It's not too late to create an OASIS tool
Your next big step is benchmarking
If you haven't already created and implemented a tool using the data set from the Outcome and Assessment Information Set (OASIS), then now is the time to start. The word on the street is that the Baltimore-based Health Care Financing Administration (HCFA) will stick to the Oct. 1, 1998, deadline for home care agencies to implement OASIS, even if the prospective payment system (PPS) is postponed until the year 2000.
"HCFA has told us they don't want to slow down OASIS because they need it so desperately," says Theresa Forster, vice president for policy for the National Association for Home Care (NAHC) in Washington, DC.
However, if your home care agency is not ready for the October deadline, then you can take comfort in knowing you're not alone. A recent NAHC survey showed that only about one-third of the 1,600 home care agencies that responded were already using OASIS, says Mary St. Pierre, BSN, director of regulatory affairs for NAHC.
Even if OASIS were not mandated by Medicare, it would be well worth using as a total quality improvement tool, says David McKinnon, RN, supervisor of total quality improvement for the Visiting Nurse Association of Central Connecticut in New Britain. The agency serves 27 towns, primarily in one central Connecticut county. The OASIS data set will give the agency an opportunity to compare its own outcomes, as well as to benchmark data against outcomes of regional and national home care agencies, McKinnon says.
Move to the head of the class
The VNA of Central Connecticut is one of 40 New England VNAs that completed an OASIS tool as part of a quality improvement project started by the VNA of New England in Needham, MA. The nonprofit membership organization's goal is to have all 68 member agencies using OASIS and then to benchmark outcomes regionally, says Alan Wright, RN, MS, director of network development for the association.
"We've been engaged in this project because we know that having outcomes data is essential for strategic advantage," Wright says. "We're basically trying to put the nonprofit VNA back in front, in a leadership role in home health care."
The VNA association has not developed an OASIS tool for its members, but it has provided member agencies with samples provided by the Center for Health Services and Policy Research (CHSPR) of Denver. A part of the University of Colorado Health Sciences Center, CHSPR is the organization that created the OASIS data set.
OASIS data have been used in two national projects funded by HCFA: one is the Prospective Payment Demonstration, and the other is the National Medicare Quality Assurance and Improvement Demonstration. The quality assurance study, conducted by CHSPR, uses OASIS data and involves 52 home care agencies. The Prospective Payment Demonstration involves 91 home care agencies and is implemented by Abt Associates, a research company in Cambridge, MA. The Prospective Payment Demonstration has a quality assurance part that uses a subset of OASIS data, along with items specific to that demonstration project.
The VNA of New England has a contract with its member agencies and the CHSPR that requires the agencies to submit their integrated OASIS assessment forms to the association. Wright will review them based on CHSPR's own criteria, he says. "The criteria we are following are parallel to what HCFA will come out with," Wright says.
The VNA of New England also has provided OASIS training material, an implementation manual, and sample policies and procedures to member agencies. (See story on how to create an OASIS tool, p. 131.)
Back to basics for benchmarking
Wright says the next phase for VNAs in New England will be to compare their outcomes regionally. Nationwide, other home health agencies and perhaps some state associations also will want to use OASIS data sets for regional benchmarking. A few computer vendors are developing software designed to make that task easier.
Last spring, Wright submitted requests for proposal, asking computer software vendors to find a means for the VNAs to use OASIS data and to develop reports.
The benchmarking should start with the basics, Wright says, such as the top ten diagnoses in home care: wound care, congestive heart failure (CHF), chronic obstructive pulmonary disease (COPD), diabetes, asthma, heart failure, general osteoarthritis, pneumonia, hypertension, and chronic ischemia.
Then benchmarking should focus on these key points:
· What are comorbidities associated with each diagnosis?
Patients may have CHF and COPD, for example. "The majority of comorbidities are within the set of primary diagnoses," Wright says. "This would confirm what people have suspected, and we're going to track that over time."
· What are patients' average risk factors or a range of risk factors by diagnosis?
In the OASIS data set, home care agencies assess different risk factors, such as the safety status of the home or whether other people in the home are assisting in the care of the patient, Wright explains.
"Agencies will be able to pull out diagnoses, look at how risk factors cluster around diagnoses, and make sure their clinical employees are adequately trained in making assessments and providing interventions," Wright says.
· What are the outcomes for different patient groups based on diagnoses or risk factors?
In order to make comparisons and to benchmark OASIS data, there must be a risk adjustment, Wright says. Demographics will provide one type of risk adjustment. But there are many other factors that account for variation, Wright says. These may include whether the patient has wounds, family support, use of all senses, etc.
"In order to adequately account for those differences and to have a level playing field, you need to know how the different factors influence the outcome," Wright says.
Some of the early vendors to offer benchmarking with OASIS data will not be able to adjust for risk factors because they don't have any risk data yet. "They have not been able to develop a statistical model, but eventually HCFA will use the statistical model the CHSPR has developed," says Wright. "But HCFA is three to five years away from being able to provide that," he adds.
Choose outcomes with punch
In the meantime, home care agencies can at least compare their own outcomes to show improvements over time. Affiliated Community Visiting Nurse Association Inc. in Rockland, MA, has begun to do exactly this with some of its disease management programs, says Joanne O'Regan, RN, MS, vice president of admissions for the agency, which serves southeastern Massachusetts.
The agency began to collect data on seven OASIS items for its disease management programs, including cardiac cases, says Joanne Dalton, PhD, RN, CS, program development manager for Affiliated Community VNA. "We had to think it through - which OASIS items would be the most affected by the disease management program - and I selected seven I felt would have the greatest impact," Dalton explains.
The agency has used the resulting outcomes data to demonstrate to managed care companies how cardiac patients improved under the agency's disease management program, O'Regan says.
"We take the scores of all the patients and show what they were on admission and what they are on discharge in 60 days," O'Regan adds. "It provides a lot of valuable information."
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