OASIS proficiency key to surviving transition
Let staff suggest ways to adapt to PPS changes
In the month before the start-up of the prospective payment system (PPS), improving Outcome and Assessment Information Set (OASIS) data is job one, say those who have been studying the ramifications of the final PPS rule.
"The first thing [home health agencies] absolutely need to do is make sure the clinical staff know how to do OASIS in a completely accurate and consistent fashion," explains William Dombi, Esq., vice president for law at the National Association for Home Care in Washington, DC. "The care plan and the daily record of care must be consistent with the findings in OASIS. You don’t have a diagnosis on the OASIS that’s not shown in any relationship to the plan of care."
At the VNA of Boston, there are plans to update training on OASIS to ensure that assessments are being carried out consistently among nurses and other clinicians, says H. Kenneth McNulty, vice president for finance at the VNA.
"You don’t want some clinicians being tougher than others," McNulty says. "The thing everybody is talking about is consistency between the physical therapists vs. nurses doing admissions."
But OASIS isn’t the only key to surviving — and even thriving — in this rocky transition period, as everybody adjusts to the new system. Lucy Lee, RN, MHA, CHCE, owner of Lee Health Care Inc. in Hamilton, TX, says an agency’s leadership is key to its success in handling the changes.
"People who are very knowledgeable and who have plans are going to be better able to handle it than people who just try to wing it from a management perspective," Lee says.
Many agencies have special PPS committees in place, some of which have been operating for months to foresee problem areas and devise solutions. Companies that were part of the PPS demonstration project, such as In Home Health Inc. in Minnetonka, MN, have been using their experiences under that system to prepare for the real thing.
In addition to PPS committees at individual agencies, In Home Health has a corporate committee with several subgroups examining specific issues related to the final rule, says Cathy Nielsen, RN, CPHQ, corporate compliance officer and vice president for clinical services.
"Clinical management is looking at revising our nursing care plan," she explains. "Operations is looking at revisions to referral forms. There are several subgroups working on individual projects and then bringing them back to the table."
Calling all willing participants
Ruth Constant, RN, MSN, EdD, CHCE, president of Ruth Constant & Associates of Victoria, TX, owns and operates three Texas home health agencies. Representatives of the agencies have come together for years in a director’s committee, which recently has been focusing on the transition from the interim payment system to PPS.
Lee says her agency’s PPS committee, which has swung into action since the final rule was published, comprises "anybody who wants to be on it. We’ve got clerical people, nursing supervisors — I think we have about 15 people so far who’ve said they wanted to be on it. By starting with people who indicate an interest on their own, [we can] develop a process that they’re willing to implement.
"Probably, we’ll get more done that way than setting up the process and telling them what to do," she predicts.
Timing is everything
Here are five other keys to navigating the first few months of PPS:
1. Know the timetable. All patients have a new start date of Oct. 1. For this episode, Dombi says, agencies have the option of using an OASIS assessment performed any time in September for that Oct. 1 patient.
"Patients whose last OASIS was before Sept. 1 would have to have a new OASIS before Oct. 1, but that OASIS could be prepared anywhere from Sept. 1 to Sept. 30," Dombi explains.
The arrangement eases the burden at the start of PPS, but agencies should anticipate a real bottleneck a few months later, at the end of the first episode of care, Lee says.
"It’s going to be a huge mess. Everybody we have who hasn’t been discharged will come up for recertification on Nov. 29 — Happy Thanksgiving!" she says wryly.
2. Educate staff. Nielsen says it’s important that employees, especially clinical staff, understand the financial ramifications of PPS. "As part of inservicing, you should be looking at the financials as well as operational and clinical issues that are involved with that care."
For example, when explaining OASIS, nurses should understand the financial consequences of an incomplete or incorrect assessment, Lee says. "We need to be telling them how important it is that they answer these 23 questions correctly and what are the ramifications if they don’t," she explains. "These are the ones that impact our payment, and the impact on our payment then impacts the resources available to take care of the patient."
3. Educate physicians. Dombi suggests that home health agencies prepare physicians for the care plans they’ll receive in September, which will run through Nov. 29, the end of the first episode.
"That’s a one-time approach to care planning so they can get everybody into the 60-day episode cycle," he says. "Doctors may look at that and say, We don’t usually do plans like that’ or This patient doesn’t have a need for service through the 29th.’"
At In Home Health, "we’ve already started educating physicians," Nielsen says. "We’ve been providing them with some written materials to give them a heads-up on what this entails."
The company is recommending that its individual agencies work with doctors on-site or through one-on-one discussions.
Beyond the initial start-up, physicians should be prepared for other aspects of home health care to change as agencies become more efficient, Dombi suggests. He says home health agencies will have more flexibility to use technological advances such as telemedicine to provide care more economically.
4. Remain flexible. As PPS gets under way, unforeseen problems will arise, and the Health Care Financing Administration in Oakbrook Terrace, IL, may continue to make changes to deal with them.
What employees learn today may change tomorrow, and they need to be prepared to deal with the changes as smoothly as possible, Lee says. Mostly, she says, it’s a matter of attitude, and that attitude needs to come from the top.
"I have always said that employees can turn on a dime, and they do, because they want to please and they want the patients to be happy and well cared for," Lee says. "They are willing and able to change quickly, just given guidance and direction and information."
Eyes on the goal: Good care
Nielsen says one lesson from her company’s participation in the PPS demonstration was to watch carefully to make sure the new emphasis on financial considerations didn’t get out of hand.
"We saw some of our managers [being] a little too aggressive at first in cutting back on visits and putting some pressure on the clinicians," she explains. "We were able to alleviate that by doing some training with the operations people to say the goal is not to reduce visits but to provide appropriate, efficient patient care."
Signals to watch for may include an immediate, dramatic decrease in visits or an increase in patient complaints. Nielsen suggests calling patients directly for feedback to check for potential problems.
5. Fight for change. Even while learning how to use the new prospective payment system, agencies can keep trying to change it.
It’s important for agencies to keep lobbying, both through professional associations and directly with their congressmen.
"I think people need to still be very aggressive with their local, state, and national government and associations," Nielsen says.
"The fact that we’ve got the final rule doesn’t mean that we should stop here. I would encourage people to remain really involved with organizations to keep this issue in the limelight," she says.
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