OASIS Alert

"So, Mrs. Jones, does your mother swear at strangers on the street or see and hear things that aren't real?": It's definitely not the ideal ice-breaker, and it's why many nurses stumble on OASIS.

There is a definite under-reporting of behavioral problems in home care, according to consultant Kay Hollers with Healthcare Executive Resources in Austin, TX. And if agencies don't answer M0610 correctly, they're not only misrepresenting the patient's condition and putting themselves at risk of adverse events, they're also cheating themselves out of reimbursement they deserve. Marking one of the boxes on this item adds three points to the patient's case mix score.

M0610 asks home health agencies to assess any behavioral problems a patient exhibits on a weekly basis, including memory slips, impaired decision-making, verbal disruptions, physical aggression, disruptive behavior (excluding verbal disruptions) and delusional, hallucinatory or paranoid behavior. Many clinicians dread this question, because it often is difficult to broach the subject tactfully.

Also, many nurses and therapists are reluctant to mark a behavioral problem they observe, because they feel they're making a diagnosis of a mental disorder, says consultant Rose Kimball with Med-Care Administrative Services in Dallas. But that's not the case at all, she urges. "They're just saying the patient has exhibited this behavior," Kimball explains.

With this in mind, it might be a bit easier for nurses to acknowledge problematic behavior they observe during the assessment. But unless a problem is glaringly obvious, nurses still might have to come out and ask the patient and/or a family member or caretaker if any such problems exist. This presents a particularly difficult situation during a start of care assessment, because the parties involved still are basically strangers, Hollers tells Eli.

If a behavioral problem does exist, chances are good that it will be a sensitive subject for the patient and family, Hollers notes. Sometimes nurses must be prepared to ask "some probing questions," says Rachel Hammon, director of clinical practice with the Texas Association for Home Care. And nurses can't always take the patient's word for it when it comes to whether they're experiencing behavioral problems, she warns. "If someone gives you an answer but you observe something different, look for a reason for that difference."

That means clinicians sometimes must put on their sleuth hats and rely on keen observation skills to get the lay of the land. "Nurses should try to make their own observation of any inconsistencies in the patient's behavior or in the family's behavior," Hollers suggests. Examine the patient's surroundings for any signs of trouble, Hammon counsels.

Agencies also can prepare staff to discuss behavioral problems with new patients and their families by allowing them to practice ahead of time, Hollers advises. "Do role playing at the agency and actually try to help people come up with sample scripts," she says. That way, clinicians don't feel like they're heading blindfolded into uncharted territory. Also, holding these kinds of practice sessions gives clinicians the opportunity to compare assessment strategies "finding out from other clinicians how they've addressed it is helpful," Hollers advises.

But no matter how careful and prepared your nurses are, there will be times when a behavioral problem slides by unnoticed until later in the patient's episode, Hammon admits. And in that case, it will show up as an adverse event.

In this case the best thing to do is simply to note the reasons why the nurse didn't pick up on the problem initially and move on, she says. "When you take into account the whole picture, you should be able to answer [M0610] fairly well, but there are going to be times when the adverse event is unavoidable," Hammon concludes.