oasis-c - managing the bumps in the road lynda laff, rn, bsn, cos-c laff associates

OASIS-C - Managing The Bumps In The Road

Lynda Laff, RN, BSN, COS-CLaff Associates

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OASIS-C…Fast Track to P$P

*CMS ultimately plans to create a standard patient assessment that can be used across all post-acute care settings.

Harmonization of practice across settings

*Federal Register/Vol. 74, No. 44, Monday, March 9, 2009*OASIS –C: Public comments & Responses

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OASIS-C Process Measures

• Standardizing assessment/quality measurement across (post-acute) health care settings. The PAC demo began in 2008 and will result in a report to Congress in 2011 in the potential to use a single instrument to measure patient care and costs longitudinally. In the interim, OASIS, MDS, and the IRF to create the CARE TOOL. This tool will be determining like elements that can be described and measured the same way across settings of care.

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Value Based Purchasing

Payment contingent on outcomes performanceClinicalFinancial – cost savings

High performers = higher payments

Medicare providers will be subject to three patient outcomes measures for APU update!

End Result Outcomes

Process Outcome Measures

HH-CAHPS

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Outcomes Reporting

Home Health Compare and CASPER Report Schedule

Report Method Date Available Data Period of:

OASIS-B1 CASPER 12/2009 10/2008-9/2009

OASIS-B1 HH Compare 1/2010 10/2008-9/2009

OASIS-B1 HH Compare 4/2010 1/2009-12/2009

OASIS-C Process CASPER 9/2010 1/2010-6/2010

OASIS-C Process HH Compare 10/2010 1/2010-6/2010

OASIS-C Outcome CASPER 05/2011 3/2010-2/2011

OASIS-C Outcome HH Compare 07/2011 4/2010-3/2011

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Information Deficit

• “Black Hole” for end result outcomesWill not be reported until (CASPER) May 2011Will be publically reported (HHC) July 2011

• Process measuresReported (CASPER) September 2010Publically reported October 2010

• Will you be driving blind?This is the information you need to know…

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Home Health CompareProcess Measure Summary

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See Where You Stand…

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Patient Detail Report …lets you sort by any column.

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End Result OutcomesHome Health Compare

Improvement in Upper Body Dressing

% of HH episodes where patients improved in ability to dress upper body

(M1810) Current Ability to Dress Upper Body

Improvement in Lower Body Dressing

% of HH episodes where patients improved in ability to dress lower body

M1820) Current Ability to Dress Lower Body

Improvement in Bathing % of HH episodes of care during which the patient got better at bathing self.

(M1830) Bathing

Improvement in Bed Transferring % of HH episodes of care during which the patient improved in ability to get in and out of bed.

(M1850) Transferring

Improvement in Ambulation-Locomotion

Percentage of home health episodes of care during which the patient improved in ability to ambulate.

(M1860) Ambulation/Locomotion

Improvement in Management of Oral Medications

Percentage of home health episodes of care during which the patient improved in ability to take their medicines correctly (by mouth).

(M2020) Management of Oral Medications

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End Result OutcomesHome Health Compare

Improvement in Dyspnea Percentage of home health episodes of care during which the patient became less short of breath or dyspneic.

(M1400) When is the patient dyspneic?

Improvement in Pain Interfering with Activity

Percentage of home health episodes of care during which the patient's frequency of pain when moving around improved.

(M1242) Frequency of Pain Interfering with Activity

Improvement in Status of Surgical Wounds

Percentage of home health episodes of care during which the patient demonstrates an improvement in the condition of surgical wounds.

(M1340) Does this patient have a Surgical Wound?(M1342) Status of Most Problematic (Observable) Surgical Wound

Improvement in Urinary Incontinence

Percentage of home health episodes of care during which the patient had less frequent urinary incontinence, or had a urinary catheter removed.

(M1610) Urinary Incontinence or Urinary Catheter Presence:(M1615) When does Urinary Incontinence occur?

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Utilization OutcomesHome Health Compare

Emergency Department Use without Hospitalization

Percentage of home health episodes of care during which the patient needed urgent, unplanned medical care from a hospital emergency department, without admission to hospital.

(M0100) Reason for Assessment(M2410) Inpatient Facility Admission(M2300) Emergent Care

Acute Care Hospitalization Percentage of home health episodes of care that ended with the patient being admitted to the hospital.

(M0100) Reason for Assessment(M2410) Inpatient Facility Admission(M2430) Reason for Hospitalization

Discharged to community Percentage of home health episode after which patients remained at home.

(M0100) Reason for Assessment(M2420) Discharge Disposition

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Potentially Avoidable Events Home Health Compare

Emergent care for wound infections, deteriorating wound status

Percentage of home health episodes of care during which the patient required emergency medical treatment from a hospital emergency department related to a wound that is new, is worse, or has become infected

(M2300) Emergent Care (M2310) Reason for Emergent Care

Increase in Number of Pressure Ulcers

Percentage of home health episodes of care during which the patient had a larger number of pressure ulcers at discharge than at start of care.

(M1306) Unhealed Pressure Ulcer at Stage II or Higher(M1308) Current Number of Unhealed Pressure Ulcers at Each Stage

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Measurable Processes

• Timely Care • Coordination of Care• Assessment • Care Planning• Intervention Implementation • Patient and Caregiver Education • Prevention Strategies

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Process Outcome MeasuresHome Health Compare

Timely Initiation Of Care(Timely Care)

% of home health episodes of care during which the start or resumption of care date was either on the physician-specified date or within 2 days of the referral date.

(M0102) Date of Physician-ordered Start of Care(M0104) Date of Referral(M0030) Start of Care Date(M0032) Resumption of Care Date(M0100) Reason for Assessment

Depression Assessment Conducted(Assessment)

% of home health episodes of care during which patients were screened for depression (using a standardized depression screening tool) at start of home health car

(M1730) Depression Screening

Multifactor Fall Risk Assessment Conducted For Patients 65 And Over(Assessment)

Percentage of home health episodes of care in which patients 65 and older had a multi-factor fall risk assessment at the start of care/resumption of care.

(M1910) Multi-factor Fall Risk Assessment(M0066) Birth Date(M0090) Date Assessment Completed

Pain Assessment Conducted(Assessment)

Percentage of home health episodes of care during which the patient was assessed for pain using a standardized pain assessment tool, at start/resumption of home health care

(M1240) Pain Assessment using a standardized pain assessment tool

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Process Outcome MeasuresHome Health Compare

Pressure Ulcer Risk Assessment Conducted

(Assessment)

% of home health episodes of care in which the patient was assessed for risk of developing pressure ulcers at start of care/resumption of care.

(M1300) Pressure Ulcer Risk Assessment

Pressure Ulcer Prevention In Plan Of Care(Care Planning)

% of home health episodes of care in which interventions to prevent pressure ulcers were included in the physician-ordered plan of care for patients assessed to be at risk for pressure ulcers.

(M2250) f. Intervention(s) to prevent pressure ulcers plan of care

Diabetic Foot Care And Patient/Caregiver Education Implemented During Short Term Episodes Of Care(Implementation)

% of short term home health episodes of care during which diabetic foot care and education specified during the physician-ordered care plan was implemented for patients with diabetes.

(M0100) Reason for Assessment (M2400) a. Diabetic foot care intervention(s)

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Process Measures – HHC

Heart Failure Symptoms Addressed During Short Term Episodes Of Care(Implementation)

Percentage of short term home health episodes of care during which patients exhibited symptoms of heart failure for whom appropriate actions were taken

(M0100) Reason for Assessment (M1510) Heart Failure Follow-up:

Pain Interventions Implemented During Short Term Episodes Of Care(Implementation)

Percentage of short term home health episodes of care during which the patient had pain and pain interventions were included during the care plan and implemented by the end of the episode.

(M0100) Reason for Assessment (M2400) d. Intervention(s) to monitor and mitigate pain

Drug Education On High Risk Medications Provided To Patient/Caregiver At Start Of Episode(Education)

Percentage of patients/caregivers educated about high-risk medications at start/resumption of care and instructed on how to monitor the effectiveness of drug therapy, how to recognize potential adverse effects, and how and when to report problems.

(M2010) Patient/Caregiver High Risk Drug Education

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Drug Education On All Medications Provided To Patient/Caregiver During Short Term Episodes Of Care(Education)

Percentage of short term home health episodes of care during which patient/caregiver was instructed on how to monitor the effectiveness of drug therapy, how to recognize potential adverse effects, and how and when to report problems

(M0100) Reason for Assessment (M2015) Patient/Caregiver Drug Education Intervention

Influenza Immunization Received For Current Flu Season(Prevention)

Percentage of home health episodes of care during which patients received influenza immunization for the current flu season

(M1040) Influenza Vaccine(M1045) Reason Influenza Vaccine not received

Pneumococcal Polysaccharide Vaccine Ever Received(Prevention)

Percentage of home health episodes of care during which patients were determined to have ever received Pneumococcal Vaccine (PPV).

(M1050) Pneumococcal Vaccine (M1055) Reason PPV not received

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Potential Medication Issues Identified And Timely Physician Contact At Start Of Episode(Prevention)

Percentage of patients whose drug regimen at start or resumption of home health care was assessed to pose a risk of clinically significant adverse effects or drug reactions and whose physician was contacted within one calendar day.

(M2002) Medication Follow-up

Potential Medication Issues Identified And Timely Physician Contact During Short Term Episodes Of Care(Prevention)

Percentage of home health episodes of care in which the patient's drug regimen during the episode was assessed to pose a risk of significant adverse effects or drug reactions and whose physician was contacted within one calendar day.

(M0100) Reason for Assessment (M2004) Medication Intervention

Pressure Ulcer Prevention Implemented During Short Term Episodes Of Care(Prevention)

Percentage of home health episodes of care in which interventions to prevent pressure ulcers were included in the physician-ordered plan of care and implemented since the previous OASIS assessment.

(M0100) Reason for Assessment (M2400) e. Intervention(s) to prevent pressure ulcers

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Outcome Improvement

• Requires Episode ManagementCase management and accountabilityContinuity and coordination of care Admission Nurse Models

• Hand-offs = errors• The more staff involved – the less the accountability• Look back questions – M2400

Primary nursing• Requires adequate staffing model• Must provide incentive for patient management

• Scheduling is a process – not care management!Cannot dictate patient careMust respect continuity

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Therapy Case Management/Collaboration

• Therapy Case ManagementManagement of assistantsReporting on utilization and outcomes

• Scope of Practice– PT- only patients – set expectations / work with limitations

• Medication management – APTA recommendations• PT/INR – lab monitoring

• Team PlayersTeam managementParticipation and reportingParing therapists with RN case managerContract therapists

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Supervise and Manage

• Management and Supervision How do you know?What checks are in place?How long does it take?Who is validating information?Were the suggested corrections actually made?What “tools” do you use?Are there repeated errors? If so – WHY?

– Repeated errors cost money

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Case Conference

• One on one review of patients on census – not a 2 hour meeting!• Expect clinician to be prepared• Can be done remotely• Must be done without fail…no excuse accepted • Danger Zone…

Clinician “does not know patient”“Hasn’t seen patient in 3 weeks”“Cookie cutter” schedulingVisits never increase or decrease – always a 60 day episodeFrequent patient declines Potentially avoidable eventsAbundance of “missed visits”LOS longer than national benchmarkCase weight extraordinarily low

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Team Conference

• Can be done remotely or in office – bi-weeklyAttendance required not recommendedClinicians must be preparedDiscuss ONLY those patients –

Multiple disciplinary problems or care plan changesNot progressing according to planPotential for early discharge3 weeks from recertification or discharge

• Must be documented

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Common OASIS-C Challenges

M1510 Heart Failure Follow-up

M2002, M2004, 2010, 2015 Medication Management

M 1300, M1302, M1306, M1307, 1320, M1324, M1350

Wound Assessment; Pressure Ulcer Prevention; Pressure Ulcer Treatment

M2250 Evidence of communication with the physician to include specified best practice interventions in the plan of care.

M2400 Evidence that specified interventions were included in the physician-ordered plan of care AND implemented

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Process Measure AuditOUTSOMES MEASURE Yes No OASIS ITEMS INTERVENTIONS Yes No

Did Pt. receive flu vaccine for current season?

(M1040) Influenza Vaccine(M1045) Reason Flu Vaccine Not Given

Has Pt. ever received the pneumonia vaccine?

(M1050) Pneumonia Vaccine(M1045) Reason Not Given

Was patient admitted as ordered by MD or within 48 hours of referral or hospital discharge?

(M0102) Date of Physician-ordered Start of Care(M0104) Date of Referral(M0030) Start of Care Date(M0032) Resumption of Care Date(M0100) Reason for Assessment

Were patient specific parameters included in the plan of care?

(M2250) A. Patient-specific parameters for notifying MD on 485?

Was MD contacted if indicated?

Was a depression assessment completed?

Patient at risk for depression?________

(M1730) Depression Screening(M2250)d. Depression interventions

Were depression interventions implemented if indicated?

Was a multi-factor Fall Risk Assessment Conducted for pts. 65

Score__________

(M1910) Risk AssessmentM0066 Birthdate(M0090) Date Assessment Completed

Were Fall prevention interventions implemented if indicated?

Was a pain assessment conducted? (M1240) Pain Assessment using standardized tool

If assessment indicated pain were measures to mitigate pain initiated?

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Process Measure AuditOUTSOMES MEASURE Yes No OASIS ITEMS INTERVENTIONS Yes No

Was a pressure Ulcer Risk Assessment Conducted?

Score__________

(M1300) Pressure Ulcer Risk Assessment(M2250) Interventions to prevent PU

Were pressure ulcer prevention measures included in the 485 and implemented?

Were principles of moist wound healing included in 485?

(M2250) Pressure Ulcer Treatment on 485

Were Diabetic Foot Care orders and Patient Education included in Plan of Care?

(M2250) b. Diabetic foot care in plan of careM2400)

Were measures to address diabetic foot care included in the 485 and patient education implemented if indicated? T

Was patient diagnosed with heart failure?

(M0100 Reason for Assessment(M1510) Heart Failure Follow Up

Were heart failure symptoms addressed during the episode of care if indicated? T

Was a complete drug regimen review performed?

(M2000) Drug Regimen Review(M2015) Pt./Cg. Drug Education

Was patient instructed to monitor the effectiveness of drug therapy, to recognize adverse effects and when to report problems?

Was patient identified to be taking high risk medications?

(M2010)Pt./Cg High Risk Drug EducationM2015)Pt./Cg. High Risk Drug Intervention

Evidence of pt/cg education about high risk medications?

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M1510 Home Health Compare

• Measure:• Heart Failure Symptoms Addressed During Short

Term Episodes Of Care (Implementation)Percentage of short term home health episodes of care during which patients exhibited symptoms of heart failure for whom appropriate actions were taken

(M0100) Reason for Assessment (M1510) Heart Failure Follow-up:

• NQF Endorsed

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Heart Failure Follow Up

(M1510) Heart Failure Follow-up: If patient has been diagnosed with heart failure and has exhibited symptoms indicative of heart failure since the previous OASIS assessment, what action(s) has (have) been taken to respond? (Mark all that apply.)

⃞ 0 - No action taken

⃞ 1 - Patient’s physician (or other primary care practitioner) contacted the same day

⃞ 2 - Patient advised to get emergency treatment (e.g., call 911 or go to emergency room)

⃞ 3 - Implemented physician-ordered patient-specific established parameters for treatment

⃞ 4 - Patient education or other clinical interventions

⃞ 5 - Obtained change in care plan orders (e.g., increased monitoring by agency, change in visit frequency, telehealth, etc.)

Time Points: Transfer/D/C

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Must Have Heart Failure Diagnoses

• The patient must have a diagnosis of heart failure in the following;

M1010: Inpatient Diagnoses,

M1016: Diagnoses Causing Change in Treatment, or

M01020/1022/1024: Primary/Secondary diagnoses for home care.

Consider any new or ongoing heart failure symptoms that occurred at the time of the previous OASIS assessment or since that time.

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Heart Failure Follow Up Tips

• Tele-monitoring• Disease management protocols

Vital sign monitoring Weight gainMedication management – standing ordersDiet instruction

• Telephone contact – Must call if visited only 1 x weekDocument a telephone visit on a standardized form

• Develop heart failure indicators/thresholdsFlow charts

• Discuss parameter variances at case conference• Reports to case manager by team members• Scope of practice for physical therapists – develop cardiac rehab protocols• Last professional clinician out - responsible

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Medication Regimen Review

(M2000) Drug Regimen Review: Does a complete drug regimen review indicate potential clinically significant medication issues, e.g., drug reactions, ineffective drug therapy, side effects, drug interactions, duplicate therapy, omissions, dosage errors, or noncompliance?

0 - Not assessed/reviewed [ Go to M2010 ] 1 - No problems found during review [ Go to M2010 ] 2 - Problems found during review NA - Patient is not taking any

medications [ Go to M2040 ]

Time Points: SOC/ROC

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M2000 Scenario

During a SOC visit the SN notes a potential drug – drug interaction when two drugs are taken simultaneously. The issue was resolved during the visit by educating the patient to take one of the medications in the AM and the other in the PM.

How should the SN answer M2000?

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Drug Regimen Review


⃞ 0 - Not assessed/reviewed [ Go to M2010 ]

⃞⃞ 1 - No problems found during review [ Go to M2010 ]

⃞ 2 - Problems found during review ⃞ NA - Patient is not taking any medications [ Go to

M2040 ]

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OCCB January Q & As

Question 33: The assessing clinician identifies a problem with medications. The patient

has not picked up a prescription because she was not sure she absolutely needed it. If the assessing clinician’s education results in the resolution of the situation prior to the completion of the comprehensive assessment, can the clinician indicate on M2000 that there is no clinically significant problem, eliminating the need to address it in M2002 Medication Follow-up?

Answer 33: If a medication related problem is identified and resolved by the agency staff by the time the assessment is completed, the problem does not need to be reported as an existing clinically significant problem.

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M2002 – Home Health Compare

• Measure:• Potential Medication Issues Identified And Timely

Physician Contact At Start Of Episode (Prevention)– Percentage of patients whose drug regimen at start

or resumption of home health care was assessed to pose a risk of clinically significant adverse effects or drug reactions and whose physician was contacted within one calendar day.

• (M2002) Medication Follow-up

• NQF Endorsed

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M2002 Medication Follow Up

(M2002) Medication Follow-up: Was a physician or the physician-designee contacted within one calendar day to resolve clinically significant medication issues, including reconciliation?

0 - No 1 – Yes


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M2000, M2002

• During the initial assessment, the SN reviewed the medications in the home and included them in the patient’s med list.

• The PT visited the patient the next day, noted that the SN had not checked for drug – drug interactions. He ran the program and discovered a potential for a high risk interaction.

• He contacted the SN and called the MD’s office about the potential drug interaction but the MD was out of town until the following day.

• The receptionist told the SN that the patient had been taking those two medications for several months with no problems.

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M2000, M2002

• How should the SN answer M2000?




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M2000, M2002





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M2000, M2002



0 - No 1 – Yes

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M2000, M2002



0 - No 1 – Yes

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Questions / Answer October 2009

M2002 Medication Follow-up and M2004 Medication Intervention

Question 34: Must the physician acknowledgement of the agency’s communication, and resulting reconciliation occur in the specified time frame (within one calendar day), in order to select response “1” for M2002 or M2004?

Answer 34: Yes, in order to select response 1, the two-way communication AND reconciliation (or plan to resolve the problem) must be completed by the end of the next calendar day after the problem was identified.

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• Measure: • Potential Medication Issues Identified And Timely

Physician Contact During Short Term Episodes Of Care (Prevention)

Percentage of home health episodes of care in which the patient's drug regimen during the episode was assessed to pose a risk of significant adverse effects or drug reactions and whose physician was contacted within one calendar day.

(M0100) Reason for Assessment (M2004) Medication Intervention

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M2004- Medication Intervention

(M2004) Medication Intervention: If there were any clinically significant medication issues since the previous OASIS assessment, was a physician or the physician-designee contacted within one calendar day of the assessment to resolve clinically significant medication issues, including reconciliation?

0 - No 1 - Yes NA - No clinically significant medication issues identified since

the previous OASIS assessment

Time Points: Transfer/DC not to inpatient facility

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M2004 Medication Intervention - Tips

• What would you do….– If it was YOUR MOTHER?

• Medical Director• When you know of a potential adverse event…

Help!

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M2010 -Medications

(M2010) Patient/Caregiver High Risk Drug

Education: Has the patient/caregiver received

instruction on special precautions for all high-risk

medications (such as hypoglycemics,

anticoagulants, etc.) and how and when to report

problems that may occur? 0 - No 1 - Yes NA - Patient not taking any high risk drugs OR patient/caregiver

fully knowledgeable about special precautions associated with all high-risk medications


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M2010 High Risk Drugs - Tips

• Identify high risk drugs – access high risk drug information from internet, accrediting body etc.

• Create a laminated list of high risk drugs including special precautions for each drug.

• Access software packages with teaching guides for high risk drugs.

• Develop high risk drug education handouts to give to patients.

• Include a high risk drug list as an item on a “check off” list for clinicians to complete after a SOC, ROC, Recertification and/or medication change as appropriate.

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High-Alert Medications Potentially Used In Home Health Care

Drug Category Medications (Does not include all drugs that could potentially be listed in this category)

Anticoagulants: An anticoagulant is a drug that helps prevent the clotting (coagulation) of blood

Heparin, Coumadin, Lovenox, Plavix, ASA, Anisindione, Dicumarol

Inotropic Medications: Affecting the force of muscle contraction. An inotropic heart drug is one that affects the force with which the heart muscle contracts.

Digoxin, Milrinone, Lanoxin,Digitek, digibind, Caduet

Oral hypoglycemics: Used for controlling blood sugar in adult-onset diabetes

Actos Oral , Januvia, Diflucan (Fluconazole ), lyrica (Pregabalin ), Glucotrol (Glipizide ), Glucotrol XL

Insulin: Insulin is a naturally-occurring hormone secreted by the pancreas. Insulin is required by the cells of the body in order for them to remove and use glucose from the blood.

Lente, Lantus SubQ, Humalog, Regular human insulin (Novolin R, Humulin R) NPH human insulin (Novolin N, Humulin N)

Narcotics, Opiates : Narcotics are drugs that numb the senses, relieve severe pain, and induce sleep

Methadone, Codeine, Meperidine, Morphine, hydrocodone, Oxycontin, Percoset, Zanex, Haldol, Diazepam, Roxanal

Chemotherapuedic Agents: Cancer treatment drugs

Azathioprine, Busulfan, Chlorambucil, Cyclophosphamide, Cytarabine, Cytoxan, Fluorouracil, Mercaptopurine, Taxol, Taxotere, Ixempra, velban, vincristine, Oncovin

Methotrexate (Non oncologic use)

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• Measure:• Drug Education On All Medications Provided To

Patient/Caregiver During Short Term Episodes Of Care (Education)

Percentage of short term home health episodes of care during which patient/caregiver was instructed on how to monitor the effectiveness of drug therapy, how to recognize potential adverse effects, and how and when to report problems

(M0100) Reason for Assessment (M2015) Patient/Caregiver Drug Education Intervention

NQF Endorsed

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M2015 Drug Education

(M2015) Patient/Caregiver Drug Education Intervention: Since the previous OASIS assessment, was the patient/caregiver instructed by agency staff or other health care provider to monitor the effectiveness of drug therapy, drug reactions, and side effects, and how and when to report problems that may occur?

0 - No 1 - Yes NA - Patient not taking any drugs

Time Points: Transfer/Discharge

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M2015 Item Guidance

• Drug education interventions should address all medications the patient is taking – prescribed and over-the-counter – by any route.

• Education must be clearly documented.

• Effective, safe management of medications includes knowledge of effectiveness, potential side effects and drug reactions, and when to contact the appropriate care provider.

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Purchase or Develop Teaching Sheets

• Identify most commonly used drugsAccess pharmacy teaching toolsComputer programs

• Use patient – friendly language• Keep it simple

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M1300 Pressure Ulcer Risk Assessment

• Measure:• Pressure Ulcer Risk Assessment Conducted

% of home health episodes of care in which the patient was assessed for risk of developing pressure ulcers at start of care/resumption of care.

(M1300) Pressure Ulcer Risk Assessment

• NQF Endorsed

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M1300 Pressure Ulcer Risk Assessment

(M1300) Pressure Ulcer Assessment: Was this

patient assessed for Risk of Developing Pressure

Ulcers?

⃞ 0 - No assessment conducted [ Go to M1306 ]

⃞ 1 - Yes, based on an evaluation of clinical factors, e.g., mobility, incontinence, nutrition, etc.,

without use of standardized tool

⃞ 2 - Yes, using a standardized tool, e.g., Braden, Norton, other


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NPUAP Risk Assessment Criteria

• Risk AssessmentConsider all bed-bound and chair-bound persons, or those whose ability to reposition is impaired, to be at risk for pressure ulcers.

Use a valid, reliable and age appropriate method of risk assessment that ensures systematic evaluation of individual risk factors

Assess all at-risk patients/residents at the time of admission and at every visit.

Identify all individual risk factors (decreased mental status, exposure to moisture, incontinence, device related pressure, friction, shear, immobility, inactivity, nutritional deficits) to guide specific preventive treatments.

Document risk assessment subscale scores and total scores and implement a risk-based prevention plan

*National Pressure Ulcer Advisory Panel

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Pressure Ulcer “Best Practice” Tips

• Develop a policy and process for pressure risk assessment for all bed-bound and chair-bound persons, or those whose ability to reposition is impaired AT LEAST at admission, resumption of care AND recertification to ensure that an appropriate plan is initiated for patients identified to be at risk for pressure ulcers.

• Educate clinicians to have the patient undress!• Educate clinicians to assess high risk patients every visit

Observe patient’s ability toFollow directionsHear and understandObserve patient’s Manual dexterityPotential for SOB upon exertion

• Implement an evidence based pressure ulcer risk assessment tool

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M1306 Unhealed Stage II PU

(M1306) Does this patient have at least one

Unhealed Pressure Ulcer at Stage II or Higher

or designated as "unstageable"?

0 - No [ Go to M1322 ] 1 - Yes

Time Points: SOC/ROC/F/U/D/C

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M1307- Oldest NE Stage II PU

(M1307) The Oldest Non-epithelialized Stage II Pressure

Ulcer that is present at discharge

⃞ 1 - Was present at the most recent SOC/ROC assessment

⃞ 2 - Developed since the most recent SOC/ROC assessment: record date pressure ulcer first identified:

__ __ /__ __ /____ __ __

month / day / year

⃞ N/A - No non-epithelialized Stage II pressure ulcers are present at discharge

OASIS-C:

Time Point: Discharge

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M1307 This is a Really BIG deal!

• The intent of this item is to;

Identify the oldest Stage II pressure ulcer that is present at the time of discharge and is not fully epithelialized

Assess the length of time this ulcer remained unhealed while the patient received care from the home health agency.

Identify patients who develop Stage II pressure ulcers while under the care of the agency.

• In other words, was there anything the agency could or should have done to prevent and/or heal the PU?

• What “best practice” was implemented?

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M1307- Oldest NE Stage II or Higher PU

• Audit every patient record of patients discharged with a stage II (or higher) PU

• How do you “look back”Software systemData scrubberManual report

• How do you validate information?AuditCase conference

• Educate cliniciansWound stagingWOCN and NPUAP guidelinesOASIS-C Home Health Compare Outcomes

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M1320 Most Problematic PU

You admitted a patient with a pressure ulcer on his heel. 50% of the wound bed of the ulcer was covered with eschar. How would you score M1320?

(M1320) Status of Most Problematic (Observable) Pressure Ulcer:

0 - Newly epithelialized 1 - Fully granulating 2 - Early/partial granulation 3 - Not healing N/A - No observable pressure ulcer

Time Points: SOC/ROC/D/C

http://rds.yahoo.com/_ylt=A0S020v1Ed1KPCEB0WujzbkF/SIG=1274h9nri/EXP=1256088437/**http:/www.rehabpub.com/ltrehab/672000/patient2.jpg

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M1320 Status of Most Problematic PU

(M1320) Status of Most Problematic (Observable) Pressure Ulcer:

0 - Newly epithelialized 1 - Fully granulating 2 - Early/partial granulation

3 - Not healing N/A - No observable pressure ulcer

A pressure ulcer with necrotic tissue (eschar/slough) obscuring the wound base cannot be staged, but its healing status is either Response 2 – Early/partial granulation if necrotic or avascular tissue covers <25% of the wound bed, or Response 3 - Not healing, if the wound has ≥25% necrotic or avascular tissue.

*Clinicians often incorrectly score N/A here

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M1324 Stage of Most Problematic PU

Same patient – how would you score M1324?

(M1324) Stage of Most Problematic Unhealed (Observable) Pressure Ulcer:

1 - Stage I 2 - Stage II 3 - Stage III 4 - Stage IV N/A - No observable pressure

ulcer or unhealed pressure ulcer

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Guidelines

• (When determining the healing status of a pressure ulcer for answering M1320, the presence of necrotic tissue does NOT make the pressure ulcer NA – No observable pressure ulcer.)

• When scoring M1324 – remember - a pressure ulcer with necrotic tissue (eschar/slough) obscuring the wound base cannot be staged, but its healing status is either Response 2 – Early/partial granulation if necrotic or avascular tissue covers <25% of the wound bed, or Response 3 - Not healing, if the wound has ≥25% necrotic or avascular tissue.

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M2400 - Home Health Compare

• Measure:• Pressure Ulcer Prevention Implemented During

Short Term Episodes Of Care (Prevention)Percentage of home health episodes of care in which interventions to prevent pressure ulcers were included in the physician-ordered plan of care and implemented since the previous OASIS assessment

(M0100) Reason for Assessment (M2400) e. Intervention(s) to prevent pressure ulcers

• NQF Endorsed

68

(M2400) Intervention Synopsis: Since the previous OASIS assessment,were the following interventions BOTH included in the physician-ordered

plan of care AND implemented? Time Points: Discharge/Transfer

( Plan / Intervention No Yes N/A Not Applicable

a. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care

0 1 2Patient is not a diabetic or is a bi-lateral amputee

b. Falls prevention interventions 0 1 2Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since the last OASIS assessment

c. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment

0 1 2

Formal assessment indicates patient did not meet criteria for depression AND patient did not have diagnosis of depression since the last OASIS assessment

d. Intervention(s) to monitor and mitigate pain 0 1 2

Formal assessment did not indicate pain since the last OASIS assessment

e. Intervention(s) to prevent pressure ulcers 0 1 2

Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS assessment

f. Pressure ulcer treatment based on principles of moist wound healing

0 1 2

Dressings that support the principles of moist wound healing not indicated for this patient’s pressure ulcers OR patient has no pressure ulcers with need for moist wound healing

69

M2400 Intervention SynopsisPressure Ulcer Intervention

• Yes – ONLY if the clinical intervention was included in the plan of care AND implemented at the time of the previous OASIS assessment or since that time.

70

NPUAP Skin Care for PU Prevention

• Skin Care– Perform a head to toe skin assessment at least daily, especially checking

pressure points such as sacrum, ischium, trochanters, heels, elbows, and the back of the head.

– Individualize bathing frequency. Use a mild cleansing agent. Avoid hot water and excessive rubbing. Use lotion after bathing. For neonates and infants follow evidence-based institutional protocols

– Establish a bowel and bladder program for patients with incontinence.– When incontinence cannot be controlled, cleanse skin at time of soiling, and

use a topical barrier to protect the skin. Select under pads or briefs that are absorbent and provide a quick drying surface to the skin. Consider a pouching system or collection device to contain stool and to protect the skin.

– Use moisturizers for dry skin. Minimize environmental factors leading to dry skin such as low humidity and cold air.

– Avoid massage over bony prominences.


71

NPUAP Nutrition PU Prevention

• Identify and correct factors compromising protein/ calorie intake consistent with overall goals of care.

• Consider nutritional supplementation/support for nutritionally compromised persons consistent with overall goals of care.

• If appropriate offer a glass of water when turning to keep patient/resident hydrated.

• Multivitamins with minerals per physician’s order


72

NPUAP Staff Education Recommendations

• Education• Implement pressure ulcer prevention educational programs that are structured,

organized, comprehensive, and directed at all levels of health care providers, patients, family, and caregivers.

• Include information on:– Etiology of and risk factors for pressure ulcers– Risk assessment tools and their application– Skin assessment– Selection and use of support surfaces– Nutritional support– Program for bowel and bladder management– Development and implement individualized programs of skin care– Demonstration of positioning to decrease risk of tissue breakdown– Accurate documentation of pertinent data

• Include mechanisms to evaluate program effectiveness in preventing pressure ulcers.


73

Mechanical Loading & Support Surface Recommendations

• Mechanical Loading and Support Surfaces– Reposition bed-bound persons at least every two hours and chair-bound persons

every hour consistent with overall goals of care.

– Consider postural alignment, distribution of weight, balance and stability, and pressure redistribution when positioning persons in chairs or wheelchairs.

– Teach chair-bound persons, who are able, to shift weight every 15 minutes.

– Use a written repositioning schedule.

– Place at-risk persons on pressure-redistributing mattress and chair cushion surfaces.

– Avoid using donut-type devices and sheepskin for pressure redistribution.


74

Mechanical Loading & Support Surface Recommendations

• Use lifting devices (e.g., trapeze or bed linen) to move persons rather than drag them during transfers and position changes.

• Use pillows or foam wedges to keep bony prominences, such as knees and ankles, from direct contact with each other. Pad skin subjected to device related pressure and inspect regularly.

• Use devices that eliminate pressure on the heels. For short-term use with cooperative patients, place pillows under the calf to raise the heels off the bed.

• Place heel suspension boots for long-term use.

• Avoid positioning directly on the trochanter when using the side-lying position; use the 30° lateral inclined position.

• Maintain the head of the bed at or below 30° or at the lowest degree of elevation consistent with the patient’s/resident’s medical condition.

• Institute a rehabilitation program to maintain or improve mobility/activity status.


*

75

M2400 – Pressure Ulcer Intervention

• Teach patient and/or caregiver about frequent position changes

• Instruct regarding proper positioning to relieve pressure• Careful skin assessment and hygiene including education for

the patient and/or caregiver on daily skin assessment, hygiene and skin care.

• Use of pressure-relieving devices such as enhanced mattresses and chair cushions.

• Initiate physical therapy as appropriate to teach safe mobility.

76

M1334 Problematic Stasis Ulcer

(M1334) Status of Most Problematic(Observable) Stasis Ulcer:

0 - Newly epithelialized INCORRECT ANSWER! 1 - Fully granulating 2 - Early/partial granulation 3 - Not healing


For the purpose of this OASIS item, when complete epithelialization has been present for more than 30 days, the stasis ulcer is no longer described as a stasis ulcer and should not be included in this item.

77

Surgical Wound or Pressure Ulcer?

Scenario:• A patient was admitted to home care with a pressure ulcer

that was 50% covered with black eschar. Measurements were 6 cm (L) by 2cm (W). The patient ultimately was hospitalized for a flap procedure.

• The flap procedure failed and the flap graft or pedicle was revised.

• At ROC, should the wound be identified as a dehisced surgical wound or is it now a pressure ulcer since the flap procedure has failed?

78

M1340 Surgical Wound

(M1340) Does this patient have a Surgical Wound?

0 - No [ Go to M1350 ] 1 - Yes, patient has at least one (observable) surgical wound 2 - Surgical wound known but not observable due to non-

removable dressing [ Go to M1350 ]


79

Is It a Surgical Wound or Is It Pressure Ulcer?

• OASIS C guidance indicates that this wound is no longer a pressure ulcer once a flap procedure has been performed. It is a surgical wound. If the current wound began with dehiscence of the flap, it is still a dehisced wound. If the flap had healed and subsequently broken down, it would be a pressure ulcer.

80

M1340 “Cheat Sheet”

Is A Surgical Wound Not A Surgical Wound

Non-epitelialized, non-infected wound closed by sutures, staples or chemical bonding

Healed incision, scar, keloid

A muscle flap, skin advancement flap, or rotational flap replacing a pressure ulcer Debrided pressure ulcer

A surgical "take-down" procedure of a previous bowel ostomy Skin graft

Orthopedic pin sites, central line sites, stapled or sutured incisions, and wounds with drains

Ostomies (no ostomy is considered a surgical wound)

Medi-port sites and other implanted infusion devices or venous access devices PICC line (inserted peripherally)

Cataract surgery of the eye, surgery to the mucosal membranes, or a gynecological surgical procedure via a vaginal approach

81

M1350

Sara Jones has a mole on her arm, a keloid

scar on her leg and a tattoo on her shoulder. None of the above items are addressed in the plan of care. M1350 “Does this patient have a wound” ?

82

M1350

Answer: M1350 Does this patient have a wound? NoRationale:

1. Skin lesions or open wounds that are not receiving clinical intervention from the home health agency should not be considered when responding to this question.

2. Do not include tattoos, piercings, and other skin alterations unless ongoing assessment and/or clinical intervention by the home health agency is a part of the planned/provided care.

83

M1350

Bob Green has a new tracheostomy with orders for dressing changes to the surgical site. How would you answer M1350 “Does this patient have a wound”?

84

M1350

Answer: M1350 “Does this patient have a wound”?

Yes

Rationale: Ostomies, other than bowel ostomies, (e.g.,

tracheostomy, thoracostomy, urostomy) ARE considered to be skin lesions or open wounds if clinical interventions (e.g., cleansing, dressing changes) are being provided by the home health agency during the home health care episode.

85

M1350 “Cheat Sheet”

YES - Is a Skin Lesionor Open Wound

No - Not A Skin Lesionor Open Wound

Ulcers, rashes, persistent redness w/o break in skin Bowel Ostomy

Any skin condition that is clinically assessed and included in the plan of care

A skin condition not assessed or treated; not in plan of care

Burns, diabetic ulcers, cellulitis, abscesses, wounds caused by trauma of various kinds, etc.

Cataract surgery, gynecological surgery performed vaginally, mucosal surgery

PICC lines and peripheral IV sites Tattos, piercings unless clinical intervention is performed by HHA

Ostomies (trachestomy, thoracotomy, urostomy) when clinical intervention is performed by HHA

86

(M2250) Plan of Care Synopsis: Does the physician-ordered plan of care include the following: Time Points: SOC/ROC

Plan / Intervention No Yes N/A Not Applicable

a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings

0 1 2

Physician has chosen not to establish patient-specific parameters for this patient. Agency will use standardized clinical guidelines accessible for all care providers to reference

b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care


c. Falls prevention interventions 0 1 2Patient is not assessed to be at risk for falls

d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment 0 1 2

Patient has no diagnosis or symptoms of depression

e. Intervention(s) to monitor and mitigate pain 0 1 2 No pain identified

f. Intervention(s) to prevent pressure ulcers 0 1 2Patient is not assessed to be at risk for pressure ulcers

g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician

0 1 2Patient has no pressure ulcers with need for moist wound healing.

87

Home Health Compare

• Timely Initiation Of Care (Timely Care)• Measure:

% of home health episodes of care during which the start or resumption of care date was either on the physician-specified date or within 2 days of the referral date.

• (M0102) Date of Physician-ordered Start of Care• (M0104) Date of Referral• (M0030) Start of Care Date• (M0032) Resumption of Care Date• (M0100) Reason for Assessment

• NQF Endorsed

88

M0102, Physician Ordered SOC date M0104, Date of Referral

Question 2:

When determining the physician-ordered SOC or the date of referral should communication from the hospital/SNF DC planner be considered as representing physician referral?

Answer 2:

Yes, a referral received from a hospital or SNF discharge planner on behalf of the physician should be considered when determining the physician-ordered SOC date or the date of referral.

89

M0104, Date of Referral

Question 3: The home health agency received a referral on June 1st, and

then on June 2nd received a faxed update with additional patient information that indicates a possible delay in the patient’s hospital discharge date. What is the referral date for M0104?

Answer 3: If start of care is delayed due to the patient’s condition or

physician request and no date was specified as the start of care date, then the date the agency received updated/revised referral information for home care services to begin would be considered the date of referral. In your scenario, June 2 is the correct response for M0104.

90

M104 Guidance

• If the originally ordered start of care is delayed due to the patient’s condition or physician request (e.g., extended hospitalization), then the date specified on the updated/revised order to start home care services would be considered the date of physician-ordered start of care (resumption of care).

91

M1730 - Home Health Compare

• (M1730) Depression Screening• Measure:

% of home health episodes of care during which patients were screened for depression (using a standardized depression screening tool) at start of home health care

(M1730) Depression Screening

• NQF Endorsed

92

Home Health Compare

• (M1910) Fall Risk Assessment • Measure:

% of home health episodes of care in which patients 65 and older had a multi-factor fall risk assessment at the start of care/resumption of care.

(M0066) Birth Date(M0090) Date assessment Completed(M1910) Multi-factor Fall Risk Assessment

• NQF Endorsed

93

Home Health Compare

• (M1240) Pain Assessment • Measure:

Percentage of home health episodes of care during which the patient was assessed for pain, using a standardized pain assessment tool, at start/resumption of home health care.

(M1240) Pain Assessment using a standardized pain assessment tool

• NQF Endorsed

94

Pain Assessment & Mitigation

Scenario:• A pain assessment was conducted and the patient was

identified to have no severe pain (score 1 at M1240)• At M1242 Frequency of pain interfering with movement was

answered “2” - less often than daily• The patient is controlling his pain with Tylenol and the nurse

reviewed this with him. • How would you answer row d M2250 Intervention(s) to

monitor and mitigate pain?

95

M2250 Guidance

• Row e: If the physician-ordered plan of care contains interventions to monitor AND mitigate pain, select “Yes.”

(Medication, massage, visualization, biofeedback, and other intervention approaches have successfully been used to monitor or mitigate pain severity).

• BUT - If the physician-ordered plan of care contains orders for only one (or none) of the interventions select “No.”

96

(M2400) Intervention Synopsis: Since the previous OASIS assessment,were the following interventions BOTH included in the physician-ordered

plan of care AND implemented? Time Points: Discharge/TransferPlan / Intervention No Yes N/A Not Applicable

a. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care


b. Falls prevention interventions 0 1 2Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since the last OASIS assessment

c. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment

0 1 2

Formal assessment indicates patient did not meet criteria for depression AND patient did not have diagnosis of depression since the last OASIS assessment

d. Intervention(s) to monitor and mitigate pain 0 1 2

Formal assessment did not indicate pain since the last OASIS assessment

e. Intervention(s) to prevent pressure ulcers 0

1

2Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS assessment

f. Pressure ulcer treatment based on principles of moist wound healing

0 1 2

Dressings that support the principles of moist wound healing not indicated for this patient’s pressure ulcers OR patient has no pressure ulcers with need for moist wound healing

97

Home Health Compare

• Measure:• Diabetic Foot Care And Patient/Caregiver Education

Implemented During Short Term Episodes Of Care (Implementation)

% of short term home health episodes of care during which diabetic foot care and education specified during the physician-ordered care plan was implemented for patients with diabetes.

(M0100) Reason for Assessment (M2400) Diabetic foot care intervention(s)

• NQF Endorsed

98

Home Health Compare

• Measure:• Pain Interventions Implemented During Short Term

Episodes Of Care (Implementation)Percentage of short term home health episodes of care during which the patient had pain and pain interventions were included during the care plan and implemented by the end of the episode.

(M0100) Reason for Assessment (M2400) d. Intervention(s) to monitor and mitigate pain

• NQF Endorsed

99

M2400 Instructions

• Pain intervention must be included in the plan of care AND implemented at the time of the previous OASIS assessment or since that time.

• For “No” responses, the care provider should document rationale in the clinical record. If the plans/interventions specified in the row are not appropriate for this patient, NA is the correct response – see guidance for selecting NA for each row below.

100

M2250 Instructions

• Patient-specific parameters for notifying physician – included in the plan of care– Row a: If the physician-ordered plan of care contains specific clinical

parameters relevant to the patient's condition that, when exceeded, would indicate that the physician should be contacted, select “Yes.” The parameters may be ranges and may include temperature, pulse, respirations, blood pressure, weight, wound measurements, pain intensity ratings, intake and output measurements, blood sugar levels, or other relevant clinical assessment findings.

– Select “NA” if the physician chooses not to identify patient-specific parameters and the agency will use standardized guidelines that are made accessible to all care team members.

101

OCCB January Q & As

Question 3: “Regarding M2250, physician-ordered plan of care: Can the nurse or

therapist communicate the patient's condition to the physician and request orders for the plan of care through his designee? Or does this exchange have to be directly with the physician? We generally call the office and leave information for the physician and request orders for various disciplines and so on, the physician will either call us back directly or often he will have his office nurse or assistant call back orders. Does this meet the expectation for the agreement on the plan of care between the home health agency staff and the physician?”.

Q & A Clarification: Question 3: Regarding CMS OASIS OCCB 10/09 Q&A #32, what is meant by

“communication can be directly to/from the physician, or indirectly through physician’s office staff on behalf of the physician, in accordance with the legal scope of practice.”? Can the physician’s secretary be considered Office staff if she/he speaks directly to the physician with the clinicians questions and then gives the information directly back to the clinician?

102

OCCB January Q & As

Answer 3: The reference to “in accordance with the legal scope of practice” refers to the State

requirements defining who can take orders from physicians. Each HHA should have a policy and procedure consistent with State law that describes who can take orders from the physician. In most States it is going to be a clinician. It is important to understand that all orders must come from the physician and eventually be signed by the physician.

If you receive an order from the physician’s “assistant” that person has to be legally

qualified in your state to take physician orders . The individual at your agency who receives that order must also be legally qualified to take orders. The physician is required to have directly communicated the verbal order to his designated qualified person.

CMS explained that they were concerned that in some cases home health agencies were taking orders from unknown sources who may not be qualified to communicate orders and also that those orders may not be directly from the MD.

If you know that the person you are receiving orders from is qualified to communicate

an order (cannot be a secretary unless the state law allows – I know of none who do!) your RN can accept the order and answer “yes” to the OASIS-C question.

103

OCCB January Q & As

Question 25: “In order to report on M2250 that physician orders exist, does that

initial verbal/faxed communication need to include details of the specified best practice interventions (e.g. fall prevention interventions, pain monitoring, specific clinical parameters requiring physician notification, etc.)?”

“Could it be determined that all these specific practice orders were

present if the communication with the physician were more general - (like the patient's clinical findings are discussed with the physician and there is an agreement as to the general POC between the admitting clinician and the physician. Then the formal detailed POC is sent to the physician for signature, outlining the specific parameters and interventions)?”

104

OCCB January Q & AsAnswer 25: The OASIS-C did not change the expectations and requirements for communicating

with the physician to obtain verbal orders prior to providing services. The Medicare Benefit Policy Manual, defines clearly how orders can be obtained

verbally if complete orders were not provided in the referral. Chapter 7, Section 30.2.5 states:

"Services which are provided from the beginning of the 60-day episode certification period based on a request for anticipated payment and before the physician signs the plan of care are considered to be provided under a plan of care established and approved by the physician where there is an oral order for the care prior to rendering the services which is documented in the medical record and where the services are included in a signed plan of care."

All orders would be under the same instruction from CMS, including those which are reported in M2250 and M2400.

105

M2250 InstructionsOCCB April Q & As

• Question: When do I pick NA for M2250a?• Answer: When completing M2250a – Patient Specific parameters, at SOC or ROC;

• “Yes” if the plan of care includes specific parameters ordered by the physician for this specific patient or after reviewing the agency’s standardized parameters with the physician, the physician agrees they would meet the needs of this specific patient.

• “No” if there are no patient specific parameters on the plan of care and the agency will not use standardized physician notification parameters for this patient.

• “NA” if the agency uses their own agency standardized guidelines, which the physician has NOT agreed to include in the plan of care for this particular patient.

106

M2250 InstructionsOCCB April Q & As

• Question: For M2250g May I answer “Yes” if either the physician ordered plan of care has orders for pressure ulcer treatments based on the principles of moist wound healing, OR if I requested these orders from the physician but the physician refused to agree to them or have not been established yet?

• Answer: M2250, row g may be answered “Yes” if by the end of the allowed assessment time period (5days for SOC and 2 days for ROC) the physician ordered care plan includes orders for pressure ulcer treatment of moist wound healing. You may also answer “Yes” in cases where the moist wound healing treatment was requested of the physician, by the end of the allowed assessment time period. It would not be required that the response from the physician be obtained in order to qualify as a “Yes”. If the physician response is “No”, moist wound healing is not appropriate for this patient “NA” would be the correct response.

Lynda Laff, RN, BSN, COS-CLaff AssociatesConsultants in Home Care & HospicePhone: (843) 671-4170Email: [email protected] Website: www.laffassociates.com

Contact Information

oasis-c - managing the bumps in the road lynda laff, rn, bsn, cos-c laff associates

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