Why the NAC Has Become a Strategic Driver of Value-Based Success in Skilled Nursing

This article was originally featured in Skilled Nursing News.

As value-based care continues to reshape post-acute environments, skilled nursing providers are being evaluated on more than the care they deliver. Increasingly, success depends on an organization’s ability to identify risk early, reduce avoidable hospitalizations, support successful transitions, and demonstrate measurable outcomes for hospitals, health plans, and other value-based partners.

Meeting those expectations requires providers to align assessment data, patient status, care planning, interdisciplinary collaboration, and clinical decision-making in real-time. That reality is placing greater focus on one of the most influential, yet often underrecognized, roles in skilled nursing: the Nurse Assessment Coordinator (NAC), often referred to as the MDS Coordinator.

Positioned at the intersection of clinical care, quality performance, patient transitions, and financial outcomes, NACs help organizations identify risk sooner, coordinate timely interventions, and drive performance in an increasingly value-based environment. At the same time, patients are arriving in skilled nursing settings with greater clinical complexity, creating a narrower window for providers to recognize changes in condition and intervene.

For Jim Shearon, RN, BSN, MSHA, Vice President of Clinical Solutions at Real Time Medical Systems (Real Time), and Michele Self, MA-SLP, Customer Success Manager at Real Time, that combination of clinical insight and operational visibility has made the NAC one of the most strategically important roles in the building.

“The Nurse Assessment Coordinator is the individual who sets eyes on the patient and the chart as soon as they know they’re coming and right as they enter the facility,” Self says. “They follow that patient’s care throughout their stay.”

That unique perspective enables NACs to connect patient data, clinical insights, and interdisciplinary observations from across the organization, helping care teams recognize changes sooner, respond more effectively, and stay aligned around patient goals from admission through discharge.

Turning assessment into action

In skilled nursing, changes in condition rarely begin with a major event. More often, warning signs emerge gradually through subtle shifts in function, behavior, clinical status, or documentation patterns. Because NACs work across assessment, care planning, documentation review, and patient monitoring, they are often among the first to recognize when something is changing.

“They’re constantly monitoring the patient in the chart and at the bedside,” Self says. “When they notice that change, their voice is the one telling their team, ‘Something’s going on with this patient.'”

That visibility becomes increasingly important as patient complexity rises and providers face growing pressure to improve outcomes while reducing avoidable utilization. Identifying changes before they escalate into significant clinical events can alter a patient’s trajectory, support timely intervention, and help prevent unnecessary hospital transfers.

For Shearon, one of the greatest opportunities for providers lies in identifying emerging risk factors before they appear in traditional assessments or outcome measures.

“If we wait for the MDS process to tell us something has changed, it’s too late,” Shearon says. “The opportunity is to recognize risk while there’s still time to intervene and influence the outcome.”

In a value-based environment, organizations that can detect and respond to risk quickly are better positioned to improve outcomes, strengthen quality performance, and manage the total cost of care. Much of that visibility comes from the NAC’s ability to connect information across disciplines, assessments, and care planning activities throughout the patient’s stay.

Connecting care teams and supporting successful transitions

Risk identification is only valuable if the right people receive the information and act on it. That’s where the NAC’s role as a connector across the interdisciplinary team becomes critical.

Nursing, therapy, providers, social services, and case management each contribute important insights about a patient’s condition and progress. The NAC helps bring those perspectives together by ensuring assessments, documentation, and care plans accurately reflect the patient’s status and evolving needs. Because NACs work across disciplines, they are uniquely positioned to identify patterns, connect observations, and help teams stay aligned around patient goals, emerging risks, and treatment priorities.

According to Shearon, organizations realize the greatest value from the role when NACs are integrated into clinical decision-making rather than viewed solely as documentation resources. Skilled nursing providers need to position the NAC “in the center of the IDT team, and not sitting in a silo off to the side,” he says.

That same coordination plays an important role in discharge planning, which begins much earlier than many realize. Successful transitions are not built during the final days of a patient’s stay. They begin at admission, often during the initial baseline care plan discussion, when patient goals, support needs, and discharge expectations first start taking shape.

As patient needs evolve throughout the stay, discharge plans must adapt accordingly.

“If everyone’s not on the same page with that change and direction of treatment, the patient could leave the facility without complete follow-through,” Self says.

Documentation helps keep the interdisciplinary team aligned around patient needs, treatment goals, and discharge readiness.

Shearon notes that successful discharge planning also requires understanding how patients function beyond scheduled therapy sessions or clinical encounters.

“That’s what NACs bring to the team, that whole 360-degree view of what’s going on with that patient,” he says.

When discharge planning starts early and remains connected to ongoing assessment and communication, providers are better positioned to support safer transitions, reduce readmission risk, and build confidence with hospitals, health plans, ACOs, and other referral partners.

Why assessment accuracy matters more than ever

The NAC’s impact extends well beyond clinical coordination. Assessment accuracy directly influences quality performance, reimbursement, and an organization’s ability to demonstrate value.

MDS data affects quality measures, Five-Star ratings, reimbursement, and how effectively patient complexity is captured. When changes in condition and clinical needs are accurately documented, providers are better positioned to demonstrate the quality of services being delivered while ensuring reimbursement appropriately reflects the care provided.

“Assessment accuracy isn’t just about reimbursement,” Shearon says. “It’s about making sure the organization has an accurate picture of the patient so the right clinical and operational decisions can be made.”

Strong documentation also strengthens trust with referral partners. Increasingly, hospitals, health plans, ACOs, and other value-based partners are evaluating skilled nursing providers not only on outcomes, but also on their ability to identify risk, communicate effectively, and respond quickly when patient needs change.

“They don’t want to hear us come back in a week and go, ‘Oh, by the way, this happened four days ago,'” Self says. “They want us to keep them informed in the moment, in real-time.”

That level of transparency has become increasingly important as referral partners narrow networks and evaluate providers based on outcomes and performance. Organizations that consistently demonstrate strong care coordination, timely intervention, and clinical accountability are often better positioned to strengthen those relationships.

When the NAC role is under-supported, the effects often surface first in assessment accuracy, care planning, and communication before ultimately impacting organizational performance. As staffing pressures persist across post-acute care, organizations that view the NAC solely as a documentation resource may miss opportunities to leverage the role’s broader clinical and operational impact.

Shearon summarizes the role’s significance in simple terms.

“The NAC is the glue,” he says. “They’re holding it all together.”

Enabling value-based success through clinical intelligence

As the NAC’s influence on outcomes, quality performance, and reimbursement continues to grow, access to timely, actionable patient data becomes increasingly important.

For many organizations, the challenge is not a lack of data. It is identifying which patients require attention before a hospitalization, clinical decline, documentation gap, or missed intervention occurs. Data-driven clinical solutions help address that challenge by surfacing meaningful changes in patient status, emerging risk factors, and actionable trends that might otherwise remain buried within patient records.

By surfacing documentation trends, emerging risk indicators, and high-priority patients, advanced analytics and clinical insights platforms help NACs focus their attention on where intervention can have the greatest impact. Rather than requiring teams to manually search through large volumes of patient data, these tools help prioritize interventions and support faster, more informed decision-making.

For organizations participating in value-based initiatives, that visibility can help accelerate intervention, strengthen post-acute care coordination, and proactively address patient risk before it results in avoidable hospitalizations, care gaps, or poor outcomes.

Shearon believes providers should focus on solutions that do more than simply collect and organize data.

“It’s not just, ‘Here you go, install it and leave,'” he says. “It’s ongoing assessment and evaluation of how we can improve.”

Solutions such as Real Time help transform post-acute EHR data into actionable insights, enabling NACs and interdisciplinary teams to identify risk earlier, prioritize interventions, and act before emerging issues become costly clinical events. Rather than replacing clinical judgment, AI-powered analytics help amplify it by providing greater visibility into patient-level and population-level risk.

As hospitals, payers, and value-based partners place greater emphasis on outcomes, risk management, and performance transparency, the ability to turn insights into action becomes a competitive differentiator. NACs sit at the center of those efforts, helping organizations translate assessment data into meaningful clinical and operational decisions.

Increasingly, the question is no longer whether the NAC contributes to organizational success. The question is whether providers are fully leveraging one of the most strategically important roles driving outcomes, quality performance, and value-based success.

You may view this article on the Skilled Nursing News website, here.