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Posts tagged ‘OASIS’

Nov 11

Is Your Patient Frail?

Nothing is ever simple! A year ago, I would have never thought that a standard definition of frailty would come in useful. Isn’t the word, ‘frail’ self explanatory? As it turns out, it is not. The OASIS-C asks for frailty indicators giving weight loss as an example.

A colleague found a great article from The Journal of Gerontology Sciences which uses the symptoms of weakness, poor endurance, weight loss, low physical activity, and slow gait speed to assess frailty. The article states that more than one symptom is generally present. Conditions associated with frailty are those we see every day in home health. They are: undernutrition, functional dependence, prolonged bed rest, pressure sores, gait disorders, generalized weakness, aged .90 years, weight loss, anorexia, fear of falling, dementia, hip fracture, delirium, confusion, going outdoors infrequently, and polypharmacy.

If you are thinking that many of your patients meet this criteria for frailty, you are likely correct. Using the definition stated above, about seven percent of the population over age 65 is frail and a full 30% of persons over 80 are frail. Consider that our patients are the ‘active adults’ targeted by Florida’s condominium industry looking for a place to play golf and Mah Jong and it is easy to believe that our percentage of frail patients is much higher.

To assess your patient, look for some of the associated symptoms. Check your diagnoses for those that might contribute to frailty. Most importantly, assess your patient always being leery of those stoic patients who report being stronger and more capable than they actually are. Collaboration with home health aides and physical therapy may paint a much clearer assessment.

We always welcome your comments below and you are always welcome to email us at haydelconsulting@haydelconsulting.com.

Thanks to Lavonne for sharing the link with me.

Mar 22

Bundled Services and Outcomes

Bundling of Services

One legislative policy option for controlling postacute care costs is for Medicare to make a “bundled” payment to hospitals to cover episode costs.

This policy is being suggested by an economist Pete Welch in the Health and Human Services Division of the Congressional Budget Office. In short, bundled services would include all post acute care services for a period of thirty days to be included in the hospital DRG payment.  If post acute care services were ineffective, the financial risk to the hospital would be considerable.

It is only a ‘suggestion’ at this time but there is a very real possibility that Congress will take this suggestion seriously as a means to reduce post acute costs to Medicare. Whether this is good or bad depends on where you are sitting. But, as a consultant, my job isn’t to determine the suitability of such a proposal but rather to get clients ready for the possibility of bundled services.

It stands to reason that if hospitals are going to be paying for the first thirty days of care following a hospitalization they will have serious motivation to choose the best post acute care option with the best potential to meet the needs of the patient thereby reducing costs. Furthermore, the hospitals would have to justify their decisions.

Therefore, if I owned any type of facility that rendered care to patients following an inpatient stay, I would start now to ensure that my reported outcomes were as pristine as possible. And the outcome I would focus the most attention on is Acute Care Hospitalizations. If and when this comes to pass, I cannot see a hospital deliberately choosing an agency or facility that had a high rate of hospitalizations.

And if this doesn’t come to pass, there are millions of other reasons why preventing hospitalizations is a good thing. Ask any patient or family member of a patient who has been hospitalized lately how their lives were disrupted by an inpatient stay.

Mar 3

OASIS MO620

MO620, is one of the most frequently misunderstood OASIS questions in our experience. It asks for the frequency of behavior problems and then goes on to give the examples of wandering episodes, self abuse, verbal disruption, physical aggression, etc.).

Reading further in Chapter 8 of the OASIS Manual in the definition section, it states:

MO620 identifies frequency of behavior problems which may reflect an alteration in a patient’s cognitive or neuro/emotional status. “Behavioral problems” are not limited to only those identified in MO610. For example, “wandering” is included as an additional behavioral problem. Any behavior of concern for the patient’s safety or social environment can be regarded as a problem behavior.

Therefore, if MO610 has any response other than ‘none of the above’, MO620 would be expected to reflect the frequency of the problem behavior. It would be an inconsistency in data to any problem noted in MO610 and have any response less than ‘several times each month’ noted in MO620.

Keep in mind that MO620 can also refer to problems that are not noted elsewhere in the OASIS assessment. Memory impairment may be such that it does not require 24 hour supervision but may be of concern in the patient’s social environment.

The key to consistently answering MO620 correctly is to understand that the question refers to all problem behaviors, not just the four examples stated.

As always we are open to comments and questions in the comments section below or by email at haydelconsulting@bellsouth.net.   Making PPS Work for You, an online educational offering about OASIS is now available from Haydel Consulting Services LLC.

Feb 26

2 Comments

The Intoxicated Patient

This week, I was visiting with a client and read a Resumption of Care assessment where the nurse had charted that a patient had, “a strong odor of alcohol, slurred speech and problems with balance”. I thought this was a very appropriate description of a patient who was ‘drunker than Cooter Brown’. Further on in the assessment that I noted very minimal, if any, impairment documented in the functional domain. The patient used a cane but was able to transfer, bathe, and dress independently.

This became a lively debate at the agency that day. The patient who had been on service long before his readmission was capable of living independently in the home. He had not been drinking prior to the hospitalization but had a history of alcohol abuse and liver disease. One nurse said that because alcohol impairment was temporary and he was able to perform these tasks on a regular basis, that the chart should reflect his usual ability more than fifty percent of the time.

Another nurse stated that the patient had a prior history of alcohol abuse that it was unlikely that this was an isolated event and thus the patient wouldn’t be safe the majority of the time in the future.

I just sat in the corner and wondered if ever the day would come when I heard everything. But as I thought more about the issue, it occurs to me that many patients are temporarily impaired on a regular basis, not just the occasional patient who abuses alcohol. This could be the result of pain medications or anesthesia/sedation after an outpatient procedure or varying abilities secondary to a disease process. Therefore, even though we don’t get many intoxicated patients, the answer was very important.

Here is what the OASIS manual, chapter 8 says about scoring the functional domain questions:

The patient’s ability may change as the patient’s condition improves or declines, as medical restrictions are imposed or lifted, or as the environment is modified. The clinician must consider what the patient is able to do on the day of the assessment. If ability varies, choose the response describing the patient’s ability more than 50% of the time.

The time period being assessed is the day of assessment. So if a client is able to perform a task more than 50 percent of the time on the day of assessment, questions would be answered accordingly. A patient who awakens with pain in the mornings might not be safe to bathe or dress independently for an hour or so until pain medication takes effect but assuming the medications do not have side effects, the patient would be able to safely perform the tasks mentioned more than 50 percent of the day of assessment.

Conversely, a patient who is admitted following an outpatient procedure where strong sedatives were used might not be safe to bathe or dress independently for the rest of the day. In this case, the degree of functional impairment should reflect the patient’s ability under the lingering effects of sedation.

Patients taking powerful narcotic pain relievers might also be temporarily impaired. The key to answering the questions in the functional domain is how often the patient requires narcotic pain relief.

In recent clinical work, we have clearly uncovered the need for additional OASIS/PPS training. In the next week, we will be making available web based training for all clients and other interested agencies. Please email us at haydelconsulting@bellsouth.com if you have an interest in providing additional training for your clinicians.

As always, your comments, stories and questions are most welcome.

Feb 23

Hospitalization in the Five Day Window

In spite of careful planning on the part of nurses, therapists and physicians, it sometimes happens that a patient will go to the hospital after a recertification OASIS was completed and actually stay in the hospital for the duration of the episode and into the following episode. When this happens, it is frequently the case that the patient must be discharged and readmitted, but not always.

If a patient comes out of the hospital after the episode has ended and if (and only if) the patient has the exact same HHRG as the prior episode, only a resumption of care assessment is required. To determine if the HHRG is exactly the same, you may use the CMS toy grouper or PPSGrouper.com. Alternately, your software may have the capability or you can painstakingly compare answers with the last assessment while remembering that differing answers do not always result in differing HHRGs.

If the HHRG does differ then the patient must be discharged and readmitted to the agency. In order to accomplish this, most agencies begin a new chart. This is also problematic because often times, the second chart appears to be incomplete. For instance, you may have a situation with unstable caregivers that has previously been addressed by your social workers. In the new chart, all a reviewer may see is the unstable caregiver situation without reference to any intervention. Therefore, our suggestion is that when you must readmit a patient due to intervening hospitalizations to always reference that this is a readmission due to OASIS considerations. This allows your quality assurance department, your surveyors and reviewers and most importantly your consultants to understand that a prior chart with additional information does exist.

A document that addresses OASIS Considerations for PPS has been linked under the Essential Links section in the sidebar to your left. As always, we welcome your comments or your emails at haydelconsulting@bellsouth.net.

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