OASIS Alert

Examine these areas to plan your strategy.

You may not know what the item instructions are until late summer, so focus your efforts on the new OASIS C process measures.

The OASIS C assessment tool contains a number of new process items that home health agencies will need to address. These items were added in part to capture care that HHAs can control, according to Angela Richard of the University of Colorado Health Science Center, speaking at an industry conference in March.

These process items are meant to identify patients who are at high risk for problems, so many agencies already use them, Richard said.

Agencies can implement these processes gradually, because at this point they are optional, she said.

What they are: Process items on the OASIS C ask questions about whether the agency has conducted certain kinds of assessments and whether there are any orders related to the results of the assessments, explained Chicago-based regulatory consultant Rebecca Friedman Zuber. Then at the next assessment you are asked if you implemented the plans you made to address the problem, she told listeners to a recent Eli-sponsored audioconference OASIS C: What You Need To Know About This Major Assessment Overhaul.

The process components are a significant part of OASIS C, Zuber said. Agencies should spend time reviewing their clinical processes and make improvements right away, so they can do well once they begin using OASIS C, she said. The soon-to-be-implemented process measures cover these areas:

M1300 asks whether you assessed the patient for the risk of developing pressure ulcers.

If the answer is "yes," you are asked whether the assessment was based on an evaluation of clinical factors such as mobility, incontinence, and nutrition or if you used a standardized tool.

M1302 asks what you concluded about the patient's pressure ulcer risk.

Resource: Two popular pressure ulcer risk assessment tools are the Norton scale and the Braden scale. The Norton includes five categories: physical condition, mental state, activity, mobility, and incontinence. You can review it at http://coa.kumc.edu/GEC/modules/norton_scale-printing.htm.

The Braden includes six categories: sensory perception,moisture, activity, nutrition, and friction/shear. To review the Braden scale, go to www.bradenscale.com/braden.pdf.

M2250 (Plan of Care Synopsis) asks if the physician-ordered plan of care includes interventions to prevent pressure ulcers. One possible answer states that the patient "is not assessed to be at risk for pressure ulcers."In M2400 (Intervention Synopsis) section (e) asks whether you included an intervention to prevent pressure ulcers in the physician-ordered plan of care and if you implemented the intervention. Besides answering "yes" or "no," you can answer "not applicable" because "formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS assessment."

Heads up: Section (g) of M2400 asks about pressure ulcer treatment using moist wound healing. This is a clear indication of the increasing emphasis the Centers for Medicare & Medicaid Services is placing on evidence-based practice, Zuber said. The data show that moisture-retentive dressings are the way to go in treating pressure ulcers, and this item is one more tool CMS is using to move physicians in that direction, she suggested.

M1240 asks if you used a standardized pain assessment tool to give the patient a formal pain assessment. If you answer "yes" and it indicates severe pain, M2250 (Plan of Care Synopsis) will ask you if the physician-ordered plan of care includes interventions to monitor and mitigate pain.

Then M2400 (Intervention Synopsis) will ask if the care plan included these interventions and if you implemented them.

Self-defense: Start training staff now for the documentation needed to support these process measures, Zuber advised. Some of the process measures provide a template for the documentation clinicians should be doing now, but are not, she said.

With OASIS C you will need to have as much information about diagnoses as you can when you assess the patient, said Abt Associates' DeborahDeitz, speaking at aMarch industry conference.

For example, you need to know if the patient has heart failure so you complete M1500 for that patient. And M2250 (Diabetic foot care) requires you to know if the patient has diabetes.

M2250 (Plan of Care Synopsis) asks if the physician-ordered plan of care includes diabetic foot care -- such as monitoring for lesions on lower extremities and education of  the patient and caregiver on proper foot care.

In M2400 (Intervention Synopsis) section (a) askswhether the patient's plan of care includes diabetic foot care and if you implemented that care. The item provides an N/A selection if the patient is not a diabetic or is a bilateral amputee.

New way: Much more data will be collected at transfer and discharge, Deitz confirmed.

A number of the process questions will require you to look back over the clinical record for the episode to be sure you completed the interventions included in the plan of care, Zuber explained. This will require changes in agency processes, she emphasizes.

In M1500, if the patient has been diagnosed with heart failure, you are asked whether, at any point since the previous OASIS assessment, the patient exhibited symptoms indicative of heart failure -- such as dyspnea, edema, weight gain, etc. On this item, possible answers include "yes," "no," "N/A," and "Not assessed."

M1510 asks what actions you've taken if the patient has a diagnosis of heart failure and has exhibited symptoms. You are asked to mark all that apply, including contacting the patient's physician, advising the patient to go to the ER, implementing standing orders for that patient, clinical interventions, and obtaining new orders for the plan of care.

Depression is typically under-assessed in the elderly, Zuber cautioned. It can lead to nutrition problems, delay recovery from illness or surgery, increase cognitive impairment, and expand use of health care services.

M1730 asks if you have screened the patient for depression, using a standardized assessment tool. The item includes within it a two question PHQ-2 Pfizer scale, so you can answer the itemand assess for depression at the same time.Or you can say you screened the patient with a different standardized assessment tool and either he met the criteria for further evaluation or he did not.

M2250 (Plan of Care Synopsis) asks whether the physician-ordered plan of care includes depression interventions.

M2400 (Intervention Synopsis) asks if you included depression interventions in the plan of care and implemented them. You can also choose N/A if the patient has neither met the criteria for depression nor had that diagnosis since the last OASIS assessment.

Resource: For a depression scale from the Best Practice project of the Hartford Institute for Geriatric Nursing, go to www.hartfordign.org, choose "Clinical Resources" from the top menu bar and then select "Try This" from the clinical resources box.

7. Falls risk (M1910, M2250, and M2400).M1910 asks if you gave the patient a "multi-factor falls risk assessment." This includes factors such as falls history, multiple medications, mental impairment, etc.

M2250 (Plan of Care Synopsis) asks if the physician-ordered plan of care includes falls prevention interventions. You can indicate if the patient was assessed not to be at risk of falls.

M2400 (Intervention Synopsis) asks if you included falls prevention interventions in the plan of care and if you implemented them.

You can indicate N/A here if your assessment showed the patient not at risk for falls.

Prevention: Falls account for more than half of the injury-related hospitalizations for those over 65. Falls risk assessments and post-fall assessments are both needed in your clinical processes, experts agree. Falls prevention and medication review go hand in hand, because multiple meds increase the likelihood of falls.

M2000 asks if your drug regimen review indicates potential clinically significant medication issues, such as side effects, dosage issues or noncompliance. If so,M2002 asks if you contacted the physician or physician-designee within one calendar day to resolve the issues.

Whether or not you identified medication issues, you are directed to M2010, which asks about high-risk drug education.

The item asks if you have provided patient/ caregiver instruction on all high-risk medications the patient is using. Then M2015 asks if you have provided education to the patient/caregiver about other medication the patient is taking.

Requirement: The drug regimen review includes all medications and supplements, not just prescriptions, Zuber instructed.

And you need to continue the review throughout the episode, such as when side effects or noncompliance occur or when medications are added or dropped, she added.

M1040 ask if your agency provided a flu vaccine for this patient. If not, M1045 asks you to identify the reason.

M1050 asks if your HHA provided the patient with a pneumococcal vaccine. If not, M1055 asks for the reason.

Why? Recent flu outbreaks have focused public attention on the importance of vaccines. You may find people more receptive to getting an annual flu shot and CMS wants you to do your part in providing this preventive measure.

Learn the facts: Just because a patient has had a pneumococcal vaccination in the past doesn't mean he's up-to-date. People 65 or older should receive a second dose (booster) of vaccine if they received the first dose more than five years earlier and they were under 65 at the time, the Centers for Disease Control and Prevention recommends. For more vaccination information and educational material, go to www.cdc.gov.