OASIS Alert

The barrier may not be your clinical efforts after all.

If you've had trouble showing improvement in your patients'ability to transfer, even after focusing on it intensely, you're not alone.

Although many agencies choose to address M0690 (transferring) as an outcome-based quality improvement project, it is one of the most difficult items on which to capture outcomes improvement, explains physical therapist and OASIS consultant Linda Krulish with Home Therapy Services in Redmond, WA. A big jump in this item usually means a change in scoring practices, rather than clinical changes, she notes.

M0690 assesses the patient's ability to move from bed to chair, on and off the toilet or commode, into and out of the tub or shower, and ability to turn and position him/herself in bed if the patient is bedfast. The six answer choices run from "0" (able to independently transfer) to "5" (bedfast, unable to transfer and unable to turn and position self). This question focuses on what the patient is able to do safely on the day of assessment, experts emphasize.

When assessing the patient's ability on the three items, if ability varies, select the answer that applies to the majority of the activities, according to the assessment strategies for M0690 in Chapter 8 of the OASIS Implementation Manual.

Reality: This "majority instruction" does make this item less sensitive to change, Krulish notes. In fact, recent statistics for episode in 2003 show that 87 percent of patients at start of care score either a "0" or "1" on M0690, she reports. "This doesn't leave you much room for improvement," she argues.

Many patients can perform two of the transfers safely, but not the third. This means that a patient may be scored "0" or "1" even if she is unable to transfer safely into and out of the tub or shower -- the hardest of the three items -- Krulish says.

Trap: An "outcome interval analysis" will show why it is difficult to demonstrate improvement in M0690, Krulish tells Eli. "Look at what you have to do clinically to show improvement," she suggests. If the agency works with the patient and improves her ability in tub or shower transfers so it equals the other two transfer items, that improvement won't show up on the outcome measures.

In answering M0690 -- like other OASIS questions on activities of daily living -- "the devil is in the details," counsels consultant Pam Warmack with Clinic Connections in Ruston, LA. It's important that all the staff understand what the answers mean, she stresses.

Getting started: If you are working on improving M0690 outcomes, it's worth taking a half hour for staff to meet in a group and discuss just this question, Warmack suggests. By having staff talk with each other about what they understand the answers to mean, you can discover and correct misconceptions, so everyone is answering consistently. For example, some staff may not know that "human assistance" goes beyond physical help and includes verbal cues and reminders.

Mistakes: Other common problems are interviewing the patient rather than asking for demonstrations, not understanding that ability includes cognitive and emotional states and not taking medical restrictions into account. If the patient can independently move from bed to chair and bed to commode, but is under doctor's orders to stay in bed, then that transfer is not a safe one, Krulish says.

Select response "1" when the patient can perform at least two out of the three transfers safely with an assistive device, standby assistance from another person or a steadying hand of another person, but not if the other person actually does the lifting, explains the M0690 instruction in the final report of the 3M National OASIS Integrity Project.

Another challenge: Besides the lack of sensitivity to improvement of M0690, the other major problem is agreeing on a definition of an "assistive device," experts say. The Centers for Medicare & Medicaid Services hasn't yet clarified what an assistive device is, Krulish says, although CMS has answered specific questions for some providers. There is still confusion about why using the arms of one item for support is an assistive device, while using the arms of another similar item is not, she says.

This lack of clarity creates inconsistent data collection, agencies find. "Our agency now has a policy that grab bars, raised toilet seats, canes and walkers are assistive devices in answering M0690, but furniture is not," explains OASIS educator Patty McMillan with Burr Ridge, IL-based Health Care At Home. Reaching this kind of agreement can improve your agency's data consistency even if your definition is not the same as your neighboring agency.