Expert Advisor
OASIS-driven care improves outcomes, decreases visits
Use key OASIS items, such as where the patient comes from and who the patient lives with, to drive your case management meetings and you'll be on your way to improving outcomes and decreasing visits, if one agency we helped is any indication.
When St. Joseph Mercy Home Health's clinicians started participating in formal case conference meetings that focused on OASIS items and patient goals, scores for six of the 10 Home Health Compare outcomes improved in the Ann Arbor office and eight of the 10 outcomes improved for the Howell office. And best of all, the new process easily pays for itself when the agency prevents two therapy downcodes per week. St. Joe's prevents eight therapy downcodes per month and also saves money by decreasing visit averages to 11 from 19 per episode.
Prior to implementing this program, St. Joseph's staff held monthly case conferences with individual clinicians to discuss all of their patient cases, but their meetings often relied on clinicians' anecdotes about patients. They didn't focus on OBQI, the team's goals or the direction of patient care and this lead to inefficient visit utilization and negatively affected financial and clinical outcomes. That's why we implemented the following case-management model.
OASIS drives the case management
In the formal case-management model, the QA coordinator and nursing supervisors ask the nurse or therapist to focus on the answers to a few key OASIS items, which drives the plan of care and helps patients meet their goals. Here's a look at these OASIS questions:
ü M0175 (inpatient facility) through M0210 (medical diagnosis) determine where the patient came from, the diagnosis, and whether or not there was a medical or treatment change. This information helps determine the patient's rehab needs.
For example, patients discharged from skilled nursing facilities are more likely to benefit from three weekly therapy visits compared to one, because they're used to receiving rehab as often as six times a week in the skillled nursing facility.
Patients discharged from acute medical or rehab facilities clearly have a more defined and rapid onset of functional decline.
ü M0340 (patient lives with) through M0370 (frequency of caregiver assistance) –Patients with no in-home caregiver present their own specific level of safety and functional performance concerns.
These patients may require social work or therapy referrals. Social workers connect patients with either the Catholic Services Center or a private duty aide to help with bathing. And therapists set the patient up with shower chairs and other assistive devices to keep them safe while bathing.
And when there's a willing and able caregiver in the home, clinicians teach them to reinforce safety recommendations and help the patient improve faster.
ü M0825 (high therapy threshold) – The agency prevented high-therapy downcodes by consistently reviewing patients who were predicted to be high-therapy. This process ensures that theagency provides the necessary therapy visits when patients require them. Or, clinicians need to submit a significant change in condition to adjust the claim when circumstances change throughout the episode and alter the need for therapy services.
ü M0640 (grooming) through M0700 (ambulation and locomotion) –
Changes in the patient’s functional ability provide clues for the patient's therapy needs. For example, patients who decline from an independent "0" to a more dependant score, such as "2" could require both occupational and physical therapy services to reverse these losses.
4 more case management drivers
The answers to the OASIS questions above are just a part of the case management model that led to St. Joe's success. During these meetings, the QA or nursing supervisor also asked clinicians to review the following:
1. Patient profile – Clinicians are asked "who are we treating?" It requires them to think about the patient's age, prior facility and level of care, primary diagnosis and caregiver status to create a visual of the patient.
2. The HHRG – Clinicians are trained to look at the individual patient's HHRG score in terms of what Medicare projects the episodic payment to be. This ensures that the services provided coincide with the disciplines involved in the case.
It would raise a red flag, for example, if the patient scores an F0, indicating no functional deficit, and many therapy visits were ordered. Conversely, we'd reevaluate the situation if the patient scores an F4, and clinicains didn't initiate any therapy visits.
Clinicians must understand the impact of the HHRG score on reimbursement. For example, C3F4S3 could equal as much as $6000 and may lead to increased scrutiny from their intermediary. Therefore, clinicains need to answer the OASIS correctly to capture the patient's acuity and program the visits around these needs.
ü Plan of care review – This ensures that clinicians address the patients' needs identified in the OASIS items. For example, clinicians should be sure that there's an OT or PT assigned to the case if there's a grooming , bathing or ambulation deficit.
St. Joe's clinical managers look at the types of therapy involved to ensure that PTs, who are in short supply, aren't seeing patients who are more appropriate for OTs for instance. And they check to see if they initiated occupational therapy on cases with home health aides. That's because OTs can help patients learn how to bathe themselves rather than just giving a bath like a home health aide is trained to do.
4. Progress note review – Clinicians ask:
ü Are we doing what we planned?
ü How is the client responding?
ü Are our skilled interventions evident in the notes every visit?
ü How can we modify our approach?
ü Are we teaching (so client will not lose gains after discharge)?
ü Are they learning?
ü Are we ready to discharge?
This forces clinicians to ask themselves if they've implemented an assertive home program to restore previous functional levels.
For example, therapists need to teach patients proper strengthening and balance exercises to help them progress toward their goals if the patient has trouble walking 15 feet on the first visit.
Nurses and therapists all meet separately
St. Joe's case management model also differs from the traditional case management model because not all disciplines meet at the same time.
St. Joe's clinical managers meet with the nurses and therapists one-on-one rather than including all disciplines on the case as done in a traditional case-management model.
This keeps the meetings short and focused on the patient. Plus, it puts more emphasis on the documentation to recreate the experience that Medicare surveyor would have when auditing a patient chart. The surveyor relies on the documentation in the charts and doesn't take time to hear from all disciplines involved in the case.
About the authors: Teri N. Thompson and Arnie Cisneros are co-owners of Home Health Strategic Management in East Lansing, Mich, and have a combined total of 40 years home care management experience. You can contact them at: www.homehealthstrategicmanagement.
Coleen Conway-Svec is the System Integration Leader for St. Joseph Mercy Home Care & Hospice a member of Trinity Health.