation is helping, regional support is helping but there’s too much pulling on the floor of guys that we need.”
With facilities needing to maximize their reimbursement now more than ever, one strategy that more operators have started to implement is using regional MDS coordinators and MDS “floaters” to help out when experiencing thinning direct care staff.
“I had two conversations this morning with operators who previously maybe didn’t focus as much on reimbursement as others, but [with] some of the cuts coming in the proposed rule for PDPM coupled with occupancy challenges, staffing and raising costs, I’m starting to see an increased focus on reimbursement,” Vincent Fedele, Zimmet partner and director of analytics at Zimmet Healthcare Services Group, told SNN.
A short-term solution with long-term implications
Current staffing challenges have led more nursing homes to bring in MDS coordinators to work the floor and help out with patient care, but that strategy creates new problems of its own.
“It’s good for a day or two but it’s a Band-Aid. Right now, any RN you can find you’re trying to grab them,” Mills said.
With a $320 million Medicare cut proposed for 2023, the pressure for SNFs to most efficiently, properly and fully capture PDPM reimbursement will only grow.
Georgie Faulk-Sherwood, vice president of clinical reimbursement for Focused Post Acute Care Partners, thinks pulling MDS coordinators onto the floor should be a last resort for SNFs.
“We always say that we need to hold our MDS coordinators to a different standard which means they can’t be on call unless it’s adamantly an emergency because they are our moneymakers,” Faulk said during Skilled Nursing News’ recent Clinical Executive Conference in Chicago. “They need to be in the community, they need to be assessing those residents because they are making your money.”
Still, with staffing turnover the way it is – the SNF industry only added 900 jobs in April after losing 2,500 jobs in March – operators often have little choice in the matter.
“Our MDS coordinators have gotten really good at being CNAs,” Lorie Morris, SVP of assessment coordination for Prestige Healthcare, said during the same panel at the Clinical Executive Conference. “Our coordinators have spent time working as a caregiver and one of them called us that she was going to cook in the kitchen.”
Morris would like to think that when MDS coordinators and nurses are taking care of residents or are helping pass medication out they are getting to know residents better which could in turn help with assessments, however, this can lead to lags in MDS documentation and coordination.
“Sometimes staffing the way it is when you have an MDS coordinator working on the floor, they’re not getting the quality documentation that I would hope to see there,” she added.
The Polaris Group, a consulting firm which provides offsite and outsourced MDS coordinators to long-term care communities across the country, has seen MDS documentation fall months behind at some facilities due in part to their need for those nurses to provide patient care.
“If somebody’s not there to give them medication, of course you’re going to pull your MDS nurse, or your DON, or whoever is sitting in the office,” Wendy Strain, Polaris Group’s director of consulting services, told SNN. “But if at the end of the day, if you’re not bringing in the reimbursement you deserve, how are you going to run the building?”
Strain said it’s an “easy fix” for that day, but if a facility is constantly behind and doesn’t look at MDS in “real time” that’s when things can be missed with reimbursement.
She’s seen MDS coordinators quit at facilities due to being “overworked” with patient care. Strain worked with one facility whose billing and MDS completion was two months behind so they were unable to bill following the resignation of their MDS nurse.
Being two months behind can translate to hundreds of dollars a day per resident that’s being left on the table that the facility is entitled to, Strain added.
Creating more backstops for the MDS process
As staffing shortages persist, several companies like Zimmet Healthcare Services and The Polaris Group have seen a rise in their MDS services as adding more checks-and-balances through outsourcing and MDS “floaters” have become a popular strategy for operators to ensure that turnover doesn’t affect PDPM reimbursement.
“During Covid we found that many of our clients were in situations where they had no MDS or had an illness or had staff out for months so we came up with a plan to do off-site remote MDS completion,” Strain said. “In the beginning, I didn’t think it would work. I was old school and felt like the MDS nurse had to be on-site.”
However, seeing some of the challenges operators were having with MDS accuracy and completion, Polaris started offering outsourced, off-site, remote MDS coordinators in January that would go in and take over the department “as much as the operator wanted.”
Strain said one benefit is that the service takes the “temptation” away from operators to instead use the MDS coordinator for patient care.
“I was discussing it with one CEO and owner and who said they won’t have that MDS nurse to pull to the floor and I said ‘exactly,’” she explained.
Zimmet has seen its MDS outsourcing platforms grow four-fold since October.
The consulting firm offers two types of MDS outsourcing opportunities to SNFs. The first is more of a temporary staffing model and if a staff member is out Zimmet comes in to “plug a hole” on a short-term basis.
The other is that Zimmet takes over MDS functions more holistically and “leads the charge” in completing MDS assessments.
“At larger organizations often you’ll see they have their dedicated MDS person in the building and then they’ll have kind of like a float person that plugs in holes throughout the organization,” Fedele explained. “Option B is really conducive to that float person, where we plug in holes and act as a flow coordinator across the larger organizations.”
He added that it’s become a very “scalable” approach and from a value proposition standpoint, it’s an “easy sell” as Zimmet leverages technology and workflow automation to improve the MDS process and make it more cost efficient.
Others have tried to improve their MDS support in-house.
“We have four regional directors of clinical reimbursement that are pseudo MDS coordinators that oversee a group of buildings and when we have an opening we’re able to use them to help out,” Fedele said. “We still have to have eyes on the patient but through [remote services] we can review documentation and become more efficient on the MDS process.”
Strain has seen some operators follow this trend as well and others try to do it more internally by developing a pool of MDS coordinators.
On the other side, she has also seen a rise in MDS nurses seeking remote work.
“Whether it be with a company like ours or a corporate facility who is willing to let the MDS nurse work offsite, it’s been a huge trend,” she said. “If you peek into the MDS Coordinator Facebook groups, you’ll find several groups and hardly a day goes by that somebody isn’t asking questions about how to get a remote job or how to convince their their owner-operator administrator that they could do a better job from home because of the distractions in a facility.”