Lynda Schoonbeek, CMP, Director of Education
HCA of New York State
Since the OASIS-C was implemented in January, we are having trouble with PT-only cases. Many of our PTs are refusing to complete the Medication section of the revised OASIS; they state the med issues lie outside their scope of practice. Some refuse to complete the med sheet, which would involve copying the specific med information for each of the patient’s medications? How can we comply with regulations in this area?
The issue of medication management in PT-only Home Health cases has been the subject of much debate since the introduction of the proposed OASIS-C document last year. Obvious in it’s’ development and evolution of care philosophies that define clinical delivery under the Prospective Payment System, the OASIS-C addresses contemporary patient needs for evidence-based treatment responses . The modifications seen in this latest Home Health assessment tool clearly define a clinical directive that providers and clinicians must adopt if they expect future success.
Many physical therapists expressed a reluctance or unwillingness regarding the Medication section (M2000 – M2015) of the proposed OASIS-C. The general position of the commenting PTs was that the specificity of the Medication section was outside their scope of practice. Though many of the responses were based on the high-risk medication instruction and monitoring requirements, some resistance was seen to the basic idea of transcribing med/dosage/delivery information. Not surprisingly, Home Health providers did not share their views; they expected physical therapists to complete the Medication section as per CMS guidelines.
When examining the problem that occurs when PTs are unable or unwilling to complete the OASIS-C Medication section, providers certainly seem to be caught in the middle. Required to comply with CMS reporting and qualification regulations, Home Health agencies must identify protocols to assure this important medication section be completed and managed successfully. Further complicating the issue is the historical difficulties providers have experienced in acquiring, managing, and retaining physical therapists. Staffing shortages often result in contracted therapy employees comprising the majority of homecare rehab positions, and agencies consistently report an inability to successfully manage these clinicians.
When researching the development of the OASIS-C, including the involvement and support of the American Physical Therapy Association (APTA), it becomes clear that therapists who, for any reason, are unwilling to complete the Medication section are out of step with the current performance levels of their profession. In a 2009 letter to CMS Office of Regulatory Affairs, the APTA submitted comments regarding the OASIS-C.
The APTA stated;
“…the physical therapist is more than capable of completing this item. It is within the scope of the physical therapist to perform a patient screen in which medication issues are addressed even if the physical therapist does not perform the specific care needed to address the medication issue. The physical therapist is competent and qualified to serve as a case manager and facilitate coordination of care with physicians and nurses.”
The APTA House of Delegates adopted a position statement which stated;
“Physical therapist patient/client management integrates an understanding of a patients/client’s prescription and nonprescription medication regimen with consideration of its impact upon health, impairments, functional limitations, and disabilities. The administration and storage of medications used for physical therapy interventions is also a component of patient/client management and thus within the scope of physical therapist practice.”
In an era with the transition to a physical therapy doctoral degree educational level so recently completed, the idea that PTs lack the education in this area appears somewhat short of acceptable. The APTA sites the 2004 Normative Model of Physical Therapist Professional Education, of which pharmacology is a primary content area. This includes pharmacokinetics and affecting factors, dose-response, administration, and interactions.
So how do we proceed regarding the Medication section of the OASIS-C in PT-only cases? Physical therapists who claim lack of educational insight into these areas should be prepared to participate in some type of continuing education to gain skill and fluency with the Medication section. Whether employing CEU-based education, curriculum affiliated refresher courses, or provider sponsored in-services, it is incumbent upon the physical therapist to acquire the knowledge base required for effective participation in the Home Health benefit. In addition, assertive participation from the physical therapist helps eliminate conflict regarding the Medication section. The MedQIC Website has useful information to guide medication management, and PTs can easily develop protocols that establish a cooperative approach that serves both providers and clinicians.
Likewise, providers have a vested interest in adopting protocols of their own that can support and ease PT concerns while addressing this area of the OASIS-C. Agencies that mandate nursing reviews and assistance for PTs who need help in the medication area; reviewing, consulting, and identifying problematic drug interactions or high-risk concerns, also help therapists’ performance in this area. The most successful approaches are seen when Home Health agencies create collaborative protocols that help them achieve CMS requirement levels by assuring in-office nursing reviews of the Medication section of all PT-only Start of Cares.
Agencies in areas of the country that have experienced audits and denials to date have seen decreases in therapy utilization as a result of scrutiny of claims for appropriate programming. As the need for therapy visit coverage (and therapists) decreases, many PTs may find their attitudes changing with regards to their ability to support Home Health providers with the Medication section. Physical therapists that plan on continuing to provide care for quality-based Home Health providers in the future will be completing and managing this portion of the OASIS-C.
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