Home Health & Hospice Week

If you've had nurses wanting to quit over the new OASIS assessment tool, you're not alone. The increased time required to complete the new assessment and the many trouble spots among the new items are driving clinicians crazy.

"I am hearing a lot of grumbling from our members whose nurses are complaining about the  ncreased burden and threatening to quit," notes Joe Hafkenschiel with the California Association for Health Services at Home. "This is yet another unfunded cost at a time when they are trying to cut our payments by $40 billion plus."

"I know of one RN director who has resigned because of her frustration with dealing with" wound assessment problems, particularly the definition of the term "re-epithelialized," reports consultant Pam Warmack with Clinic Connections in Ruston, La.

In the first weeks of OASIS C, clinicians have been spending up to double the time they formerly did to complete OASIS, says Judy Adams with Adams Home Care Consulting in Chapel Hill, N.C. "Many agencies have moved their time allowance for an OASIS C from two visits to three visits," Adams tells Eli.

The bright side: At least some of the increased time burden will ease once staff get used to the new tool. Over time, clinicians will become more familiar with the new items and the changes in the definitions for responses, Adams points out.

Clinicians conducting assessments are running into lots of hot spots in the new OASIS C tool, including these frequently cited problems:

• Wound items. "The integumentary status items continue to be challenging for folks," says Chicago-based regulatory consultant Rebecca Friedman Zuber.

"Most agencies' clinicians are struggling with the pressure ulcer items, particularly M1308," Warmack agrees. "They can't seem to grasp how to complete the two columns defining when an ulcer has been present at start of care or resumption of care."

Clinicians are seeing contradictions in the OASIS User's Manual's Chapter 3 item-by-item guidance, Warmack says. They're asking "if pressure ulcers are not to be 'reverse staged,' how can the words 'current,' 'un-healed,' and 're-epithelialization,' be applied to WOCN guidelines?"

(See Eli's HCW, Vol. XVIII, No. 44, p. 340 for tips on completing the pressure ulcer items.)

• Look back items. Home health agencies are having a tough time figuring out how to organize their records to facilitate OASIS C completion at transfer and discharge, says Sharon Litwin with 5 Star Consultants in Ballwin, Mo.

The new look back questions are creating a huge issue for Memorial Home Health in Fremont, Ohio. Staff are having a rough time determining how and where to document pertinent items to be able to quickly and accurately answer the related questions at discharge, says Carol Theis, performance improvement coordinator with the agency. "Currently we are using a tracking tool in our computer system which is causing double documentation for clinicians," Theis tells Eli.

HHAs are still "figuring out how to set up processes and documentation strategies for completing the new transfer and discharge data sets," Zuber observes. Many of the look back items support the new process measures.

These items are where many providers are seeing a major time drain. "RNs feel trapped by having to answer questions which say they have ensured best practice orders were both on the plan of care and implemented," Warmack says. "The transfer [assessment] has gone from taking five minutes to complete to over an hour in some cases. Obviously providers were not staffed to incur that kind of change in productivity."

And the time crunch isn't necessarily better for paperless HHAs. In some cases, "the providers who are on point of care have not had the software support in completing this task of looking back that they were led to believe they'd have," Warmack adds.

"One agency told me they are using a tracking tool that then is taking more than 40 minutes per chart to do a look back," Litwin says. "That will never be practical -- there just isn't that much time."

• Physician responses. A number of new OASIS C items require a physician response within one day. For example, M2002 and M2004 ask whether the HHA contacted the physician within one calendar day "to resolve clinically significant medication issues, including reconciliation."

Note: The "to resolve" language means that for the agency to answer "yes," the physician needs to have gotten in contact with the agency to acknowledge receipt of the information, experts say.

This is a big challenge for Vital Link, A Home Care Company in Hammond, La., says director of performance improvement Kathleen Saucier. The one-day timeframe is very worrying to

many agencies, says consultant Karen Vance with BKD in Springfield, Mo. "The level of success has everything to do with what kind of relationship the agency has with their physicians," Vance says.

"HHAs are frustrated that MDs are slow to return calls, so they are unable to meet the criteria for acknowledgement of the HHA messages within one calendar day," Adams says. Plus, "the MDs are upset about the extra calls and request for orders."

Unfair burden: Many providers think the Centers for Medicare & Medicaid Services should have notified the physicians of these new requirements instead of leaving it all up to the agencies, Adams relates.

Plus: The timeframes for various OASIS C process measure items may lead to agencies inadvertently completing the assessment incorrectly,

Zuber worries. "The medication items use the calendar day definition, which means from the time the call is placed to the physician until the end of the next calendar day," she explains. Meanwhile, "the heart failure item uses the actual same day." "Clinicians ... will either fail to note this difference or will confuse/merge the two timeframes when they are completing the data collection," Zuber fears. Then "the ultimate data will be inconsistent and ... less useful than it might be."

• Items addressing meds. In addition to the timeframe issues, the drug questions have other problems. Agencies aren't sure how to define things like "clinically significant," "high risk," and adverse events, notes consultant Lynda Laff with Laff Associates in Hilton Head Island, S.C.

For example: In M2010, "many agencies have not yet identified 'high risk drugs,' so the clinicians are making inaccurate decisions about what to address," Laff says.

• Transition. This problem may be more short-lived, but many staff aren't clear about how to  ill out transfer or discharge OASIS C assessments when the SOC/ROC was done under OASIS B-1.

"Because they don't match, the main thing is to do a review of med orders and teaching, pain, fall, skin assessment, etc.," Litwin suggests. "But there may be more N/A or NO answers" when discharging on OASIS C after a SOC/ROC that's OASIS B-1. "We all have to do the best we can in the transition," she concludes.