Home Health & Hospice Week

New cross-setting OASIS items will overwhelm beleaguered HHAs, commenters warn CMS.

If you’re tired of the merry-go-round of OASIS items changing, adding, and dropping off the patient assessment tool, it’s not over by a long shot.

As has become typical, the Centers for Medicare & Medicaid Services proposes multiple changes to the OASIS tool in its latest proposed rule issued in July. Revisions include dropping and adding items, but the biggest OASIS alteration may be the addition of 20 standardized patient assessment data element (SPADE) items (see box, p. 296). Further, many of those new OASIS items contain an extensive number of sub-elements.

Background: In the 2018 rulemaking cycle, CMS proposed adding many of the currently proposed items. After commenters expressed significant concerns about the added burden, CMS settled on adding only these items: GG0100 Prior Functioning: Everyday Activities (converting over from the old M1900); GG0110 Prior Device Use; GG0130 Self-Care; J1800: Any Falls Since SOC/ROC, whichever is more recent; and J1900: Number of Falls since SOC/ROC, whichever is more recent (see Eli’s HCW, Vol. XXVI, No. 42).

Now CMS has circled back to add those postponed items, as well as some new ones, the agency notes in the 2020 proposed rule. HHAs would have to start collecting the new SPADE item data for admissions and discharges that occur in January 2021, for use in 2022.

CMS reminds readers that the IMPACT Act of 2014 requires the Department of Health & Human Services “to modify the [Post-Acute Care] assessment instruments in order for PAC providers, including HHAs, to submit SPADEs under the Medicare program,” according to the proposed rule.

In the proposed rule, CMS notes that back in its 2018 rulemaking cycle, it didn’t “finalize the majority of our SPADE proposals in recognition of the concern raised by many commenters that we were moving too fast to adopt the SPADEs and modify our assessment instruments in light of all of the other requirements we were also adopting under the IMPACT Act at that time,” the rule says. CMS also wanted to conduct more testing on the items before requiring them.

Now, it’s time to get going again, CMS indicates. “HHAs have had an opportunity to familiarize themselves with other new reporting requirements that we have adopted under the IMPACT Act,” the rule says. “We have also conducted further testing of the proposed SPADEs … and believe that this testing supports their use in our PAC assessment instruments.”

Put A 5-Year Freeze On OASIS Changes

Many commenters on the proposed rule are far from agreement with CMS on the proposal.

“Spectrum Health questions relevance and necessity of some of the items, especially in the Special Services, Treatments, and Interventions domain,” the health system based in Grand Rapids, Michigan, tells CMS in its comment letter. In the testing to which CMS refers, “very few patients received the services/treatments post-acute care providers would be required to report. Multiple items had 0 percent of patients noting use of the service/treatment, and several others showed less than 3 percent of patients receiving the service,” Spectrum points out. “Some of the items also demonstrated only fair or even poor reliability.”

Duplication is another problem, Spectrum charges. Noting whether a patient receives these treatments is a good practice, but this is “information already considered by care teams and … can be gleaned from administrative sources rather than painstaking assessment that requires gathering information from multiple sources,” the letter says. Some of the new items, such as those on incontinence, duplicate already existing items, Spectrum adds.

The heavy burden of the SPADE items is far from justified, insists the Johns Hopkins Home Care Group in its comment letter. “The proposed updates and addition of SPADEs to the HHQRP directly conflict with the intent of the ‘Patients over Paperwork Initiative,’” says the provider based in Baltimore. “These additional measures will place additional burden on clinicians, requiring them to spend even more time on unnecessary documentation that provides little value to patients and increases agencies’ costs and time during the start of care.”

Costs will be of paramount importance under the Patient-Driven Groupings Model, with elimination of Requests for Anticipated Payment. The SPADE additions “add further risk to agencies who must manage start of care costs appropriately,” JHHCG’s Mary Myers says in the agency’s letter.

And the cross-setting questions are sometimes just a bad fit for home care. “HHAs are the only provider type that is not facility-based under the IMPACT Act,” Myers points out. “This important differentiation is causing many challenges and additional burden for HHAs as they try to navigate additional assessment questions that do not pertain to the home as a site of care.”

Adding the proposed new measures and SPADEs “would significantly increase the number of assessment items to the Outcome and Assessment Information Set (OASIS) instrument, resulting in a very different data set in 2021 than what agencies are currently using,” cautions Pat West with Pioneer Home Health Care Inc. in Bishop, California.

On one hand: “These changes will initially be quite burdensome for agencies to implement due to the number of new items and the fatigue agencies are experiencing related to having to accommodate multiple alterations to the OASIS assessment over the past several years,” the National Association for Home Care & Hospice observes in its comment letter. “Adding to the burden is the time it takes for CMS to receive final approval from the Office of Management and Budget for the modified data set.”

On the other hand: “NAHC is reluctant to recommend delaying the implementation of the new measures or any of the proposed SPADEs since that would require additional iterations of the OASIS instrument; leading to continued costs and burdens,” the trade group says.

If CMS is going to move ahead with its new items, it should go ahead and implement them all at once, NAHC suggests. But it should make sure HHAs have the OASIS tool draft at least six months prior to the implementation date, “to allow for staff training and other necessary preparations required for agency implementation.”

And then, CMS should “refrain from issuing any revisions to the OASIS instrument for at least five years after the 2021 implementation of the proposed changes,” NAHC urges.

Keep an eye out: Unlike with other areas, CMS actually has some leeway in how it will implement SPADEs, especially in the newly added social determinants of health category. Stay tuned to the home health final rule expected later this month or early next month to see how CMS reacts to the industry’s comments.