by Trisha Tulloch, RN, BSN, MSN, HCS-D
TRISH TULLOCH
In the summer of 2008, we at RBC Limited were privileged to work with two home health demonstration agencies participating with the Centers for Medicare and Medicaid Services (CMS) and Abt Associates to field test the revised OASIS-C. Since that time we have supported dozens of agencies in their transition planning to OASIS-C through leadership, staff education and competencies. To help you plan and refine your agency’s transition processes to ensure success in 2010, this column shares some “Lessons Learned” from those experiences.
What are the Most Challenging OASIS-C Items?
M2400, a new process measure that is to be completed on transfer or discharge, surfaced as the most challenging item during the demonstration period. M2400 requires the clinician performing the assessment to “look back” at the care provided during this specific episode of care to determine if six specific care practices were included in the Plan of Care (POC, still called by some the 485) and if included, determine if these practices were implemented during this episode of care. You can find M2400 on page 24 of the final OASIS-C at http://www.cms.hhs.gov/HomeHealthQualityInits/Downloads/HHQIOASISCAllTimePoint.pdf
Things to remember about M2400
- The actual “look back” audit period includes a review of only the current episode in which the patient is receiving care and services.
- Subsequent OASIS-C field use indicates M2400 presents many challenges based on the documentation and/or software system used by the agency. Many agencies have developed a simple paper “look back” tool to be used during the episode of care that helps the clinician with accurate and timely completion of this item on transfer or discharge. Software vendors are challenged to consolidate this information during the episode of care on one screen, as a reference guide to clinicians completing this item as indicated.
- Agencies have also reviewed their transfer/discharge processes relative to completing OASIS-C and are considering a revised review/audit process focused on these six items to ensure accuracy prior to locking this final OASIS-C document.
- Since these items may be used in the revised Home Care Compare Report for agency Quality Outcomes and may ultimately impact agency reimbursement under a future Pay for Performance model, it is important to accurately and efficiently monitor the collection and analysis of these data elements.
M2100, the Care Management grid, directs clinicians to assess the types and sources of caregiver assistance for multiple activities, including medication administration, Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) as well as medical treatments and advocacy for medical care. The level of caregiver ability and willingness is assessed and documented in the M2100 grid. You can find M2100 on page 21 of the final OASIS-C at
http://www.cms.hhs.gov/HomeHealthQualityInits/Downloads/HHQIOASISCAllTimePoint.pdf
Things to remember about M2100
- CMS defines caregiver abilities or willingness with grid columns for “needs training and/or support,” “not likely to provide assistance” and or “unclear if they will provide assistance.” It is critical that assessing clinicians have a comprehensive, working knowledge of these definitions.
- Agencies have found that a detailed item review with multiple realistic case scenarios provides and supports the clinician’s understanding and application of this new OASIS-C item in designating the assistance the patient needs.
- Assessing clinicians from the demonstration indicated frustration with the definitions of each level of assistance needed, as well as an inability within the restricted admission timeframe to accurately assess this item.
- Additionally, experienced home care clinicians know that caregiver availability and abilities is very difficult to fully determine during the initial start of care assessment. Agencies should develop policies and processes that support clinicians with the flexibility needed to comprehensively build a realistic POC. If this requires two admission visits to complete the POC, then clinicians should not fear recrimination or penalties if they can justify the need.
Tools to Support Accuracy on the Optional Best Practices
While CMS indicates that the newly integrated process items are optional practices, regulators and industry experts agree that identified clinical Best Practices are critical to providing quality clinical outcomes that save agencies and payers money. Furthermore, the decision to continue the optional approach with your staff may adversely impact your future patient and agency outcomes, community marketing initiatives and eventually reimbursement in a pay-for-performance payment structure.
Proactive agencies have reviewed and identified optional best practices they intend to perform when using the revised OASIS-C. A recent poll by Home Care Outcomes indicates that agencies are currently performing many of the identified best practices. In fact, current transition training by RBC indicates many agencies are already performing 70-80% of these Best Practices and that clinician training revolved around the revised documentation of these practices on specified OASIS-C assessment items.
What Best Practices has your agency selected, and what tools support clinician completion of these items?
- Software vendors have integrated a variety of Best Practice tools into their system to support clinician completion of these items.
- Demonstration and transition agencies have indicated that easy tool access for use by clinicians in the home is vital.
- Consider using available Best Practice tools to simplify assessment and documentation of these practices. CMS includes links to several Best Practices in Chapter 5 of the OASIS-C Guidance Manual, which can be found at http://www.cms.hhs.gov/HomeHealthQualityInits/14_HHQIOASISUserManual.asp#TopOfPage
Training and Leadership Processes to Support the Transition
Administrative and management leadership understands that any change in clinical practice needs ongoing support and close monitoring to ensure accurate and consistent implementation. Recognize that a learning curve will exist in the transition to the revised OASIS-C that will take a considerable amount of time. Hopefully you are in the middle of considering how your agency will support field clinicians during transition to OASIS-C. Consider the following questions when developing and revising your plans.
- How will your agency ensure consistent understanding of the revised and new OASIS-C elements?
- What have you done to provide the support to reinforce implementing the revised and new items in 2010?
- How will you support your clinicians to ensure optimal practices that enhance and refine care in the delivery of your home health services?
- Will you provide the incremental training and review time to discuss these new items to ensure accuracy and consistency throughout 2010?
- How will your clinicians learn common errors to avoid with the revised OASIS-C tool?
Consider these options:
- Mini staff meetings or regular in-service sessions to update staff on revised OASIS-C items. One demonstration agency has already initiated a weekly morning mini OASIS-C training session that provides a quick review and tool for each revised or new item in an incremental process throughout October, November and December.
- Bi-weekly team meetings that integrate the application of OASIS-C items into current case review. One agency indicates that the additional time for discussion and application supports clinician understanding of score variations beginning in 2010.
- Share your strategies with your colleagues. (see editor’s note, below)
Consider these options:
- Provide each clinician with the Final OASIS-C Guidance (Chapter 3)
- Provide each clinician with your updated Best Practice tools to complete the new OASIS-C items
- Ensure clinicians easy access to agency OASIS-C experts who can readily answer their questions when completing these documents in the New Year
From Editor Carolyn Humphrey: Look for articles in upcoming issues of The Informed Home Care Clinician detailing strategies and approaches we have learned from you and your colleagues to help you address these questions. We are here to provide you with the best and easiest-to-apply information for all the issues you face each day. Our commitment is to have a minimum of one OASIS-C column in every issue and other need-to-know OASIS-C material in each issue’s “News You Can Use” segment. Let us know what you think and what you want us to cover on the critically important topic of transitioning to OASIS-C.
Trisha Tulloch is a Senior Consultant with RBC Limited of Staatsburg, New York. A seasoned clinician with more than 30 years in health care practice, Trisha’s diverse experience includes leadership roles in both Home Health and Hospice. A Registered Nurse with code credentials from the Board of Advanced Medical Coding, she is a nationally recognized speaker who provides both clinical and administrative expertise to agencies across the country. Responsible for oversight of RBC Limited’s Health Care Division, she collaborates with industry experts and attorneys for Corporate Compliance, Fact Finding, Fraud and Abuse and Regulatory Standards. Her specialty in coding and OASIS education and training, utilizing RBC Limited’s Integrated Oasis Solutions methodology, reflects her unique skill set to promote industry best practices. Contact the author through RBC Limited: www.rbclimited.com
