As a home healthcare veteran of nearly 25 years, I've found myself in a number of roles ranging from frontline clinician to agency administrator. In my years as a home care educator and clinical consultant, I have had a front-row seat for all the changes the industry has endured. Having entered the home healthcare industry during the 90s with handwritten care plans and head-to-toe admission assessments, the Prospective Payment System (PPS) from the Centers for Medicare and Medicaid Services (CMS) was an earthshaking change. My feelings, similar to many in the industry, were based on a number of factors; lack of preparation and training regarding the Medicare Home Health benefit, the independence of frontline clinical staff, and concerns regarding excessive documentation.
Right up to the start of PPS, providers were united in their hopes that it wouldn't actually occur. But in 1999, it did. Providers responded in a two-step fashion. First, they educated themselves and their staff regarding the CMS Home Health PPS model, including the Outcome and Assessment Information Set (OASIS) tool. Next, they made a decision that, in hindsight, defined the course of home care for the next 15 years. Rather than employing standard utilization review experts to manage the new PPS Model, home healthcare allowed frontline clinical staff to manage the care model as they managed their assigned patient episodes.
The provider I worked for learned of the PPS model initiation 3 days before it took effect. Much of the industry was similarly unprepared for the groundbreaking adjustment. As a result, 37% of providers failed to make the shift and went out of business. I can't help but look back and wonder why we didn't embrace the new care model from the beginning.
For me, I saw the OASIS tool as a fact of life and sought a path to make it meaningful to patient care. There had to be a way to achieve the acuity-based care Medicare sought without abandoning our patients. I had to put personal feelings aside; this had nothing to do with me, but everything to do with the patient. I started to understand that the OASIS really wasn't my enemy, but rather the key to successful patient-centered care. I conducted the OASIS as directed by CMS, and it required me to actually get the patient up and perform a functional walk. That itself was the key revelation about how great the OASIS could be. Why perform an interview and struggle through all of the questions when performance evaluation was a quick and easy option? Why not follow the process, actually get the patient up, and gain great insight into the person? Interestingly enough, after I did, the questions made more sense and the OASIS was easier to complete. The functional walk coupled with the use of the Guidance Manual led to more information about patient deficits. This led me to the obvious next step of creating care plans based on actual individual patient needs. Instead of relying on medication lists, diagnosis codes, and interview questions, actually performing the OASIS assessment was patient centered. It improved accuracy, capturing actual patient deficits, and led to the creation of individualized patient-centered care plans.
It is 18 years later and the OASIS is still an enigma, often fought instead of embraced as a tool for patient-centered care. Common complaints about the OASIS follow three themes:
"Who has the time to spend on that? We only get 2 hours for an admission."
"I have been doing this for a long time and I know what the patients need."
"How can someone outside of the home tell me what the correct OASIS scores are? I saw the patient; that is fraud."
Every day I respond to these comments in the name of patient care. To start, time restraints; "We only get 2 hours for an admission." Though time constraints can be relevant, it is possible to get a timely start of care (SOC) completed with most OASIS questions answered if a functional walk is performed. Admission interviews continue at an alarming rate in lieu of the functional walk. The explanation for this is: it is easier and quicker. Let's make this personal. If your favorite out-of-state aunt was receiving home care, how would you feel about the fact that the SOC clinician performed the admission through an interview? In these cases, the OASIS assessment is the last element of the admission. Many valuable items are lost, including an accurate prior level of function, objective baselines, and functional deficits related to safety. As a result, a generic care plan is derived from an inadequately performed OASIS admission. This is the best case for completing a functional walk as an essential element of the OASIS admission. Why not apply this to everyday operations, fully embracing the OASIS as the key to a deficit-driven care plan?
The second scenario of "In my professional opinion, I have been doing this for a long time and I know what the patients need," is not an element of the PPS model. Under PPS, a heart failure (HF) patient is not just an HF patient; that is, the fact that the patient has an HF diagnosis does not alone define the plan of care. Functional walks outline the other areas of deficit that need to be addressed in a patient-centered program model. PPS pushes us to define these patient deficits in objective, standardized terms, and treat accordingly. It is specifically designed to counter the labeling of patients with programs based on one-size-fits-all care pathways from programs that lacked the comprehensive OASIS assessment.
Finally, "How can someone outside of the home tell me what the correct OASIS scores are? It is my patient. That is fraud." In response, I ask everyone in home care the following question: How many times has CMS come into the home to see what you are doing? Have they ever called you to discuss your process, professional experience, or accuracy? Never, and yet CMS has power to audit and deny any OASIS assessment and episode. In home healthcare, as in any care setting, the patient does not belong to us as individual clinicians. When working in other care sites, my assigned patients could be reassigned at a moment's notice, but the patients belonged to all of us. In settings outside of home healthcare, utilization review personnel are routinely converting admissions into care plans with clinical consultation regarding inaccuracies. No one in hospitals or other settings relates that process to fraud. Yet, in home healthcare, the word is used freely and interchangeably with processes designed to gain accuracy.
With the OASIS Guidance Manual, CMS gave us a great reference and guidance tool for completing the OASIS. I personally could not conceive doing an OASIS admission without it. It is impossible to commit all OASIS intents, responses, and accuracy to everyday memory, but OASIS admissions are completed daily without the Guidance Manual as a resource. Sounds crazy to think that we have the answers to the open-book test, yet we choose to take it from memory. Real-time use of utilization review team experts can guide OASIS accuracy using the Guidance Manual and clinical reports from SOC clinicians.