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Posts tagged ‘home health care’

Feb 16

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Low Tech Telemedicine

 

An enormous amount of health care dollars are spend every year on high dollar telemedicine technology with the goal of improving patient care. We support technology in health care. It is clearly the way of the future and any and all tools available to agencies should be employed when they promote communication and patient care.

But before your agency purchases high dollar equipment, are you completely sure that all technology currently available to you is being used? What about the expensive telephone system that decorates your office?

In determining frequencies, we generally try to establish how often the patient will require visits by the clinician. Most Clinicians, in an effort to err on the side of caution, will schedule generously. What many agencies have already discovered is that certain follow-up tasks can be accomplished with a short phone call in lieu of a visit.

Consider a newly diagnosed diabetic patient who is seen five times in succession on the first week of admission with plans to reduce visits to twice weekly after the skill of blood glucose monitoring is mastered by the patient. At the end of the fifth visit, the patient is able to independently perform the skill but is still a little unsure. The nurse might very easily perform a sixth visit to ensure that the patient is comfortable performing a new skill. Or, maybe, all the patient really needs is a little reassurance in the form of a telephone call.

This same logic applies to reducing frequencies at time of recert or after an acute exacerbation. It isn’t necessary to drop cold turkey to a lower frequency. A phone call to check on the patient between visits goes a long way to ensure the nurse that the correct clinical decision has been made. And obviously, should a need become apparent during a phone call, an additional visit can always be added to the schedule.

Other phone calls I would like to see made include:

  • Phone calls after visits missed due to no answer to locked door.
  • Phone calls after MD visits
  • Phone calls when there is a change in caregiver situations at the house
  • Follow up after the beginning of a new medication or the cessation of a long term medication

     

Of course, all the phone calls in the world won’t go far to protect you in a survey or payment review situation. But considering that care coordination deficiencies are among the most commonly cited survey deficiency, the process of making phone calls and including documentation in the clinical record can go far to show the quality of care your agency gives.

 

To make it easy for nurses to improve care coordination through low tech telemedicine techniques, clean and uncluttered forms should be available. Consider including a stack with weekly schedules. Add checkboxes for physician and interdisciplinary communication to ensure that coordination is well documented.

Dec 7

OASIS-C Summary of Changes

We have completed an initial review of the proposed OASIS-C changes compared to the current OASIS B-1 data set and summarized our findings below. As consultants, we have a opinions and a burning desire to share – and we do exactly that in the coming weeks. However, this post is limited to a simple outline of the changes as we see them. Because it is only an initial review, it is possible that we have minor omissions in our review and welcome any corrections. Furthermore, we will be preparing comments for CMS and as such, your comments and opinions are not only welcome but solicited in the coming weeks.

Clinical Records and Diagnosis

There are two new questions in the Clinical Record items (the section that deals with reasons for assessments, person completing assessment, etc.) These questions refer to the referral date for Start of care/resumption of care dates and the actual date that care began or was started. Currently, CMS has a 48 hour time frame between referral and admission and a 24 hour time frame for resumptions of care. Some states such as Louisiana mandate 24 hours between referral and admission.

The data collected regarding prior diagnoses has changed in its format. Additionally, the OASIS-C data set is asking for each inpatient procedure and associated ICD-9 code to be included.

The diagnosis coding for the episode remains in the same format with four columns including severity. As with the data set released for use last January, CMS does not ask for onset or exacerbation dates. This is not a CMS requirement but some Fiscal Intermediaries strongly suggest (read: require) O/E dates. Expect vendors who mass produce assessment tools to include it.

The Overall Prognosis, Rehab Prognosis and Life Expectancy questions are being replaced with questions regarding Frailty and Stability. Influenza and pneumococcal vaccination status are being assessed. Another new question is one that assesses if the plan of care includes guidelines for physician notification in the plan of care.

Only one question regarding living arrangements is included in this section. A more in depth assessment is found at the end of the assessment.

Sensory Assessment

The current question regarding the patient’s ability to hear and understand spoken language has been split into two separate questions – one regarding ability to hear and the other regarding ability to understand verbal content. The vision question that we are familiar remains unchanged.

Like vision, the question regarding pain remains unchanged but three other questions regarding pain have been added to assess whether or not a standardized tool has been used to assess pain and the presence and effectiveness of any pain management measures.

Integumentary Status

One of the most significant changes in that only unhealed pressure ulcers are noted. Instead of trying to explain the question, I have cut and pasted below:

Note that for the first time we are being asked about the number of ulcers that were present on admission. And all the teaching that has been done regarding ‘back-staging’ ulcers will no longer be necessary since the data set specifies non-epithelialized ulcers.

The language regarding stasis ulcers has been changed slightly but the assessment remains the same. This is also the case with surgical wounds.

MO440 is gone at last. A new question in it’s place assesses if the patient has any skin lesion or open wound other than ulcers or surgical wounds that receiving assessment and/or intervention. Diabetic foot care has also warranted two new questions.

Respiratory Status and Cardiac Status

The respiratory status assessment remains unchanged.

Two new questions regarding congestive heart failure have been added. One question asks if the patient exhibited any signs of failure indicated ny clinical heart failure guidelines including dyspnea, orthopnea, edema, or weight gain at any point. The second question assesses what if any actions were taken by the staff.

Elimination

The questions regarding urinary incontinence are essentially unchanged with one major addition. The question assessing when urinary incontinence occurs now includes a response of ‘occasional stress incontinence’.

The bowel elimination/ostomy questions remain unchanged.

Neuro/Emotional Status

The questions regarding confusion, anxiety and cognitive function are unchanged. However, Depression is intensely assessed in the proposed OASIS-C. For instance, the data set asks if the patient has been assessed for depression using a standardized depression screening tool. It goes on to assess depressive symptoms reported or observed. Note this question is very much like the OASIS B-1 question with an important change in the order of responses. In the new data set, if the patient has no symptoms, the answer will be one. It also includes a response for ‘other’ signs or symptoms of depression. Two other questions follow investigating if there are interventions for depression.

ADLs/IADLs

In the published proposed data set there is no assessment of ‘prior’ ability – the patient status two weeks prior to admission for each point of assessment. Therefore, the responses of ‘unknown’ are not listed in the questions. However, there are two questions that investigate whether the patient is the same/better or worse at mobility and self car ability.

The questions regarding grooming, dressing upper and lower body, and bathing are the same. There are some changes in the question regarding toileting to specify that that toilet transferring is being assess. An additional question has been added to assess toileting hygiene which assesses if the patient is able to safely maintain perineal hygiene, adjust clothes and incontinence aids if used before and after using the toilet and cleaning and managing equipment.

The questions regarding transferring remains the same but an additional answer has been added to the question regarding Ambulation. The use of a one handed device as opposed to a two handed device (cane vs walker) is now assessed.

The question regarding feeding and eating is unchanged followed by the two questions regarding changes in mobility and self care ability referenced above.

Additional questions regarding fall risks are asked along with fall and fall risk interventions. A change in the ability to perform routine household tasks is assessed.

The questions regarding transportation, laundry and housekeeping do not appear to be in the proposed OASIS C data set.

Medications

The Medications assessment has been greatly expanded. A new question regarding the potential for adverse effects or reactions is asked first. Specifically, the question asks if the drug regimen review indicates a significant potential for adverse effects or reactions including ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors or non-compliance.

Next is a question investigating whether the MD was contacted within one calendar day to resolve clinically significant medication issues, including ‘reconciliation’. Two additional questions follow regarding patient and caregiver drug education.

The language in the question regarding patient ability to take oral, injectable and inhalant medications is slightly changed. The responses remain the same. There is an additional question that asks if the patient’s ability to take meds is better or worse than before the onset of illness that initiated the care episode.

Equipment Management

The question regarding the patient abilty to manage equipment remains unchanged but this section is where an in depth review the types and sources of the assistance the patient receives is assessed. Using a grid, the clinician is asked to evaluate the patients need for assistance in ADLs/IADLs, meds, other treatments or procedures, equipment management, supervision and advocacy. In the grid, responses assess whether or not assistance is needed and how likely the caregivers are to provide that assistance.

Therapy

The therapy question remains unchanged. It still requires the number of therapy visits the patient will receive.

Emergent Care

The question regarding whether or not the patient received emergent care has been reduced to a simple ‘yes’ or ‘no’ response with an option for ‘unknown’. The reason for Emergent care has been expanded from 9 possible responses on the OASIS B-1 data set to 19 on the proposed OASIS C data set.

The familiar discharge disposition question that assesses whether or not the patient remained in the community is followed by a second question assessing how much assistance the patient requires after discharge and who is providing the assistance.

The hospitalization question also remains the same but like Emergent Care, the responses have been changed to reflect more conditions and expand the definition of current responses.

The two last questions on the current OASIS B-1 data set requiring the date of last home visit and transfer date are not listed on the OASIS C data set.

For further details, please click on the link to the left on your screen and review the proposed OASIS C data set in its entirety.

As always, you can contact us at haydelconsulting@bellsouth.net.

Nov 23

Monday Morning Quiz

We are starting the week off with a quiz to get your brain cells firing.  There’s only a couple of days that most of us have to think about home health this week and then it’s all about pumpkin pie recipes and football.  I would gingerly remind those of us on call this holiday weekend that patients are sick every hour of every day and we should be thankful that we are afforded the opportunity in life to care for patients in need even when it is most inconvenient. If that thought doesn’t lighten your load, remember that if you are working Thanksgiving Day, you are likely off on Christmas!

Our quiz today is about home health physical therapy.  Answers will be posted tomorrow.  Many of our clients are continuing to struggle with therapy management and so for the next several weeks, we will try to devote at least one column a week to home health physical therapy.  Any questions, comments or suggestions about therapy should be left below in the ‘responses’ box or emailed to Haydelconsulting@bellsouth.net.

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