OASIS Alert

Patients may perceive pain differently, but if clinicians document pain differently, reimbursement and outcomes will suffer.

Pain management is high on many agencies' list of concerns because it is one of the outcomes measured in Home Health Compare. But it also will impact surveys, customer satisfaction and even patient and family lawsuits (see related story, "Assessment").

Whether M0420 is your quality improvement focus or you're just concerned about how your agency looks on Home Health Compare, these experts' tips can point you in the right direction on this important OASIS item.

1. Keep your eyes and ears open. Use observation and interview techniques throughout your visit to look for pain clues. Be aware that patients may under-report pain for a variety of reasons, such as fear of addiction to pain medication, belief that pain is an expected part of old age, worry that pain might signal worsening of their condition or reluctance to undergo any more testing.

2. Question medications. A medication review may reveal the patient uses medication for pain or joint disease, even though she denies having pain. Noting the medication gives you another way to ask about pain. Also don't forget to ask about over-the-counter pain meds.

3. Activities are a major pain trigger. In addition to the specific pain questions, observe for pain while patients perform activities of daily living.

TIP: Try to determine if the patient is limiting activity because of pain, suggests Linda Krulish, OASIS expert and president of Home Therapy Services in Redmond, WA. A patient may seem to be a "0" on M0420 because she limits activities she normally does since they cause pain. If you take those activities into account, she actually may be a "2" or "3," Krulish notes. If the extra five points push the patient into the next clinical severity category, this can add from $200 to nearly $900 to your episode payment, according to Jim Robinson, senior financial analyst with Rohnert Park, CA-based Boyd & Nicholas.

4. Look for signs of pain if the patient is nonverbal. Observe facial expression, heart rate, respiratory rate, pallor, sweating, pupil size and irritability, the Centers for Medicare & Medicaid Services suggests in its M0420 assessment strategies in the OASIS Implementation Manual.

5. Well-controlled pain may equal "0." Answer M0420 taking into account how effective the pain medicine or other treatment is in relieving pain while allowing activities. "Pain that is well-controlled with treatment may not interfere with activity or movement at all," CMS instructs.

6. Don't skimp on documentation. Besides noting when and how often the pain interferes with activity or movement, document the location of the pain, when the pain is most severe and how long it lasts, recommends consultant Carol Conrad with Hamden, CT-based Simione Consultants. Documentation should include factors that aggravate or alleviate pain, medications the patient uses to control pain and how effective the medications are.

To improve consistency, record how the patient describes the pain, using standardized wording for your agency, she adds.

7. Strive for consistency. Documentation within the record must be consistent with the response selected for M0420, Palmetto GBA says in its Web questions and answers. The perceived level and frequency of pain should correlate with medications and interventions in the plan of care, Conrad stresses.

8. Use the same pain measurement scale throughout the agency. This can improve both assessment accuracy and pain monitoring, Conrad recommends.

Many HHAs use a zero to 10 scale:

|___|___|___|___|___|___|___|___|___|___|

0 1 2 3 4 5 6 7 8 9 10

Some agencies prefer a five-section scale:

|______|______|______|______|

None Mild Moderate Severe Worst

Other pain scales use faces with happy and sad expressions and are available in English and a variety of other languages.

Editor's Note: For more examples of pain scales, go to http://www.nurspeak.com/index.html?tools/pain2.htm.