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PDPM reimbursement takes a holistic view of the resident and relies on a set of systems working in synchronization to account for the care provided. Each system views the resident from a different standpoint. Dietitians, social workers, admissions, billing, and nurses all play separate roles and must be able to communicate with each other in standup meetings. It is only by lining up these moving parts that you will be able to maximize PDPM reimbursement in your long term care software or long term care EHR. 

Nursing home roles graphic to improve pdpm reimbursement
Functioning systems in a nursing home are critical to PDPM reimbursement.

The experts on PDPM reimbursement at your facility will be your MDS nurse and, to a lesser degree, the rehab director. Administrators and DONs do not have the opportunity to immerse themselves in the details. And while CNAs are heavily involved in providing the services that impact PDPM reimbursement scores, they will not always be invested in documenting care in your long term care software, especially when they are short on time. But while the MDS nurse is the key to your PDPM score calculation, he or she still requires the support of other members of your team. 

Perhaps a simple analogy will help demonstrate the roles of team members in calculating PDPM reimbursement and how these roles work together to support the work of your MDS nurse. Imagine your long-term care facility as a police station. The CNAs are the crime scene investigators. They are on the floor, observing residents and taking note of what they see. But it is not their job to put all the clues together. That is the job of the MDS nurse, who is like a police detective in this scenario. The MDS nurse looks at all the clues and figures out what needs to be documented in your long term care software system. 

Leaders at the facility must make sure that their systems are functioning properly. The DON is not involved in documentation in your nursing home software or long term care EHR. Rather, the DON performs the functions of a police captain (monitoring the budget and overseeing the department), a police lieutenant (overseeing hiring and acting as ambassadors by engaging with the families of residents), and a police sergeant (supervising and training nurses). Finally, the nursing home administrator is similarly not involved in documentation and instead supervises the various departments at the facility and plays the role of chief of police in our analogy. 

How the Nursing Home Administrator Can Support the MDS Nurse

Administrators carry great weight in terms of the authority they wield at long-term care facilities. They must leverage that authority to keep their systems on track. A good nursing home administrator persistently asks the MDS nurse if he or she is communicating with CNAs and physicians and getting the information needed to calculate PDPM reimbursement in the long term care software system. 

Like a chief of police, the administrator will not necessarily have to worry about the overall state of PDPM if he or she does not notice problems. However, if the administrator hears that there is a weight loss problem or a complaint about food from family members, he or she must get to the bottom of it. 

two ladies looking at a computer in a nursing home and talking about PDPM reimbursement
Long term care software can make documentation easier for the MDS nurse and director of nursing.

Nursing home administrators must: 

  • Make the job of the MDS nurse easier: If the MDS nurses’ documentation is not timely and thorough, a facility will lose money. For this reason, the administrator should strive to cut the time that the MDS nurse spends on the floor so that he or she can fully commit to documentation using the nursing home software system. This means that the DON should be on the floor before the MDS nurse. If the latter is pulled to the floor to distribute medication because of call-ins, the facility will lose money on PDPM. 

The administrator can also step in and voice the concerns of the MDS nurse. While the MDS nurse should be aware of what is and is not getting documented in the long term care software system, he or she does not have the authority to demand more from CNAs, as they do not report directly to the MDS nurse. After reminding CNAs about a problem with documentation a few times, the MDS nurse’s calls may fall on deaf ears. The administrator, meanwhile, may not know that there is a problem. Still, the administrator is in a position to demand the documentation that the MDS nurse needs from CNAs. 

  • Ask the right questions. While administrators do not need to be involved with the details of PDPM reimbursement, they do need to know what earns the facility more money and how the systems they run affect PDPM. That means understanding what to emphasize in standup meetings and working through the MDS nurse and DON to ensure that the facility is on top of documentation in its long term care software. If the DON escalates an issue, the administrator must immediately address it. 
  • See that standup meetings related to PDPM take place and the appropriate content is discussed: During these meetings, the administrator must ask the MDS nurse PDPM-related questions about new residents or residents with new conditions. Perhaps a resident has a new wound or was put on oxygen. Even things like new orders, antibiotics, IV medication, or IV fluids must be reviewed by way of the long term care EHR. 
Nurse talking to other nurse about documentation and PDPM reimbursement.
A nursing home administrator must be supportive of the MDS Nurse.

If the administrator is not firm about these standup meetings and fails to hold the relevant people accountable, the system will fall apart. It is likely that, after a certain point, it will only be the MDS nurse and therapists, which is a bad sign. The activity directory and dietary only report to the administrator, which means the DON will not be able to check if their systems are working.

Because the MDS nurse is the expert on PDPM, it is not necessary that the administrator be directly involved with the ongoings of the meetings or even attend them all. However, the administrator should review the minutes or reports of meetings and double—or even triple—check to make sure the facility is not missing out on reimbursement opportunities. For instance, the administrator may hear that a resident is a two-person assist, in which case he or she should ask if that is being documented. 

How the Director of Nursing Can Help Your MDS Nurse

A director of nursing wears two hats: a money hat and a care hat. In essence, DONs oversee a number of systems related to nutrition, activities of daily life (ADLs), wound care, and reimbursement. So they must ensure that they are getting the resources—from receiving the initial paperwork from the hospital during admissions to getting nursing assessments and their subsequent documentation—necessary to run these systems that allow the MDS nurse to maximize PDPM reimbursement in your long term care software. 

The DON must also act as a liaison between departments to get different systems speaking to each other and ensure residents receive the care that they need and that it is properly documented in your long term care EHR. It is the DON who is responsible for communication between physicians and the rest of the facility, meaning he or she is a major player in helping nurses get the information they need for reimbursement in a nursing home software system so that they can calculate it in accordance with the PDPM Medicare or Medicaid regulations. 

Doctors looking at a tablet and smiling while discussing PDPM reimbursement.
PDPM reimbursement takes team work and collaboration.

A DON must: 

  • Learn what is most important for maximizing reimbursement: Like the administrator, the DON does not need to be involved in the actual documentation. But the DON should understand how PDPM works and think like a police captain by knowing what questions to ask to make sure the system is not broken. 
  • Clarify what needs to be charted for nurses and CNAs: Along with the nursing home administrator, the DON will determine what needs to be charted, convey that to nurses, and follow up to make sure it is being done. The DON creates priorities for the staff and removes barriers for them. 
  • Facilitate communication between physicians and nurses: The MDS nurse may need a diagnosis from a physician but have trouble getting a response. It is then the DON’s job to follow up and get the physician’s attention. If the physician is unwilling to cooperate, the DON may have to look into replacing him or her. The DON will also have to make sure that each member of the staff is onsite and engaged in their work. If the dietitian does not show up one day, it is the DON’s job to reach out and look into the matter. 

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Making Your MDS Nurse Feel Valued for Contributing to PDPM Reimbursement

A major part of managing your MDS nurse will be making sure that they feel respected and valued for their important role in calculating PDPM reimbursement. This is important because it will motivate him or her to be thorough and more concerned with the standard of care at your facility, thus increasing your profit margins. But it will also make it more likely that your MDS nurse will want to continue to work for you. And, once you find a good MDS nurse, you will probably want to retain him or her for a while. 

Here are some guidelines for making your MDS nurse feel respected and valued:

piece of paper for medical insurance
MDS nurses should be recognized for their dedication to calculating PDPM reimbursement.

Be generous: Experienced MDS nurses are very much in demand and can be expensive to keep. You must be willing to offer competitive pay, which can vary depending on if the individual is an RN or LPN. You should also include a sizable sign-on bonus of several thousands of dollars. 

One advantage in hiring someone as an MDS nurse is that you can offer a reasonable schedule; unlike other nurses, it is possible to only require them to be available during certain hours (like 9 A.M. to 5 P.M.). This means that they will not have to worry about getting pulled to the floor unpredictably, which will appeal greatly to candidates, especially those who are older. 

Check in on them: Administrators and DONs must talk with MDS nurses regularly and check to see if there are any obstacles that they can remove from their paths in documenting care in your long term care EHR. Use morning standup meetings strategically. These are opportunities for you to follow up on tasks that were discussed the previous day.

Remember, an administrator sets the tone for the building, while the DON sets the bar. So they must make themselves accessible to the MDS nurse and convey that they are always willing to provide support and guidance. This, in turn, will affect how the MDS nurse holds others accountable for the purposes of reimbursement as documented in your long term care software. 

Be visible: The most appealing facilities to employees are generally those in which the administrator and DON move around and are not stuck behind their desks. They engage with staff, make their rounds to talk with residents and staff. They continue old conversations that interested nurses to demonstrate that they care. That sort of engagement will make your MDS nurse feel heard

Create a fun and lively atmosphere: Managing people is its own challenge, but leading a team of nurses can be particularly complicated. This is because these individuals are not driven by money alone. Rather, they have some sort of emotional investment in their work. Thus, you should use your emotional intelligence to determine when the team needs a pick-me-up. Pay attention to their emotional states and use events as a way to lift their spirits. This can be done by way of birthday parties and pizza parties for any and every special occasion.

Be an advocate for your team: While administrators only have so much power, they must always demonstrate that they are doing their best to keep their staff content. Suppose the MDS nurse requests a particularly expensive chair, but corporate will not sign off on it. In such situations, the administrator can, at the very least, show that he or she cares. While the administrator does not necessarily have to pay for the item out of pocket, he or she can convey that they are moving things up the chain and looking for a resolution. It is important to be transparent and involve the MDS nurse and others in the process—especially when something in the system is perceived to be broken—to give updates, and to take actionable steps. 

 What to Do When an MDS Nurse is Incompetent

If payors mention that they are not getting the documentation that they need and are hence reclaiming money (chargebacks), this could be a clear indication that your MDS nurse is not fully informed about your care system or thorough in his or her documentation in your long term care software system. 

Doctors looking at a tablet in a curious manner
Triple check meetings are a good way of getting an incompetent MDS nurse get back on track.

Triple check meetings are a good opportunity to receive an evaluation of your MDS nurse from your DON or therapy director. The latter, in particular, will often have enough experience at your facility to recognize when something is out of order. Further, the therapy director works closely with the MDS nurse and, thus, will know where to look for gaps in documentation in your nursing home software, especially as it pertains to reimbursement for therapy. 

If your MDS nurse is incompetent, you have the option of putting them on a performance improvement plan (PIP) and providing consultation by way of either the nursing home administrator or, for larger facilities, an MDS consultant. 

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