During many recent presentations on the subject of PPS reform, therapy management/utilization and clinical outcome strategies, it has become clear to the author that many clinicians still possess much confusion regarding how to correctly answer MO 700 of the OASIS document. Concerns regarding appropriate interpretation of the safety aspects of the question are further clouded by a misunderstanding of the medico-legal requirements of the Start of Care clinicians. Unless care is taken to educate and monitor the performance level of nurses, therapists and agencies in this area, OBQI results will suffer and further effects will be noticed under the impending Pay for Performance era. This article will address some of the confusion surrounding the intent and application of MO 700.
The OASIS (Outcome and Assessment Information Set) was introduced as the cornerstone of the Prospective Payment System (PPS) in the year 2000. It offered the homecare provider a multi system assessment that marked the introduction of a data based clinical and reimbursement structure. This approach allowed for the establishment of an objective scale on which to base future programming directives; OBQI, New Rule reforms, and Pay for Performance. Since October 1st 2000, Medicare providers have collected and reported OASIS data in order to be reimbursed under the PPS model. The compiled data provides opportunities for CMS to determine the effectiveness of PPS as well as outline program modifications for the future. The clinical outcome results (OASIS SOC data compared to OASIS DC data) are compiled by individual agencies, tabulated as quality measures, and posted on the internet as a national quality reporting mechanism. While agencies struggle to share the concept of outcome scores and their importance to clinicians, Medicare now has identified this information as the primary factor in the proposed Pay for Performance structure.
This brief review of the history of the OASIS document serves to highlight the importance of accurate responses during the Start of Care visit. Clearly, these responses comprise the entirety of information from which the patient’s acuity-based clinical needs are identified to serve as a programming (and reimbursement) guide. The issue of MO 700, which addresses the safety of patient ambulation, revolves around two common mistakes. First, the incorrect application of the question as focused on the topic of equipment and second, the incorrect labeling of the present mobility level based on faulty medico-legal concerns.
The MO 700 header reads as follows (please refer to an OASIS Start of Care document for response levels that complete the question):
“(MO 700) Ambulation/Locomotion: Ability to SAFELY walk, once in a standing position, or use a wheelchair, once in a seated position, on a variety of surfaces.”
Our discussion will focus on Response levels # 1 through Response #3 where most mistakes are commonly made.
1) Safety vs Equipment: The common mistake made by Start of Care clinicians is to view MO 700 as an equipment question rather than one focused entirely on safety. When a clinician encounters a patient who uses a cane, walker, or any assistive device, they often mark Response #1 on the OASIS without specifically determining whether they are SAFE with the device. Most clinicians have been educated regarding this topic but fail to note this nuance during a lengthy Start of Care visit. Clients who are unsafe to ambulate independently with their assistive device should be labeled by Response #2 on the OASIS, meaning they would require human supervision or assistance to walk safely (even with the device). Clinicians who describe a lack of understanding as to who is safe or unsafe should note whether they (the clinician) are compelled to offer physical or supervisory assistance while the client ambulates. If so, the correct OASIS answer is Response #2. If an unsafe client is mistakenly labeled Response #1, receives therapy and improves to a safe level of independence with an assistive device, the agency gets no OBQI credit for the improvement. The ramifications of such an error in the upcoming, OBQI-based Pay for Performance era are obvious.
2) Medico-legal concerns: Recently, the author has been asked questions addressing this MO 700 concern while lecturing in various parts of the country. After hearing the same comments multiple times, it became clear that the topic should be clarified in some manner. Both nurses and therapists have verbalized concerns that labeling a patient as unsafe (Responses #2 or #3), places a medico-legal burden on the clinician and the agency to assure client safety, particularly if said client lives alone. Licensed clinicians participating in the Medicare program (in any way) are required to give an honest reporting of any clinical findings under corporate compliance guidelines and their respective state practice acts. Any safety concerns should be highlighted, addressed immediately via programming, and communicated to next of kin or any other identified caregiver. But in any case, the liability concerns are significantly greater if the Start of Care clinician inaccurately labels the patient as safe when they are not.
The accuracy of all OASIS questions are important when performing a Start of Care visit, but the questions related to clinical performance outcomes, such as MO 700, are particularly relevant for OBQI scoring. The impending Pay for Performance era will serve to further highlight the need for accurate (and honest) responses in order to achieve optimal clinical and financial results.
Arnie Cisneros is a physical therapist with nearly 25 years of home care experience. He is the owner of Home Health Strategic Management in East Lansing, MI, providers of clinical service management and home care consulting expertise. He is a nationally renowned speaker regarding the PPS refinements of 2008 and therapy utilization under the New Rule. You may contact him directly at www.homehealthstrategicmanagement.com.