Happy Thanksgiving!
November 24, 2009
As home health nurses, it seems a shame just to have one day a year to celebrate being thankful. But before we all turn our attention to family and friends, I want to take a minute to share all that I am grateful for this Thanksgiving in the world of nursing.
I am grateful in an odd sort of way that I have a touch of a cold or something. Even though it is inconvenient and is slowing me down, it reminds me how many of patients feel. We can’t do this job without a little empathy.
I am grateful for the Federal Government without whom I would not have a job. We may call ourselves nurses and consultants but all of us are just glorified government employees being that most of home health revenue comes from Medicare and Medicaid. I just wish we had all those holidays. But OASIS-C training pays well and I am not complaining.
I am grateful for home health care aides. They not only leave our patients clean and fed, but they leave patients with dignity after cleaning up after them.
I am grateful for all the state, federal, local and JCAHO regulations. It seems that every move that a nurse makes is regulated by some governing body. This takes the burden of thinking away from the nurses and I am sure they have better things to think about.
I am grateful to the patients who welcome us into their homes and their lives. I am sure there are many nice nurses in the GI lab but not many people hold a warm place in their hearts for the colonoscopy nurse.
I am grateful for the clients who don’t know everything. I am not so grateful for the clients who don’t want to know anything.
I love coders. They are like fellow puzzle solvers and take away a serious burden from the nurses. Patients get better care because of coders.
I am so very grateful to my coworkers. Haydel Consulting Services may not be IBM or Microsoft but without my coworkers it would be nothing.
Finally, I am so proud and so grateful to call home health nurses my colleagues. I am proud when I tell people what I do. I enjoy teaching workshops and bragging on my clients or other nurses who have come up with creative ways to take care of patients. I love the laughter that y’all share. I am honored when you share the harder parts of being a nurse with us.
And that makes it a good day to be a nurse. Thanks to everyone and Happy Thanksgiving!
High Alert Medications
November 23, 2009
OASIS-C asks us if we have taught on high alert medications on admission and resumption of care. The chapter 3 instructions state, “High-risk medications are those identified by quality organizations (Institute for Safe Medication Practices, JCAHO, etc.) as having considerable potential for causing significant patient harm when they are used erroneously.”
The link below is the list from the Institute of Safe Medication Practices. It is the one we like best becaue it was originally designed for community pharmacies and doesn’t include medications only found in ICU’s and Operating rooms. If you know of another list that might be worth taking a look at, please forward!
As always, we welcome your comments below and your emails at haydelconsulting@haydelconsulting.com.
Open Letter to CMS
November 20, 2009
Centers for Medicaid and Medicare
Washington DC
Reference: OASIS-C Dataset
To Whom it may concern:
This letter is to inform you that my clients have opted out of the OASIS-C dataset based upon my recommendations. We will continue to use the OASIS B-1 dataset for the foreseeable future. While I recognize the problems with the current dataset, it is my opinion, fueled by the enthusiastic resistance of my clients, that the new dataset is even more confusing.
In order to teach the dataset, I have had to teach my clients how to lie. This is not a pleasant task for a consultant who respects honesty and integrity. And yet, the dataset repeatedly tell us that certain wounds will never heal but when responding to questions about healed wounds, we are to pretend that they are healed and lie.
Furthermore, we are not certain we can comply with physician notification requirements. The definitions of communication and physician designee should be clear but in the magical way of CMS, no one really knows what you are talking about. How much time do you expect my clients to spend collecting data that will be useless in another year because the questions are answered inconsistently?
One thing that I am really grateful for in the new dataset is that CMS does not mandate best practices as is stated repeatedly. All this teaching and training and my clients are still free to use mediocre practices. That’s very considerate of CMS. But, did it ever occur to you that no one wants to admit to using bad practices and therefore the data will again be rendered useless?
I am so relieved that we are spending an enormous amount of time investigating the patient’s ability to get to the bathroom, remove appropriate clothing, and manage the hygienic tasks associated with healthy skin and get back out of the bathroom safely. I noticed you added yet another question about toileting and I personally wonder if this is enough. Toileting is important. And yet, equally as important to a patient’s ability to participate in a plan of care is literacy and financial factors. Why chart that a patient is unable to get off the toilet and make a big deal about it if they can’t afford a toilet seat extension that makes it possible? And yet the dataset does not take into consideration the fact that most of my clients are rural and have a large number of functionally illiterate and impoverished patients. They are going to look horrible on outcomes reports!
Of course, there are many, many reasons why we choose not to adopt the OASIS-C dataset as recommended by CMS. Without going into all of them, consider this. I have a four inch binder on my desk with over 1000 pages of instructions on how to answer a 20 page dataset. Not only have I read every word but so have most of my clients. And we still can’t agree on what is said!
Should you decide to make any changes in the dataset or have it re-written by a person who speaks English as their primary language, please let us know at once and we will re-consider participating in OASIS-C activities.
With Warm Personal Regards,
Julianne Haydel
Consultant Extraordinaire
Note: For those readers who will choose to use the OASIS-C dataset, we are continuing education about the dataset the way it was meant to be taught; not the way we think it should be taught. Call us at 225-216-1241 for more information or check back regularly for new dates to be scheduled in December.
Starting at the End
November 18, 2009
If you want to score well in OASIS-C, chances are that your care planning will have to be taken to the next level. In reviewing clinical records the most common problem with care plans are that they are too vague. Some agencies are reluctant to put parameters on their clinical records because they may trigger too many phone calls. Orders to weigh patients have fallen off as agencies were cited on state surveys for not weighing patients. Orders for every possible intervention relating to diabetes are found on some care plans even though it is not realistically possible to carry all out all the orders in the episode.
This haphazard approach to care planning will help your agency’s performance in OASIS-C like cheesecake helps you lose weight. If you want to achieve financial and clinical success in OASIS-C, a refined approach to care planning is essential.
Starting at the end might very well be the best place to start – the end of the OASIS-C dataset. Every time you transfer or discharge a patient you will be faced with the ominous M2400. This ‘single’ data item is actually six questions. Specifically, it asks ‘Since the previous OASIS assessment, were the following interventions both included in the physician plan of care and implemented?’ for the following six individually assessed conditions:
- Diabetic foot care
- Falls preventions interventions
- Depression
- Interventions to monitor and mitigate pain
- Interventions to prevent pressure ulcers
- Pressure ulcer tx based on moist wound healing principles
Note that you will be reporting directly to CMS when you don’t address one of these areas AND perform the interventions as ordered. Those care plans that are regarded as a piece of regulatory fluff and don’t truly the guide the care of the patient will result in unfavorable information being sent to CMS.
Furthermore, if the visit nurse provides diabetic foot care or teaches regarding depression and it isn’t ordered on the care plan, it will not be reflected on this question.
So, start at the end. As you are writing care plan, keep this question in mind so that appropriate interventions will be ordered and then FOLLOW THEM!
OASIS-C training is ongoing at our training center. Please call 225-216-1241 for dates. In additions, we are available to provide training onsite at your location. As always, we welcome questions and comments in the box below as well as by email.
But Did You Call the Doctor?
November 15, 2009
Care Coordination is one of the most frequently cited deficiencies in state surveys. We seem to know the docs who don’t care about blood sugars out of parameters or won’t give wound care orders so we just don’t call them. Now, in addition to state surveys, the OASIS-C dataset will be looking at our communication with physicians.
Several questions in the OASIS-C dataset ask if the MD was notified in one calendar day. What the question really means is, “Did you notify the doc within one calendar day and get a response?” A fax confirmation is not a response for the purposes of this question!
And sometimes, the answer will be, ‘No’. No matter how hard you try or what action you take, sometimes, the physician or their designee will not be responsive. Consider a late Friday afternoon admission where a review of medications reveals that the patient is on both Zantac and Tagamet – a potential duplication of medications. You notify the MD after your admission and for some reason he doesn’t get back to you until Monday morning.
Many times, on call physicians leave all non-urgent calls for the patient’s regular physician. Some docs trust you to hold one of the meds until you hear back from them. Some docs are lazy and slow. And some, a very small minority, may not care.
So, what do you do? The way that these questions are phrased begs the ‘correct’ response of, ‘Yes’. And the same agencies that deliberately skew outcomes will undoubtedly have perfect scores on these questions. My clients will not. They have been taught to do their best and to answer according the events that take place in reality – not on Planet Julianne where every doc is doing nothing but sitting by the phone eagerly awaiting our phone calls.
And if anyone tells you to differently, remember that the OASIS-C dataset is a legal document with your signature on it. Take the time between now and the first of the year to educate referral sources. Since MD’s are also subject to outcomes, most will understand why you suddenly become so needy after the first of the year.
And if you look not so hot on paper, remember your choices are to be less than honest or devote an enormous amount of time to satisfying a dataset. In other words, look at your patient and do what needs to be done to take care of them and document appropriately. The last thing we need five years down the line is useless data because not everyone is answering the questions in the same way.
OASIS-C education is ongoing at our office and we would love to visit you onsite. If you are in need of staff training, please do not hesitate to call 225-216-1241 or email haydelconsulting@haydelconsulting.com.
