Nursing

RN/AHC Media Home Study Program CE CENTER

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After reading the article you should be able to:

1. Describe the role that communication plays in preparing the patient to be discharged to home.
2. Discuss the nurse's role in completing the Outcome and Assessment Information Set (OASIS).
3. Implement a homecare holistic assessment.

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By FRANCISCA CHIME, RN, BSN, FNP; SHARON VAN SELL, RN, EdD, PAHM; SHERRY CARTER, RN, PhD, WHNP; RETA FIELDSMITH, RN, BSN, MSN; and CHRIS KINDRED, RN, MS, PNP.

FRANCISCA CHIME is president of Modern Health Care Services in Mesquite, TX. SHARON VAN SELL, Professor, SHERRY CARTER, Associate Professor, and CHRIS KINDRED, Associate Clinical Professor, are educators for the College of Nursing at Texas Woman's University in Dallas. RETA FIELDSMITH is the clinical director at Aria Home Health in Dallas. The authors have no financial relationships to disclose. STAFF EDITOR: MARTHA K. RAYMOND, RN, BSN, BS

HOSPITAL TO HOME Post-hospital care is the key to full recovery for patients. However, discord can arise between the hospital and the home healthcare agency because of incomplete discharge instructions. These instructions should include the patient's diagnosis, treatments, medications, and the practitioners' subjective and objective notes. With only part of the history, complications can result from failure to provide adequate instructions for the chronically ill, missing instructions concerning adverse drug events, or an uncharted diagnoses such as diabetes. For example, in one study, up to 30% of those with omitted diabetes instructions were re-hospitalized.^1,2,3

One way to smooth the transition of care from the hospital to home is to plan the discharge with both the patient and caregiver. Giving the patient the autonomy to be part of the discharge plans will empower and encourage him to follow the discharge plans.⁴ Patients are at times discharged based on the hospital's need rather than the patient's need.⁵ In addition, some patients are sent home without the discharge team aware of whether or not a patient needs homecare.⁵

Communication is a big link in the discharge process and should start at the time of admission. A designated case manager should ensure that all disciplines are informed of the progress or decline of the patient, as well as discharge plans. With continual assessment and collaboration with other disciplines, the case manager will be able to meet the needs of individual patients and caregivers on discharge.

Poor communication between various healthcare providers at discharge is common and can contribute to adverse events affecting patients when they arrive home. Good communication includes all those involved in the patient's care. One of the team of healthcare providers is often a wound care nurse. A pre-discharge wound care consult includes patient teaching about the wound, the dressing, and whom to call in the event of complications. Sometimes charting inaccuracies, omissions, illegibility, undelivered information, and paperwork delays are basic reasons for misinformation. Root causes include increased physician workloads, physician-clerical failure, and poorly trained physicians in the discharge process.

The question arises as to who is ultimately responsible for discharge. At some hospitals, there is no standardized database for any one provider to bring all the information necessary for patient discharge in one place.² When aftercare is not well-documented and the transition to homecare is not smooth, patients become more vulnerable to medication errors, improper care, and other complications that can result in re-hospitalization.²

Post-hospital home healthcare is required for patients that meet Medicare home healthcare criteria. Hospitals ensure a patient's transition is safe and adequate to comply with accreditation standards and state health department regulations, and to remain eligible for Medicaid and Medicare reimbursements. Transition to homecare should neither be confusing nor complicated for patient, family, caregiver, and the home health agency. Discharge planning can help, and if done right, it will help ensure patient safety and make an impact in cost containment of healthcare funds. Patients at risk for complicated care patterns can be identified using data available at the time of hospital discharge.⁴ However, increasingly, discharge responsibilities are assigned to clerical staff members, rather than nurses or social workers.

In the elderly population, proper discharge planning is crucial. Evidence suggests that elderly patients discharged from the hospital have high readmission rates.² Delays and omissions during transfer to either a nursing home or home may exacerbate their illness. In addition, poorly planned discharge may prolong adjustment or readjustment to the nursing home, home, or healthcare facility. A small break in the discharge chain can diminish patient safety and quality of care during the fragile transition period.² Although the patient is most affected by a breakdown in communication, everyone in the nursing home or home health involved in the care of the patient is affected.²

Home healthcare agencies rely on completed discharge plans to carry out the hospital's orders for the patient. When an individual is hospitalized for illness and discharged to home for continuation of care to return to healthy status, it is the job of the discharging provider and nurse that all pertinent information on this patient—such as diagnosis, any procedure done on the patient while an in-patient, and all medications—is well-documented and sent to the agency that will help this patient achieve self-care.

REFERENCES

1. Robbins JM & Webb DA. (2006). Diagnosing diabetes and preventing rehospitalizations: The diabetes study. NIHPA. http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1618792

2. Coleman EA, Parry C, Chalmers S & Min S. The care transition intervention: Results of a randomized controlled trial. Arch Intern Med.?2006;166(17):1822-1828.

3. Triller DM, Clause SL & Hamilton RA. Risk of adverse drug events by patient destination after hospital discharge. American Journal of Health-System Pharmacy. 2005;62(18):1883-1889.

4. Coleman EA, Min S, Chomiak A & Kramer AM. Post-hospital care transitions: Patterns, complications, and risk identification. Health Services Research. 2004;39(5):1449-1466.

5. Briony D & McDonald J. The invisible contract: Shifting care from the hospital to the home. Australian Health Review. 2007;31(2):193–202.

ROLE OF THE DISCHARGE NURSE

Source: Briony D & McDonald J. The invisible contract: Shifting care from the hospital to the home. Australian Health Review. 2007;31(2):193–202.

Home Assessment

Once a patient is discharged home, a home healthcare nurse takes command. At the first meeting, the nurse fills out the Outcome and Assessment Information Set (OASIS). This form not only guides the plan of care, but also the agency's reimbursement success. In a Pay for Performance system mandated by Medicare, reimbursement and assessment go hand in hand. Furthermore, payments to homecare agencies will be based on outcomes, which are determined by comparing the admission OASIS to the discharge OASIS. In the three-tier system, the top tier includes patients with the best outcomes, and these patients lead to pay increases across the board in the home health agency. However, patients with mediocre outcomes don't bring in an additional reimbursement to the agency—and what's worse is the patient who declines, because the agency suffers a pay cut on all patient billing.

The Centers for Medicare and Medicaid Services (CMS) implemented the OASIS form with the hope that data collection would be done in a more accurate, consistent fashion while not adding additional time and paperwork for the homecare clinician.¹ The admission assessment can be quite an eye-opener. No matter how complete the hospital discharge planning, it never makes up for the firsthand observation and assessment of the client's home environment. In addition, the functional and medication questions not only ask what the patient's level is at the time of the assessment, but also 14 days prior. Making matters more complicated, the initial diagnosis is frequently accompanied by other co-morbid conditions that exacerbate the diagnosis. Patients usually provide only the information requested and seldom embellish with other problems. The clinician has the responsibility to uncover all the pertinent information about the patient. Only after evaluating the total picture can the clinician prepare an adequate plan of care, request services from other disciplines, and present the information to Medicare in the form of the OASIS format.

OASIS IMPACT OASIS is completed by a registered nurse in the field, and then submitted to the agency staff for processing. A lengthy review process of the OASIS form by the agency's quality assurance personnel is completed before the information is transmitted to Medicare. The quality assurance director of home health checks for errors, contacts the individual that completed the form, discusses any errors, and corrects the assessment. The form then becomes a legal document as part of the patient's chart. The nurse usually does not keep a copy. Due to the quality assurance review process, weaknesses in assessment techniques and incorrect completion of the OASIS form are easily linked to the nurse or the therapist.

Since the outcomes are based on comparison of admission to discharge data, these factors weigh heavily into the outcome data, and thus impact the agency's reimbursement.

WORKING THE SYSTEM A home health nurse with strong clinical skills and sound judgment can lead to a positive outcome and a better chance for higher reimbursement. Therefore, training the new nurse or the seasoned professional begins at the agency level.²

The assessment is the core function of home health nursing. Competency in data collection is also key to ensure the assessment, measurement, and dissemination of information is correct.

CMS suggests an important factor in performing accurate initial assessments is to assess your own skills and experience by asking yourself the following questions:³

» 1. Has the majority of my experience been in the acute care setting?
» 2. Are my assessment skills based on the body system approach?
» 3. Have I had to adapt my assessment skills to different patient settings?
» 4. What are the strengths and weaknesses of my communication style, my observation skills, and my ethnic and cultural skills?

After determining strengths and weaknesses, you should assess the available training by considering the following:

» 1. Can I learn from other disciplines about incorporating body systems into a functional assessment?
» 2. Does my agency provide mentoring with more experienced nurses, and training material to hone my skills?
» 3. Do I have adequate agency telephone backup for questions in the field?

HOLISTIC ASSESSMENTProviding care in the patient's place of residence affords the home health provider opportunities that other providers don't have. Patients typically feel safer and more secure in their own homes. This provides an environment with an excellent opportunity of developing trusting and caring relationships with patients and caregivers.⁴

In homecare, the assessment is centered on the whole person, in the context of their environment, to get an accurate picture of their ability to safely function in their own homes. Assessing functional capability and social interaction in the home is more accurate than in the acute care facility. Home assessment is the classic holistic approach to patient care.

In the health history, determining the patient's baseline and present activity levels are a priority. Determining whether the patient's changes are normal age-related or signs and symptoms of disease drives the plan of care. Activities of daily living (ADLs) and instrumental activities of daily living (IAD's) are best assessed by asking the person to perform the task in your presence. A comprehensive review of systems is then completed again with emphasis on function and safety. The goal of homecare is to keep the patient safe and independent in their home as long as possible. The home environment may require modification to achieve this goal.⁵

Most nurses have developed good skills in reviewing systems like cardiac or respiratory, but have never done so in the context of function and safety at home. Accurate data from the assessment is vital to developing a nursing plan of care, requesting the services of other disciplines, improving patient outcomes, and ultimately obtaining reimbursement from Medicare. The agency has a responsibility to hone the skills of the staff with in-services and training on a regular basis. ⁵

OASIS TRAINING INFORMATION The most comprehensive training, which is free, is provided by CMS, which developed a training tool called "The Importance of Conducting a Comprehensive Assessment."⁶ The mission statement noted it's a CMS-sponsored course for healthcare providers to upgrade their training using interesting audio and visual features to capture the details of the OASIS data set for assessing patients. A staff development guide is available for the agency training coordinator to improve the ease of navigation and test the knowledge gained by the staff. The program begins by incorporating questions for healthcare professionals to assess their own knowledge, prejudices, and pre-conceived ideas that affect accurate collection of data. In addition, the program allows assessment of employing agencies regarding factors that improve or inhibit their ability to function effectively in the field. The training module guides trainees through the actual visit in the home and matches questions to each component of the in-home assessment.

The program, which starts at the basic level, instructs the nurse how to conduct pre-visit tasks, including telephone availability and setting the appointment time, as well as post-visit data review and the need for additional disciplines and services. The training module transitions to the OASIS questions and can be used with audio or text instruction. The comprehensive tool provides pop-up explanations to questions answered incorrectly, as well as simple explanations and pictures to aid in learning. The site is easily accessible at no cost to any agency in the United States.

OASIS Answers is a group of professionals that provide educational workshops, usually at state or local organizational meetings.⁷ In addition, OASIS Answers provides individual consulting, online or teleconference workshops, and training manuals. A one-day consulting program titled "Blue Print for OASIS Accuracy" is a 6 1/2-hour course that targets strategies for OASIS assessment accuracy, CMS rules and regulations, and patient scenarios for group discussion. OASIS Answers provides teleconferences, and also provides Web-based training modules on a wide variety of topics. Best practices measures include how to improve function, manage medication, apply wound care, and prevent acute care hospitalization, and how OASIS accuracy impacts quality. The consulting and online training sessions are geared toward new agencies whose management personnel have limited OASIS backgrounds.

The Medicare training module titled "OASIS Web-Based Training" has 100 questions and is organized with the same flow as the OASIS assessment form, and can be found at www.oasistraining.org.

The Home Health Nurse Association developed a training program in 2001 at the onset of OASIS, which is still relevant today.⁸ The multi-discipline, multi-level curriculum corresponds with the categories contained in the American Nurse Credentialing Center test for the home health nurse certification. It covers types of homecare delivery systems; roles of nurses, therapists, and managers; and regulatory issues. Conditions of participation mandated by Medicare, eligibility, quality improvement, policies and procedures, and risk management are included in Section I of the Core Curriculum. Section II addresses theoretical foundations, including teaching, learning, crisis and change theory, nursing theories relevant to home healthcare, cultural issues, death and dying, and Maslow's Hierarchy of Needs. Additional curriculum includes HHNA Core Curriculum Section III—Clinical management, and HHNA Core Curriculum IV—Trends, Issues and Research.

The CMS training tool, OASIS Answers, OASIS Web-Based Training and HHNA training modules are available nationwide. 

References

1. Centers for Medicare and Medicaid Services. (2007a). OASIS background. U.S. Department of Health and Human Services. http://www.cms.hhs.gov/OASIS/02_Background.asp. Accessed Feb. 9, 2009.

2. Duckett K. The right assessments equal the right PPS payment. Home Healthcare Nurse. 2004;22(5):312-316.

3. Centers for Medicare and Medicaid Services. (2007b). Centers for Medicare and Medicaid Services (CMS) Outcomes and Assessment Information Set (OASIS) Training. U.S. Department of Health & Human Services. http://www.oasistraining.org/oasis11/upfront/U1.asp. Accessed Feb. 9, 2009.

4. Stanhope M. & Lancaster J. (Eds.). (2004). Community & public health nursing (6th ed.). St. Louis: Mosby.

5. Huffman M. Health coaching: A new and exciting technique to enhance patient self-management and improve outcomes. Home Healthcare Nurse, 25(4), 271-274.

6. Centers for Medicare and Medicaid Services. (2007). The importance of conducting a comprehensive assessment. http://www.oasistraining.org/oasis11/M3/M3S1_2.asp. Accessed Feb. 10, 2009.

7. Krulish LH. (2008). About Us. http://www.oasisanswers.com. Accessed Feb. 9, 2009.

8. Home Health Nurse Association. (2007/2008). Publications: HHNA Core Curriculum. http://www.hhna.org/html/Publications.htm. Accessed Feb. 9, 2009.

9. Centers for Medicare and Medicaid Services. (2008). OASIS OBQI. U.S. Department of Health & Human Services. http://www.cms.hhs.gov/HomeHealthQualityInits/16_HHQIOASISOBQI.asp#TopOfPage. Accessed Feb. 10, 2009.

10. Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2008-09 Edition. Registered Nurses. http://www.bls.gov/oco/ocos083.htm. Accessed Feb. 10, 2009.

11. The National Association for Home Care & Hospice. Basic statistics about home care. (2008). http://www.nahc.org/facts/08HC_Stats.pdf. Accessed Feb. 10, 2009.

TERMS

Outcome and Assessment Information Set (OASIS): A standardized assessment instrument completed by the homecare professional staff to report patient information to Medicare. The data elements represent core items of a comprehensive assessment for adult patients admitted to homecare, and form the basis for measuring patient outcomes with the outcome-based quality improvement. Outcomes derived from the OASIS measure changes in a patient's health status between two or more time points. The data are collected at start of care, recertification at 60 days, and discharge.¹

Patient care episode: The two-month period of time defined by Medicare to provide patient care. Additional two-month episodes can be added as long as the patient requires skilled care.¹

MO Questions: Identification markers that represent core items in the comprehensive OASIS assessment form for adult homecare patients. MO numbers designate certain areas of the OASIS assessment. For example, the MO designation: MO 300—380 is living arrangements and supportive assistance. MO 640–800 is ADLs and IADLs.¹

OBQI: Outcome-based quality improvement (quality performance, best practices synonymous)—A systematic approach involving the analysis of research data, risk adjustment, and patient outcomes implemented to continually improve the quality of home healthcare. CMS has developed a 10-chapter manual for home healthcare agencies to aid in reading and interpreting the OASIS OBQI reports, and implementing outcome enhancement activities.⁹

Statistics

Projected growth rate between 2006 and 2016 for RNs in home healthcare services is 39%, compared to 22% in hospitals during the same time period.10 Home healthcare RNs numbered 126,453 in 2006, and Medicare-certified agency full-time RNs numbered 92,728 in 2007. By the end of 2007, there were 9,284 Medicare-certified home health agencies.¹¹