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Dec 17

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OASIS-C Q & A

The National Association for Home Care and others have been submitting questions to CMS regarding the OASIS-C dataset. Below are some clarifications offered by CMS on the dataset. Thanks to Judy Adams for keeping us up to speed!

FALLS RISK ASSESSMENT

1. Does the falls risk assessment on the MedQIC website meet CMS criteria for “multi-factor” and “validated?”

CMS Response: The multi-factor falls risk assessment must include at least one standardized tool that (1) has been scientifically tested on a population of community dwelling elders and shown to be effective in identifying people at risk for falls and (2) includes a standard response scale. It is the agency’s responsibility to determine if the tools it is considering for the OASIS-C M item best practice assessments meet the requirements as detailed in Chapter 3 of the OASIS-C Guidance Manual and the CMS OASIS OCCB Q&As.

Note: The MedQIC tool referenced in Question #1 is the Missouri Alliance for Home Care’s screening tool. Based on CMS’ response, it does not meet validation requirements at this time. However, the Missouri Alliance is seeking validation of its tool, and NAHC will advise agencies once the process has been completed.

2. Does this risk assessment screening tool in the resources section of the OASIS C Guidance Manual meet the criteria of a standardized and validated tool? “Home Care Fall Reduction Initiative risk  Assessment Screening Tool (A multi-factor falls risk screening tool from the Missouri Alliance for Home Care, specifically designed for home care patients at Start of Care and Re-certification)” (Submitted by Fazzi Associates)

CMS Response:  The Missouri Alliance for Home Care (MAHC) tool, at this time, has not undergone the process of validation. The MAHC tool can be used in conjunction with a standardized, validated performance assessment like the TUG (Timed Up and Go) or Functional Reach Assessment to meet the requirements of the multi-factorial standardized validated falls risk assessment.

TOILETING HYGEINE

3. What if a patient has a new colostomy and is completely dependent on someone to empty the appliance (bag) as well as change the appliance but she can cleanse herself and care for her clothing with voiding? The patient usually changes the bag one to two times per week — unless there are problems. Is this patient a “0”? Are we interpreting correctly that the only way we would ever score this patient a “3” is if she is changing the appliance more often than she is voiding?

CMS Response: M1845-“Toileting Hygiene” assesses the patient’s ability on the day of the assessment to manage personal hygiene and clothing when toileting. If the patient has a colostomy, the hygiene would include cleaning (wiping) the perineal area after voiding and around the stoma when necessary. M1845 does not include the patient’s ability to manage the ostomy bag, stoma wafers, or other ostomy equipment. On the day of the assessment, if the patient has the ability to safely manage his or her clothing and perform the personal hygiene as described above, the appropriate score would be a “0”. How often the appliance (equipment) is changed does not factor into the scoring of this item.

OASIS-C FORMATTING

4. Is it permissible to add “hints” to our home-made OASIS C forms from the Chapter 3 OASIS item guidance to ensure continuity among our clinicians? In addition, is it permissible to indicate next to the “M” questions if they are a process item, non-routine supply item, Home Health Compare item, and outcome measure items?

CMS Response: Each agency may develop its own comprehensive assessments as it sees fit (including the addition of “hints” and other notations) as long as the assessment includes items that assess the patient’s continuing need for home care services and determine the patient’s medical, nursing, rehabilitative, social, and discharge planning needs; eligibility for the payer’s benefit; and the required OASIS items for patients that require OASIS data collection. The OASIS items must be incorporated into the assessment exactly as written, although skip patterns may be modified as needed if the agency chooses to change the sequence of the items. Refer to other CMS OASIS Q&As under Category 4a for further guidance related to formatting of the items into software.

PHYSICIAN DESIGNEE

5. Could a pharmacist be a physician designee for M2002-“Medicare Follow-up”?

CMS Response: A pharmacist is not typically a “physician- designee” in OASIS reporting. A physician designee is an individual who works in cooperation with and has been authorized by the physician (within his or her scope of practice) to facilitate care and communicate the physician’s orders. When completing the OASIS Medication process measure items, the pharmacist is only considered a “physician-designee” in a very limited situation. If, within one calendar day of identifying a clinically significant medication issue, the agency clinician communicates with the physician regarding the issue, the physician calls in a prescription change to the pharmacy causing the pharmacist to issue a prescription, then technically the pharmacist could convey the information. In this case, the clinician would still need to get an order from the physician

HIGH-RISK DRUG EDUCATION

6. For the assessing clinician to select a “Yes” response to M2010, must the high-risk drug education be provided on the actual start of care/resumption of care visit or can it be provided/completed on another visit by the same clinician within five days of start of care and two days of resumption of care? (Submitted by Fazzi Associates)

CMS Response: To respond “1-Yes” for M2010-“Patient/Caregiver High-Risk Drug Education,” the patient and/or caregiver must receive the specified education for all high-risk medications within the assessment timeframe. It is not required that it all occur on the actual start of care/resumption of care visit.

The education can be provided by clinicians other than the clinician responsible for completing the assessment. Please see the M2010 response-specific instructions in Chapter 3, which references how to handle situations where other agency staff is providing the education.

ASSESSMENT COMPLETION DATE

7. Does “assessment completed date” refer to information required to complete OASIS data items or any information contained within the agency’s comprehensive assessment? (Submitted by Fazzi Associates)

CMS Response: M0090- “Date Assessment Completed” is referring to the date the entire assessment was completed. The OASIS is just one component of the comprehensive assessment.

Dec 14

OASIS-C Errata

I confess. I had to go to Dictionary.com to look up exactly what the word Errata meant. The definition is: a list of errors and their corrections inserted, usually on a separate page or slip of paper, in a book or other publication; corrigenda.

Why is this important? Because the CMS has published the OASIS-C Errata. It can be found under the Blogroll section immediately to your left on this page. Highlights include:

  • The questions referring to since the last time OASIS data were collected specifically includes data collected during the last OASIS assessment. For instance, when asked if all meds were taught on since the previous assessment, include in your response the medications taught at the last assessment visit.
  • Flu vaccine questions are corrected numerous times. When 1040 asks if the flu vaccine was given by your agency during this year’s flu season what they are really asking is if the flu vaccine was given by your agency during this year’s flu season. Nothing more. Nothing less. If your patient received a flu vaccine elsewhere or from your agency during a separate admission, the answer is, ‘No’.
  • The definition of standardized tests has been clarified to mean those which have been scientifically tested on a population with characteristics similar to that of the patient being assessed and shown to be effective and includes a standard response tool. But wait, that’s not all! The standardized tool must be appropriately administered according to the instructions.
  • M1308 is still one of my favorite questions. It asks for the current number of non-epithelialized ulcers at each stage and gives us a grid on which to chart our answers. The instructions for closed staged III and IV now read: Although the wording in M1308 includes the term ‘non-epithelialized,’ for this item, a closed stage III or IV pressure ulcer should be reported as a pressure ulcer at its worst stage, even if it has re-epithelialized.
  • M1910 assesses the patient and their environment for falls. For publicly reported outcomes, patients under aged 65 will be excluded. The falls assessment will include a standardized tool in order to meet the requirements of this question.

There are some other very interesting changes that will be discussed later in the week. However, you can certainly read them for yourself in the document posted on our sidebar.

Your questions and comments are always welcome in the comment section below or you can email us or call us at 225-216-1241.

Dec 13

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Coping with OASIS-C

As the year draws to close, the date for OASIS-C implementation is almost upon us. Are you ready?

Wait? Did you say, ‘yes’? I didn’t think so.

We have done this before and we will likely do it again. OASIS-C is huge. It will result in sweeping changes to our daily practice of nursing. And yet, you are hard pressed to find nurses confident in their ability to answer all questions correctly. That includes me, by the way. But if you are thinking that you will never be prepared and are considering resigning your position to work at Taco Bell then you may want to take a deep breath and rethink this.

I know from experience that we can teach and learn and reteach all we want but the real fun begins when the dataset is used for actual patients. Patients are mostly inconsiderate of our dataset and will frequently find a way to avoid fitting neatly into the little pegs in a dataset. One option is to discharge all of your patients. Better yet, post on the decision health listserv. Ask questions. Call your state association. Call or email a brilliant consultant. Or muddle through. The choice is yours.

This next point is critical. Pay close attention. It is very important.

You will fail as a home health nurse if you don’t change your processes. Your agency will fail as a company if it doesn’t change its processes. Our industry will fail miserably if we don’t change our processes.

Did that get your attention? Good. I have no appetite for failure. The only nurses I have ever met with a tolerance for failure never made it through the first year of clinicals.

Does that mean we have to be perfect on New Year’s Day? I hope not. I do not plan to be perfect until I at least know how! And I won’t know how until the data set is being used on real people.

Will you remember every detail taught to you in training? Will you be able to keep all the new processes straight? If you answered ‘yes’ you belong in an institution somewhere where your brain can be studied.

Having done this before with OASIS and OASIS-B and OASIS B-1, I have only one wish concerning the implementation of the new dataset. I wish that all of my colleagues will make the necessary changes in such a way that our patients truly benefit. As an industry we have to take these changes seriously. As nurses and caregivers, we have to minimize the time and energy we spend solely to accommodate a dataset. More importantly, there are millions of sick people in their home waiting for their nurses and aides and therapists to come make their lives better. Can we possibly do both?

I think so.

For updated OASIS-C training dates or onsite training information, please email us or call 225-216-1241.

Dec 10

Teaching Low Literacy Patients

Teaching is the most common skilled service offered in home health. Unfortunately, many of our patients are unable to read at an advanced level or they are unable to concentrate on complex reading materials because of medications, stress or disease processes. Additionally, many of our patients are also visually impaired. This makes teaching the elderly a special challenge. Listed below are some websites that feature low literacy, simple to read teaching guides. There is also a great article I snagged from the Parkland Hospital website on how to teach low literacy patients.  If you have any additional resources you would like to share, please post below in the comments section.

A collection of low literacy handouts for diabetes

http://www.learningaboutdiabetes.org/lowLitHandouts.html

A great heart failure teaching guide for low literacy patients with easy to understand illustrations for the functionally illiterate patient in both Spanish and English:

http://www.nchealthliteracy.org/comm_aids/Heart_Failure_Intervention_eng_v1.pdf

http://www.nchealthliteracy.org/comm_aids/Heart_Failure_Intervention_esp_v1.pdf

Low literacy H1N1 vaccine document

http://www.ncfh.org/docs/H1N1_Low%20Literacy%20Flyer.pdf

Great General Nutrition Education Tips complete with learner feedback documentation

http://snap.nal.usda.gov/nal_display/index.php?info_center=15&tax_level=4&tax_subject=261&topic_id=1941&level3_id=6326&level4_id=11003

A great guide to teaching low literacy patients from Parkland Hospital.

http://www.parklandhospital.com/patients_visitors/health_information/pdf/gdl%20teaching%20ll.pdf

A collection of varied teaching materials at a low literacy level:

http://www.parklandhospital.com/patients_visitors/health_information/materials_viewall.html

Dec 8

Our Financial Future

Usually I am an eternal optimist but I have had a few setbacks as we are facing cuts to the Medicare Home Health Benefit. Even though home health is responsible for less than four percent of the Medicare budget, Congress voted to reduce home health payments by 13 percent (43 billion) over the next ten years. Their stated purpose is to reduce waste and inefficiency. The New York Times article can be found here.

Obviously my first thought is one of pure outrage. The politics of health care reform can be overwhelming and frightening for all of us who take care of patients or work to support those that do provide hands on care. And yet, in spite of my repeated pleas to Mr. Obama and being very frank about my opinions, it appears as though I have been largely ignored. Imagine that.

So what can we do? Do we stage a grass roots effort and hope that we can raise a few thousand dollars for a lobbyist that can never compete against the millions of dollars funneled into special funds in exchange for congressional votes? That is one option and it isn’t a bad one even though it may prove to be ineffective. But while we are writing letters, arguing loudly and doing everything we can to protect our industry, we must face the truth that home health care will likely take a hit in the near future. And if the false prophets of hope and denial are proven to be unsuccessful, we will be left with an enormous challenge.

But it’s a challenge we can meet! Every day I read in the newspapers about how bad the economy is and yet, the global numbers really don’t tell you the story of any one person’s finances. The same applies to the health care budget. Cuts will be hard but manageable if we begin to prepare now.

And the great thing about preparing for impending financial cuts is that the preparation involves all the same things we should be doing already to be efficient. Here are some steps you can take now.

  1. If you are leaving money on the table, stop. It is not unusual to find an agency leaving between five and eight percent of money on the table due to inaccurate OASIS scoring. Those same agencies have the opportunity to reduce their cuts by bringing their baseline up to the ethical maximum. And agency currently leaving eight percent on the table will only suffer a five percent cut if they work on their OASIS scoring now. And who would mind an eight percent raise even if the cuts never happen?
  2. If you haven’t already done so, look into converting to point of care computers. Although the investment of time and money is huge initially, the investment will pay off when you can reduce back office staff and all the quality of your data is impeccable. This will happen with or without cuts.
  3. Look at staffing patterns. If your agency does not use LPNs, consider doing so for stable patients. Consider reducing or eliminating nursing visits in therapy only cases. Review every process that each person in your agency performs and see if it is really necessary or ‘if it is something we have always done’. If it falls in the latter category, consider eliminating it for a period. Try to reduce the use of PRN nurses so that your agency can provide more efficient care with staff who regularly see patients.
  4. Take a really good look at the software you are currently using. If possible call for staff training. Many agencies are using software systems that have been in place long before most of the staff was hired. It is common to find that current software is able to provide tools and information that you were not aware of in the past.
  5. Slowly develop disease management programs. I am not referring to the pathways of the past that provide nurses with a set recipe for care. I am referring to education, tools and resources for nurses to take care of diabetics, CHF patients, PVD, etc.
  6. Invest in a wound care expert. This isn’t as dramatic as it seems. Find one or two nurses in your agency that excel in wound care and provide them all the education you can and try to have them see all patients with wounds at least once. Many wound care vendors provide wound care education at no cost to your agency.
  7. Teach care planning and goal setting. Eliminate the ‘random’ visit where we go get a set of vital signs and aimlessly assess the patient. All visits should be planned to work towards a specific goal!

Finally, breathe. That’s all. I came into home health during IPS. If you don’t know what IPS is, drop to your knees and say a prayer of thanks. If you remember IPS, you know that we have been through worse in the past and we will make it through anything the future throws our way.

Don’t get me wrong. I don’t want the cuts any more than the next person. But if I want to survive as a nurse in home health, the only option I have is to preserve my integrity and help you get ready for the future. And if we get lucky and healthcare reform is put on hold until we retire and fruit flavored rain becomes the norm, we will still provide better care and make more money. Can’t beat that with a stick!

As always, I welcome your comments below or you can email us here.

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