Home Health & Hospice Week

Nearly every MO item changes in revised assessment tool.

The patient assessment tool on which your payment and outcomes depend is about to get an extreme makeover--and it will mean more work for you.

The Centers for Medicare & Medicaid Services on July 27 released its revised OASIS draft. CMS plans to test the drastically revised tool in 11 home health agencies in Colorado, Massachusetts and Ohio this fall, the agency says in the Paperwork Reduction Act supporting statement for the revised form.

Timeline: If all goes as expected, CMS will revise the tool in light of the test results and then implement the new assessment form in early to mid-2009, a CMS official tells Eli. That would include time for comment on the revisions, the staffer notes.

HHAs will have a lot of revisions on which to comment, experts point out. "Nearly all of the existing OASIS items have changes in wording," says consultant Judy Adams with LarsonAllen based in Charlotte, NC. Many of the rest have at least changed M0 numbers.

Nearly 30 Process-Based Measures Added--Along With Major Burden

One of the biggest changes to the form is the addition of nearly 30 process-based measures that will start with "M1" instead of "M0." Clinicians won't have to answer every process question at every timepoint, CMS points out.

The new questions cover patient education, vaccination history, physician communication, pain, volume overload, pressure ulcers, foot care, depression, fall risks and medication.

"Process measures that support evidence-based practices ... prevent exacerbation of serious conditions, can improve care received by individual patients, and can provide guidance to agencies on how to improve care and avoid adverse events." CMS says.

Increased workload: But the process-based measures CMS wants to include could translate to a lot more work for clinicians filling out OASIS. The feds claim the added burden is negligible. That's because CMS is also cutting some items not used for payment, quality or risk adjustment; streamlining other items; and requiring process items only for some timepoints or, in some cases, certain times of the year.

"Total impact of proposed OASIS revisions, including both elimination, revision and addition of items, changes the estimated burden of the OASIS very little while incorporating process measures," CMS maintains in the PRA supporting statement.

But experts disagree. The process items are "more work intensive than those that were deleted," argues consultant Pam Warmack with Clinic Connections in Ruston, LA. "This is not an equal trade off."

"No matter how 'easy' an item is to collect, the mere addition of a new item requires some education and learning curve burden," adds OASIS consultant Linda Krulish with OASIS Answers in Redmond, WA.

And many of the process items will be far from easy, Krulish notes. "Some of these items will pose challenges for clinicians," she warns. They will add assessment requirements required in order to allow the clinician to select a response or provide an intervention.

Example: M1155 asks whether fall prevention steps have been implemented for the plan of care. To choose the "Yes" response, the clinician first must put in place the prevention steps.

Another problem: Clinicians will find it difficult to ascertain some information requested in the new assessment, Warmack protests. "Patients rarely remember when they last received [flu and pneumococcal] vaccinations and caregivers offer very little assistance," Warmack says. HHAs then must bother the physician or his office staff for the data. "Physicians are always less than thrilled to dig this information from their office files," she observes.

"The source of information for these items will be the clinical record and plan of care, rather than the patient and caregivers," expects Chicago-based consultant Rebecca Friedman Zuber. "When will CMS expect these items to be answered and who will answer them?" she asks.

And expect difficulty with completing all the prevention steps CMS wants in the already-jam-packed first visit. "While it is certainly worthwhile information to provide ... it is burdensome to require this during the first visit," Warmack insists. "The initial visit is already overloaded with requirements that most clinicians struggle to complete."

The extra prevention items aren't just a burden for the agency, Warmack points out. "It is also unfair to impose on the ill patient more information than she can realistically absorb," she judges. "CMS may defeat the ultimate goal of providing quality patient care by overregulating patient care" in the new form.

Bottom line: The process questions will add to data collection time, Zuber predicts.

HHAs also may not be happy with the wording of some of the process items, which is "awkward," Zuber notes. "They leave a lot to interpretation," Krulish adds.

But that may be something that changes before final implementation. "I expect the language to be refined through the demonstration," Krulish tells Eli.

What To Do Now

Now is your chance to comment on the OASIS changes in the early stages, Zuber urges. "If we don't let [CMS] know how we feel ... then we have only ourselves to blame," she maintains.

Hold off: But don't go overboard in ramping up on the OASIS changes yet, experts caution. Even though they are a drastic departure from current OASIS, they aren't yet finalized. Look at the draft tool critically, provide feedback, and go back to worrying about prospective payment system refinements, Zuber advises.

Don't worry about communicating changes to field staff yet, Krulish counsels. Focus on the more imminent PPS changes instead.

What's ahead: CMS will issue the final version of the form, which will incorporate testing findings, in conjunction with a PPS annual rule, the CMS official explains. As with all PPS rules, it will have a notice and comment period so providers will have a chance to submit feedback on the final version.

At that point in late 2008 or early 2009, HHAs will have to gear up for a major staff retraining effort.

Note: The revised tool and supporting statements are at www.cms.hhs.gov/PaperworkReductionActof1995 search for CMS-10238.