Results will be published in January. Fazzi will be able to distributed the project’s findings at no cost thanks to Delta’s sponsorship. We will publish information about how to obtain your free copy as soon as we have it.

Groundwork laid in October

Though the bulk of the work developing best practice recommendations occurred in Chicago on November 10 and 11, Fazzi Associates laid the groundwork during the October NAHC Annual Meeting in Los Angeles. In an innovative approach for involving clinicians throughout the country, Fazzi launched an online “Input Forum” on October 11. It was set up to give clinicians who were not on the final panels the opportunity to identify those questions and issues they would like to see addressed by the national experts in Chicago.”

All home care clinicians were asked to list their three biggest concerns and name the three new data items that worry them the most. Those results were compiled and delivered to Chicago to help stimulate panel discussions and ground them in real-world concerns expressed by their peers.

We spoke with Dr. Robert Fazzi, president of Fazzi Associates, and Delta Health Technologies president Keith Crownover to get each of their perspectives on how valuable the expert best practices will be, as well as some insights into the methodology used to develop them.

Dr. Robert Fazzi

“The recommendations that came out of these meetings are incredible,” Fazzi began. “Nearly 100 people came to Chicago and spent two days together in targeted work groups. They took their assignments seriously and spent hours examining the most minute details about how each question should be answered.

“The goal of the project was to develop best practices, best strategies, techniques and tips for generating more accurate OASIS-C answers,” Fazzi continued. “We provided the experts with national input and peer recommendations on issues that needed to be addressed, which we had been gathering for a month. Over 1,000 recommendations came in. That input phase was followed by two intense days of review and discussion in Chicago, where the invited experts were divided into ten focus groups, each with its own specific OASIS section. They collectively developed recommendations, suggestions, strategies, and tips for every OASIS question.

“They worked in groups on the first day from 2:00 to nearly midnight and from 7:00 am to 2:00 the next afternoon. Workgroups included senior clinicians from nearly every big agency, plus NAHC’s Mary St. Pierre and Deb Dietz from Abt Associates.”

The recommendations from this group are now being reviewed for regulatory and clinical accuracy. When this step has been completed, they will be subjected to further review by Fazzi Associates’ outside reviewer, Liz Madigan from Case Western University.

The project was initiated because the new format gives OASIS assessments even more impact on agency revenue than they have now. “There are over 80 changes and an array of new process measures,” Fazzi explained. ”Results of clinician assessments will have a dramatic impact on an agency’s financial and quality outcomes. Despite its importance, there has been little time for clinical leaders to come together to define best practices, strategies, techniques and the like for conducting quality assessments using the new instrument.”

Keith Crownover

“The Delta OASIS-C National Best Practices Project” began with invitations sent to recognized experts in every state, most from the nation’s largest home care organizations. Local state associations nominated invitees and others were chosen directly based on their reputations. “I was impressed for a number of reasons,” Crownover told HCTR. “Our sponsorship included room and board but these people had to get themselves to Chicago at their own expense and there were only two or three no-shows! In a few cases, individuals who were not invited asked their state association to intervene for them with Fazzi’s selection team, they wanted to participate that badly.”

The Delta president said he was also impressed with how seriously participants took their tasks. “Everyone went away talking about the infamous Table Eight,” Crownover related. “The groups started working at 2:00 that afternoon. We thought we would have to push them to keep working after dinner but most went until 10:00 and we finally had to force Table Eight to stop and get some sleep at 11:00.”

Fazzi’s staff facilitated the effort, which included analyzing each table’s written results and having them ready for in-depth, general critique and discussion by 7:00 on the morning of Day Two. Crownover said that he attended, visiting tables and sitting in on various discussion, simply because he wanted Delta to be more involved than just writing a check. “I couldn’t believe how much I learned in two days,” he said. I was most impressed with personal notes I received afterward with feedback from some of the panelists, describing their experience in Chicago.” (see “Panelist honored to participate”)

“What makes the National Forum so unique,” concluded Crownover, “is that an industry-wide challenge has been responded to by industry-wide experts. We brought together clinical experts recognized in their state as being true experts and passionate advocates for ensuring the accurate completion of each assessment. And with so many new questions and new challenges with the new OASIS-C instrument, this could not be done at a more timely moment.”

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

One note to those who began early and anticipate being finished with all necessary training by December 31. Another point made quite strongly by panelists on the above-mentioned video program, available at homehealthsurvivor.com, is that CMS has a proud history of modifying its “final” rules up to and even beyond its own deadlines. It is possible you have been training all year and will still have to provide more. Perhaps this list will help.

CMS

For those who were unable to attend the December 8 CMS OASIS-C conference call, featuring training by Ms. Angela Richard of the University of Colorado at Denver and Dr. Elizabeth Madigan from Case Western Reserve University, a transcript of the call will be available next week at http://www.cms.hhs.gov/HomeHealthQualityInits. Ms. Richard and Dr. Madigan are members of the clinical team assisting CMS with the development and refinement of OASIS-C. Representatives of the Iowa Foundation for Medical Care (IFMC) were also present on the call to review upcoming changes to the way agencies login to the OASIS Submission System and CASPER Reporting.

Healthcare Provider Solutions

www.healthcareprovidersolutions.com

CEO Melinda Gaboury, CPA has been offering a two-day training session through state home care associations for several months. She will continue visiting states in person and will soon commit the program to video, which will be available in an on-demand, streaming format that will be available 24/7.
Check with
your state association or contact Healthcare Provider Solutions for Melinda’s schedule of appearances, video information and pricing. Here is her description of HPS’s OASIS-C workshop.

This two-day, hands-on workshop is appropriate for coders and transmission clerks as well as field clinicians. It examines numerous aspects of the OASIS-C process in detail. The opening session reviews administrative process changes that will be required to be effective with OASIS-C, such as revamping intake forms, reporting M0110 and defining a correction policy. The remaining Day 1 sessions review OASIS-C section by section and offer specific instructions for completing each item based on the OASIS-C Guidance Manual and the CMS Q&A publications.

Day 2 is specific to the OASIS-C reimbursement impact. We examine adjustments that can be quite painful in the PPS system and the often overlooked impact of clinical decisions on reimbursement. We spend time on reimbursement issues as well as clinical reporting. New OASIS “M” items that impact reimbursement are scrutinized and helpful assessment strategies offered.
Since Non-Routine Supply reimbursement is defined by OASIS-C answers, we dedicate an entire session to the NRS calculation, reimbursement, orders requirements, etc.

RBC Limited Healthcare & Management Consultants

http://www.rbclimited.com/OASISCSeries_RBCBrochure.pdf

CEO Barbara Citarella, RN, and senior consultant Patricia Tulloch, RN, BSN, MSN, HCS-D, have created four 60-minute programs that can be viewed online or purchased on DVD. Cost for the entire series is $716 for unlimited staff access. C.E. credits are available for webcast participation but not via the DVD format. Trish Tulloch will respond to viewer questions by email.

Part 1: OASIS-C Overview and Item Crosswalks

Part 2: Risk Assessments & Vital Risk Assessment OASIS Items

Part 3: Home Health Resource Group OASIS-C Items

Part 4: Capturing OASIS-C Assessment Items & Quality Outcomes (available 12/17)

Briggs

https://shop.briggscorp.com/oasisc

In addition to the point-of-care software on which we reported in August (HCTR Product Review: Briggs Goes Electronic with New OASIS Offering, 8/17/09) the Iowa forms designer is branching out into online training systems, using technology from Phasient, which combines on-screen slide shows with voice presentations. “Briggs® OASIS-C Online Training” is an 11-section, seven-hour training course. It includes post-tests and management reports of employee scores and progress through the course. One interesting innovation is the inclusion of pre-tests, intended to allow staff to test out of modules they already know and to compare their own pre- and post-section knowledge.

In the online demonstration conducted for HCTR, the system came across as easy to use and the professional voice reading the script sounded as though she understood the content. Many of these voice actors come across stilted and either over- or under-rehearsed, with multiple mispronounced words. Briggs and Phasient did not succumb to that problem.

“Briggs® OASIS-C Online Training” uses novel approach to testing that may work well. With each multiple choice selection, the system immediately responds with confirmation of a correct answer or explanation of an incorrect one. Unfortunately, however, users who fail a test and must review the course and re-take the test are presented with the exact same questions, making it difficult to know whether they mastered the material or merely learned the test. Other systems we have seen randomly select 10 questions from a list of 20 or 30 each time the test is dynamically built and presented.

Other than that minor weakness, “Briggs® OASIS-C Online Training” appears at first glance to be an effective training tool. It appears the longtime home care and long term care forms leader will successfully branch out into a new market. Pricing is for either a six-month or twelve-month subscription and decreases with volume. A one-year subscription for one person is $199 but can fall as low as $45 when purchased in multi-site packages.

The Corridor Group

http://corridorgroup.com/store/catalog.aspx?id=11

http://corridorgroup.com/oasis-c.html

Kathy Dodd’s office sent us the following description of TCG’s multi-media approach.

1. “OASIS-C: Introducing the Changes” is a CD containing the CHEX eLearning course and a post-test. It sells for $299 and can be passed from employee to employee.
2. “OASIS-C: Webinar Series” was a 4-part online course that ran from September to December. Each session emphasized different OASIS sections and presented CMS’s official guidance for problematic and new items. Handouts and recordings of the webinars are available on CD for $359. No C.E.s are provided.
3. “CHEX eLearning” is web-based training that includes several OASIS-C updated courses that can be accessed on-demand. Training packages are priced differently based on agency size, length of contract and agency needs.
4. “Home Health Quickflips” is a spiral-bound paperback offering a handy, portable reference guide for clinicians to carry with them. OASIS-C revisions were added in November. The books are ordered in bundles of four for $99.95.

Beacon Health

Diane Omdahl, RN, MS has produced a series of CD recordings of her fall 2009 audio conferences, titled “OASIS-C: What You Must Do Now.” A brochure is available for download from: http://www.beaconhealth.org/audio_conferences.php.

The course consists of these four session titles and summaries:

1. Overview of OASIS-C and Best Practices. This session introduces OASIS-C and explains why developing agency-specific best practices is essential for success.
2. Analysis of Redesigned OASIS-C Data Elements. Session 2 introduces strategies to complete OASIS-B1 data elements that have been modified and those that carry a new number; long-overdue changes in diagnoses and emergent care; revisions and new issues related to pressure ulcers, wounds, caregiving arrangements, and ADL; and EBP—vaccinations, heart failure, and pressure ulcers.
3. The Good and Bad about New OASIS-C Data Elements. Some of the more than 30 new data elements present great risk to an agency. Session 3 explores both agreeable and contentious issues found in OASIS-C.
4. OASIS-C and the Agency’s Operations. What your agency should and should not do about data elements that focus on the plan of care and physician-ordered interventions. Also, best practices and a strategy for developing a plan to meet the January 1 deadline.

Healthcare Synergy

www.healthcaresynergy.com

The Southern California software vendor completed a series of training sessions, featuring Theresa Hamilton, president of Home Health Nurse Consultants, Chicago, in late November. Though plans are not set yet, Healthcare Synergy’s Jude Mercado informed us he is in negotiations with Ms. Hamilton to schedule a follow-up series after the first of the year. The price for the original series was $125 for two days for customers of the company’s software system.

Med-Pass

www.med-pass.com

The Ohio-based forms supplier has partnered with Lisa Selman-Holman, RN, JD, to update its “Ultimate OASIS Training Program” with OASIS-C changes. The 9-part program is not specifically OASIS-C training but includes updated OASIS-C material within the context of a complete OASIS course. Pricing is by subscription, either six or twelve months, ranging from $599 per site to $895 per site. Lacking an online ordering system, Med-Pass offers a downloadable form that you fill out and fax to them to start your subscription.

TRISH TULLOCH

With less than three months until OASIS changes again, home health providers are proactively organizing and finalizing OASIS-C training initiatives to provide up-to-date information on critical new and revised assessment items based on the Centers for Medicare and Medicaid Services (CMS) Guidance. Additionally, agency leadership is assessing the impact of these changes to OASIS and revising agency processes to accommodate those requirements.

This article explains the leadership considerations that can have the biggest impact on home health providers and the decisions that need to be finalized to assure that OASIS-C staff training will enhance clinical practice consistency.

LEADERSHIP CONSIDERATIONS

Best Practices – Optional or Required?
Agency clinical leadership should first take the time necessary to compare the agency’s current comprehensive assessment format and content, which includes OASIS-B1, with the revised OASIS-C elements. CMS has created a helpful crosswalk that can form the foundation of the review. It can be found at http://www.cms.hhs.gov/OASIS/Downloads/OASISC3ColumnChangeTable.pdf .

While CMS indicates that the newly integrated OASIS-C process items are optional practices, regulators, industry and clinical experts agree that identified clinical Evidence Based Practices (EBP) — often called Best Practices (BP) — are critical to providing quality home health care. Furthermore, the decision to continue the optional approach with your staff may adversely impact agency outcomes, community marketing initiatives and eventually agency reimbursement.

It is recommended that agency leadership review OASIS-C best practice process items and plan to address agency required clinical Best Practices Standards. Written protocols for select agency best practices, as well as staff and patient education materials, may be distributed during fall training sessions. Staff competencies as well as job descriptions may need to be updated to reflect your agency decision regarding required clinical best practices.

Practice Change Considerations
Leadership knows that any change in clinical practice needs close monitoring and evaluation to ensure accurate and consistent implementation. Leadership must answer at least two difficult questions:

1. How will your agency ensure that staff is consistently implementing revised and new OASIS-C elements?
2. How will you support your clinicians to ensure optimal practices that enhance and refine care in the delivery of home health services?

Consider these options:

• Implement a revised agency, team and/or clinician scorecard on vital elements integral to the OASIS-C data set.
• Review weekly or monthly Case Mix updates for all Start of Care and Recertifications.
• Develop and use a monthly Process Report to identify how your clinicians are scoring the optional best practice items to determine the threshold your agency is achieving on these new, reportable parameters.

Keeping track of this from day one of OASIS-C implementation will arm you with data so you will not be surprised in late 2010 when process outcomes are posted to the CMS Home Care Compare web site.

Training Considerations
CMS has determined that four hours of staff training for each staff member on the new and revised assessment items will adequately meet the educational needs of home health clinicians. But seasoned educators know that practice changes, such as those evidenced in the OASIS-C, will require a longer time period to incrementally review and successfully transition from the current OASIS-B1 assessment to the revised OASIS-C document.

An incremental review of new and revised OASIS-C items using creative educational strategies beginning this fall will allow staff time to understand the changes and begin to see how to integrate the revised assessment items into their clinical practice. Begin with the best practice items and ensure your staff has the tools and knowledge to complete the screen tools and implement a relevant plan of care that addresses the screen outcomes (see list below). Offer frequent updates and the printed revised Chapter 3 Guidance to clinical staff for reference and review during and after item review sessions.

Best Practice Screens and Protocols include:

• Falls Risk Assessment
• Integument Assessment for Pressure Ulcer Risk
• Standardized Pain Assessment
• Depression Screen
• Medication Management
• Diabetic Foot Care
• Heart Failure Care
• Pressure Ulcer Treatments

Consider piloting priority OASIS-C training and field use with clinical experts and preceptors in your agency. First-hand use of new and revised items enhances lively education programs with realistic patient case scenarios to exemplify assessment variations and item scoring changes.

Clinical staff can present practice variations, as well as impact and process changes that support those field changes. Understand that dedicating time throughout the year for ongoing OASIS-C monitoring, training and individualizing clinician feedback will be critical in 2010.

Review and Update Processes that must be in place in 2010 to reinforce new education programming
Consider revising or refining your current:

• Staff updates
• Case Conference Applications
• Case Scenario presentations
• Board updates
• In-service education activities such as mini-newsletter and e-mail updates

Set the Tone for Success in 2010
Leadership sets the pace and tone for success with any agency change and home health managers are not strangers to working in a constantly changing culture. Focused energy and positive initiatives will reinforce fundamentals for success as assessments and practices change.

Clinicians need to see how revised assessments, EBP and valid and reliable tools will help them better assess and document what they have been practicing for many years. Systematizing and standardizing these practices not only enhances clinical practice but also ensures and validates that patients and caregivers will recognize organizations and clinicians who value and implement national best practice standards.

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. She has extensive experience and expertise in:

• Clinical Best Practices;
• OASIS Assessment & Documentation;
• CHAP & Joint Commission Accreditation;
• On-site Management;
• Reimbursement issues;
• In-service and training of home care staff;
• Hospice clinical, administrative and financial management;
• ICD-9-CM Coding;
• Corporate compliance;
• Strategic planning; and
• PPS.

Contact the author through RBC Limited: www.rbclimited.com