OASIS Alert

Clinicians can change your agency's future.

Do your clinicians know what a LUPA, a SCIC or a HHRG are? If not, you could be undermining your own success.

OASIS accuracy requires you to focus not just on the specific items, but on how all the pieces of the puzzle fit together. "The more your clinicians know about the prospective payment system and OASIS, the better off your agency will be," said Cheryl Lovell with Legacy Visiting Nurse Association (now Option Care Home Health) in Portland, OR.

OASIS and the prospective payment system seem like a foreign language to clinicians, Lovell told her audience at a session of the National Association for Home Care & Hospice's 24th annual meeting in October in Seattle.

In a multi-year quality improvement effort at Legacy, Lowell and Angela Bergman, also with Legacy/Option Care, addressed a variety of pieces of the quality puzzle and improved 9 of 11 quality indicators.

Five problems they focused on may hold clues for your agency:

1. Inordinate percentage of LUPAs. At the beginning of the project, Legacy had a low utilization payment adjustment rate of 33 percent, Lovell noted. Its rate is gradually decreasing and was at 27 percent after 18 months.

First, Lovell made sure clinicians understood that LUPA means the agency provided the patient with four or fewer visits in a 60-day episode. Then she probed deeper to discover why the LUPA rate was so high. Surprisingly, she found fairness to be the main reason.

Legacy's patient population is about 50 percent Medicare and 50 percent managed care. Managed care generally covered only a minimal number of home health visits and clinicians didn't think it was fair to provide more visits for some patients just because they had better insurance coverage, Lovell said.
 
Instead: In planning the visit regimen, the agency is encouraging clinicians to focus on the individual needs of each patient. The agency also hired a staff member who understood the inner workings of managed care organizations to help patients get the care they need.

2. Incorrect diagnoses. Initially at Legacy intake nurses and agency home care consultants determined the probable diagnosis before the admission visit, Bergman reported. Clinicians often left the diagnosis as it was, resulting in errors--75 percent of the time the intake diagnosis was inconsistent with the OASIS assessment, she said.

New way: Legacy focused on educating nurses about the importance of accurate diagnoses and about their responsibility for choosing the primary and secondary diagnoses, Bergman explained.

3. Inaccurate M0825 answers. Nurses generally did not consult therapists before answering M0825 (Therapy needs). And if the nurse wasn't sure the patient would qualify for 10 or more therapy visits, she would answer "no," Bergman said. If the patient did qualify for the high-therapy payment, someone had to notice, and go back to correct the request for anticipated payment, for the agency to get paid.

Better: Now, if the nurse doesn't know the answer, she is asked to leave M0825 blank and notify the nursing supervisor. Then within the five days allowed for completing the OASIS assessment, the supervisor will consult with therapists or bring the topic up in a care conference to help the nurse find the accurate M0825 answer, Bergman explained. "This is still a challenge," she added.

4. Inconsistent answers to M0420 and M0430. In reviewing charts, Bergman noted clinicians showed differences between early M0 questions about pain and later M0 questions about movement.

Even if the patient had pain when moving, clinicians often did not go back and change the earlier answers. Also, nurses just asked about activities of daily living to answer the M0 questions, while therapists observed the patient in action.

Strategy: Legacy provided self-learning training modules about pain, followed by a competency exam. They stressed improving documentation.
 
Having each field staff member do at least one record review of a case heavily involving another discipline was also "very enlightening," Lovell noted. For example, she would have a physical therapist review a case that was heavy on skilled nursing care, she said. Clinicians resisted at first but the chart review helped them learn about the skills the other discipline contributes to the episode.

5. Inadequate documentation. If documentation doesn't support a skilled visit, the agency is at risk for downcoding. Someone needs to look at OASIS documentation before it goes out the door, Lovell said. And clinicians need to understand how documentation is tied to outcomes and financial performance.

Smart idea: Legacy began tying documentation to clinicians' performance reviews, Lovell said. In the month of a clinician's performance review, supervisors audit the clinician's records. By using the clinician's own documentation, they can point out strengths and weaknesses, making this as positive an experience as possible, Lovell noted. Initially raises aren't tied to documentation, she said--but if the same problems remain, they could be.