Beware the eye of the storm: OASIS is coming when you least expect it
This time, there’s no evacuation plan, so how do you prepare staff?
The name might sound like a vision of moist greenery in a desert. But a better analogy for the Outcome and Assessment Information Set (OASIS) tool probably is a monsoon, a windy burst of rainfall that can drown those who are unprepared.
Whatever else OASIS may be nuisance, necessity, or disaster it still is a reality in the proposed changes to Medicare’s Conditions of Participation. And experts say OASIS is inexorably headed home care’s way. Preparation, which means plenty of staff education, is the only way to survive its onslaught.
The key is to provide education and leadership training, says Terry Rogers, CHCE, director of hospital-based Carraway Home Health in Birmingham, AL. Carraway Home Health serves the urban Birmingham area, and 93% of its clients receive Medicare. The agency began using an OASIS data tool on May 1 and has since been added to the National Medicare Quality Assurance Improvement Demonstration.
"We tried to get a buy-in from everyone, bottom up," Rogers says.
Home care agencies still have a few months to get a head start on OASIS because experts say the Health Care Financing Administration (HCFA) probably will not publish the new Conditions of Participation until 1998.
"They’re reviewing the comments and making decisions about that now," says Lou Anne Koch, MS, president of Eldermanage Inc. in Atlanta.
Koch provides workshops and consults with home care agencies about outcome-based quality improvement using the OASIS data set. She had worked with HCFA for seven years in the bureau of health standards and quality, and she helped to develop the proposed revised Conditions of Participation. She also was involved in the development of the OASIS data set and with outcome-based quality improvement.
"I think there is no doubt that OASIS will be required. The research has been extensive over the past seven to eight years now," Koch adds. "Everyone has supported the need for a comprehensive assessment, so care across regions can be compared."
Based on Carraway Home Health’s experiences and Koch’s suggestions, here are some guidelines to implementing the OASIS data set and educating staff in its use:
1. Instill enthusiasm.
The right attitude is essential, Koch emphasizes.
OASIS relates to quality improvement, and "until the leadership understands that themselves, they will see it as just one more thing the federal government wants them to do," she says.
"And that’s exactly the wrong approach," Koch adds. "There still is time for people to use the OASIS concepts in their own environment and to do the things they probably should be doing anyway."
Koch explains to home care administrators that using OASIS still allows agencies to be flexible in developing their own assessment tool. They simply need to include the core questions. "It just makes the whole process far more accountable," she says.
She embraces the attitude that Medicare’s push to using OASIS parallels the quality improvements many agencies have made as part of their accreditation process.
"For the first time, the expectations of accreditation and the expectations of the federal government are moving hand in glove, and I think that’s a wonderful thing for home care," she says.
"Now after 15 years of focusing on the business side of home care, we have the opportunity of moving back into the clinical business, which is what we’re all about."
2. Collect information.
The Center for Health Services and Policy Research of Denver has developed an OASIS packet that any home care agency can purchase. And the National Association for Home Care in Washington, DC, has a manual on outcome-based quality improvement.
Koch highly recommends both of these as a good starting ground. (See OASIS resources, above right.)
3. Develop a leadership team.
Carraway Home Health administrators started to discuss using OASIS last year, and then in January 1997, they started planning.
The first step was to develop a leadership team. Koch recommends these teams include employees from administration and the clinical side.
Carraway’s group included clinical managers, field nurses, administrators, accounting personnel, and medical record staff. The group immediately came up with plans for starting OASIS.
"We came up with an implementation time grid, which included educational steps," Rogers says. (See Carraway’s time study and time grid, pp. 151 and 152.)
4. Give staff an introduction.
Carraway Home Health provided a one-hour continuing education inservice to introduce OASIS to the staff, says Dee Henry, RN, staff development specialist.
The agency defined OASIS and outcomes based quality improvement, and provided background information, Henry says.
Rogers says the introduction explained why the agency was going to use the OASIS tool. "The government was going to use OASIS to measure outcomes in home health, and it is tied to PPS [Medicare prospective payment system]," he says. "So we figured the more time we had to study it and implement it, the better off we’d be."
OASIS is a standard core assessment data tool that was developed by the Center for Health Care Policy Research (CHPR) at the University of Colorado in Denver. The first data set had 79 questions about adult patients to be collected during the initial patient assessment, at certain intervals, and at discharge. Now there are 89 questions.
The questions seek information about the patient’s demographics, history, living arrangements, caregiving support, daily activities, medications, and equipment management. The questions also inquire about the patient’s sensory, neurological, respiratory, emotional, and behavioral status.
Initially, about 50 home care agencies across the country were invited to participate in a demonstration project of collecting data with the OASIS tool.
HCFA also has a demonstration project on a per-visit prospective payment system.
5. Set up a pilot study.
Carraway Home Health conducted a month-long pilot study that included one clinical team using the data set on all Medicare patients.
"I recommend that under the direction of the leadership group, they do some mini-pilot study using some questions from OASIS with some clinical situation they believe is very important," Koch says.
For example, she says, an agency could study patients in a cardiac program. "Make it something the staff can relate to, and see how it applies to quality improvement."
6. Simplify existing forms.
Koch says it’s crucial that agencies trim their current documentation fat because OASIS will take extra time. So agencies have to find some other ways that time can be given back.
In her experience, most agencies require plenty of unnecessary documentation.
"Agencies are heavily built on folklore of the past 20 years, the folklore of who says what you have to do and who has to do it," Koch says.
"And it happens every time I work with a group. They come up with examples of things they think they need to do."
Koch says her reply always is "Why do you need to do that? Is it a state or federal regulation? Is it in your agency’s policies and procedures? Or is it something your staff says you need to do?"
Their answer, Koch comments, usually is that this is the way people say it has to be done.
So the leadership group needs to tackle the job of simplifying and getting rid of pointless paperwork and unwritten rules, she adds.
The agency’s assessment tool is a good place to start. The leadership group should scan that for information that no one reads or uses, Koch says.
Another gremlin is repetition from form to form. "A lot of times agencies don’t separate out assessment from the admission process, so they might go back and restate legal rights," she says. "They repeat things, or they add things because they think somebody is going to want that."
Carraway Home Health leadership group pulled the initial admission packet and compared it with the new admission packet that incorporated OASIS, Henry says.
"We were able to eliminate 16 different forms and throw them in the trash, and we immediately got a buy-in from the staff," Henry adds.
Instead of the cumbersome multi-page forms it had been using, the agency now uses a single 18-page packet with OASIS questions, which was developed by Olsten Health Management of Melville, NY. The result is that nurses now spend a little more time filling out the assessment tool in patients’ homes, but they spend less time altogether in completing paperwork, Henry says.
7. Show staff how it works.
Carraway Home Health showed staff how the OASIS data related to a goal of improving outcomes, using specific examples.
"They are already beginning to look forward to seeing the outcomes," Henry says.
The nurses give the start of care assessment; then 67-to-71 days later they do a follow-up assessment, asking some of the same questions, she explains. "They have to look at any changes that occur with the patient in those areas, to see if the patient has improved, or stayed the same, or deteriorated." (See OASIS start of care and recert audit tools, pp. 153-154.)
The initial follow-up data has highlighted some problems that the agency will address through quality improvement.
"From a patient management standpoint, what could be better than knowing exactly what you’re doing for a patient?" Rogers says. "I think the clinical employees appreciated that, and they understand."
8. Continue staff education.
OASIS education continues at about every staff meeting, Rogers says.
Then next May, Carraway Home Health will take a broad look at a year’s worth of data and highlight weak spots and trends, Rogers adds.
The next step could include writing critical pathways to address those areas and then educating the staff on those.
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