Outcome improvement and safety in Home Care is a focus of CMS. All levels of health care are being encouraged to find evidenced- based ways to improve patient safety, prevent adverse events, and achieve optimal outcomes. OASIS C has been designed to measure improvement in processes. Data collected from the OASIS C assessment, plan of treatment, and evidenced practices will be utilized in publicly reported measures, OBQI/OBQM quality reports regarding care improvement guidance, and development of a Pay for Performance system.

In 1999, the Institute of Medicine (IOM) recommended adverse event reporting, first in the acute care setting and then to other health care delivery systems. An adverse event is defined as “an injury caused by medical management rather than by the underlying disease or condition of the patient” (IOM, November, 1999).  Systems failure remains the number one reason for medical error. Types of errors include medication, accidents/falls, and pressure wounds. Causes of error and adverse events include complex patients with complex problems (multiple diagnoses and co-morbidities, multiple medications), complex information management, and the complexities of being human (emotions, support systems, and resistance to change). The IOM encouraged improved data collection and analysis and improved systems.

By 2005, various studies reflected that the IOM goals had not been met (Leape and Berwick, JAMA, 2005). This fact encouraged various organizations, including the Joint Commission to revise and update performance standards including National Patient Safety Goals to more aggressively encourage safety and prevent adverse events. CHAP encouraged improved infection control processes by clinicians in the home. In 2010, CMS, through OASIS C, is driving evidenced-based processes. Home Health Agencies are charged to screen patients for risk in skin condition, depression, pain, falls. SOB, depression, and anxiety are considered very strong risk predictors for outcomes. In the near future, outcomes are expected to be tied to referral potential and payment reality.

Evidenced-based processes are advanced by standardized assessment tools. These measureable assessment tools are enhanced when used in conjunction with well captured patient data. That means completing an OASIS data set thoroughly and accurately. Changes in OASIS coupled with impending RAC audits should be an impetus to agency leadership to effect powerful change and/or review in their organization. Clinical accountability for timely documentation, attending educational sessions, and case conferences are essential to maintaining skill sets and excelling to achieve improved patient outcomes. Streamlining processes becomes vital.

Clinicians require a thorough knowledge of how to answer each of the OASIS M question. As adult learners, they will naturally want a better understanding of the big picture conceptual changes and how the new evidence tools will drive care quality. They may ask for more education as to how to assign risk. This is where algorithms and protocols play a part in quality care. Agencies need to establish “next steps” in care; a falls risk score of 10 may trigger a physical therapy referral or weekend hospital discharges may mean an admission to home care is completed that same day instead of the agency routine policy of “within 24 hours”.

OASIS C has the potential to measurably improve clinical excellence and increase consumer value but, assisting clinicians to embrace the change can still be challenging. One facet to review regarding clinician efficiency and accuracy is having the right tools. Having a tool designed by home care clinicians that flows through a head to toe assessment, that triggers clinician care planning, that allows for additional screening tools to be available is essential. Also, consider providing coding support for the clinician.  We all know that for the average home health agency, the home health nurse is an excellent clinical generalist, not having the luxury to specialize in one diagnostic area. (And many nurses state that is one reason they enjoy homehealth). But in the area of coding, providing coding expertise is an essential part of risk management.

OASIS C may be the impetus for transformational change for the industry. It has morphed from a mere data collection tool to a process oriented tool that requires the clinician to create a highly comprehensive client/patient-centered plan of care with a diagnosis code table of contents and evidenced –based care with expected outcomes. In the very near future, those outcomes are expected to be linked to patient/client satisfaction ratings and agency reimbursement. CMS is well on its way to expanding processes that have publicly reported measures solidly supported with evidenced – based practices. Those practices begin with tools to aid the clinician in gathering accurate data…efficiently.

Susan Carmichael
MS, RN, CHCQM, COS-C
Fellow of the American Institute for Healthcare Quality