I recently read your column in which you discussed the importance of correct and accurate programming for physical therapists who are new to Start of Care OASIS visits. I found it quite informative but nurses in our agency report concerns with patients and families who decline or refuse many of the services offered during the initial visit. Do you have any recommendations regarding these concerns for all Start of Care clinicians?

            There certainly is an art to the OASIS programming required to craft a homecare program that prompts successful clinical outcomes. Clinicians can quickly become proficient in this area, however.  Full appreciation of the PPS structure combined with scripting designed to elicit patient compliance and participation are essential. Initially, this review of the Prospective Payment System identifies the basic clinical procedures that, when delivered appropriately and efficiently, provide a form of best practice guideline for programming. Next, scripting to help guide clinical staff in the actual installation and delivery of the specific service or discipline is introduced. To conclude, the establishment of pre-RAP utilization review is imperative in order to provide ongoing administrative support for optimal programming on an individual case basis.

             The cornerstone of PPS is the multi-system assessment tool, the OASIS. This much maligned Start of Care document serves as the literal home health equivalent of the history and physical evaluation produced in all acute care hospital admissions. The basic premise of the OASIS is to address the homebound geriatric client in their entirety. Following the rational that this client may have multiple health concerns that compromise functional wellness, Medicare seeks to address underlying issues that could affect short and long-term outcomes. With the goal of addressing potential concerns that may lead to illness and/or hospitalization, the OASIS addresses most major body systems to identify areas of concern in the geriatric patient. This philosophy becomes most relevant when the level of functional mobility at hand restricts the patient to their home. Clinicians in the habit of programming as if offering the patient a smorgasbord of services from which to pick and choose will find it difficult to elicit Elite level (top 10%) patient outcomes.

            The obvious task lies in the installation of the specific services identified as necessary by the OASIS. This could include any type of discipline; PT, OT, Dietician, Social Services, etc. Inexperienced clinicians report a lack of understanding regarding the extent or depth of the clinical need required to include these services on the Plan of Care. The OASIS is quite comprehensive and specific in this area. Agencies concerned about clinical indecision should combine OASIS training and review with ongoing utilization review as described below.

            Eliciting patient acceptance of identified programming also requires a specific skill set. The reason most often given for the lack of delivery of identified and required services is that the patient or caregiver declined or refused to accept any additional disciplines. Start of Care clinicians need to remain mindful of a few realities surrounding the today’s homecare client. First, these patients remained in the hospital for up to an additional two full weeks as recently as 20 years ago. Patients (or their families) generally do not decline or refuse programming while in acute care beds. Second, if the patient found themselves in a sub-acute or step down environment, refusal of identified service needs would alter reimbursement formulas that Medicare uses to cover the costs of the admission, often resulting in additional co-payment expenditures for the patient. Third, both agencies and clinicians must realize that Medicare has determined that needed services identified by the OASIS are compulsory to efficiently and completely achieve desired outcomes. The job of the Start of Care clinician is to get the client to accept services required for good clinical outcomes. In our practice, the refusal of a needed service or discipline serves as the starting point for an ongoing discussion that often extends into the program itself. This occurs because we understand the importance of each specific service (PT, OT, MSW, etc) in the achievement of home health success.

            Finally, agencies who seek to optimize Start of Care programming must realize that ongoing support and reinforcement of the issues discussed above is required to prompt permanent changes in the clinician. The establishment and assertive maintenance of a pre-RAP utilization review to identify missed programming needs is absolutely necessary to achieve ongoing success in this area. This level of awareness-based programming will prove essential in the upcoming Pay for Performance era.

Teri N. Thompson and Arnie Cisneros are physical therapists with nearly 40 years of combined home care experience. Co-owners of Home Health Strategic Management in East Lansing, MI, they provide clinical service management and home care consulting expertise. They are nationally renowned speakers regarding the PPS refinements of 2008 and therapy utilization under the New Rule.