Posts Tagged ‘OASIS-C’

Evidenced Based Practice

Monday, April 19th, 2010

CMS, through OASIS C, is guiding the home health industry toward evidenced-based practices. These practices require the identification of a solid literature review with established clinical integrated expertise that includes the patient’s cultural, socioeconomic, and educational background.

An organized plan with expected outcomes is being mandated in this contemporary health industry. There is a need for information directed toward diagnosis, prognosis and disease prevention. Traditional sources; such as textbooks no longer meet the fast paced knowledge accumulation of today. Time treating patients has become expensive and limited. Current up to date, tested knowledge is vital to maintain diagnostic/practitioner skills and quality outcomes.

There are specific steps recommended to achieve evidenced-based practices:
1. Select a topic or a clinical question is asked:
Problem-focused such as identified through Quality improvement, benchmarking, and recurrent data
Knowledge-focused, based on research from conferences or journals
2. Form a Team
3. Have a well defined process for evidence retrieval . A common paradigm used today is PICO; a) who is the Population, b) what is the intended Intervention, c) is there a Comparison intervention or Control group, d) what is the desired outcome.
4. Classify the literature as either conceptual (theory and clinical articles) or data driven (systemic research reviews). The data is derived from clinical trials, meta analysis, and national rated articles.
5. The information should then be interpreted and critically evaluated as to application, validity, and expected outcome. Apply the evidence.
6. The decision to change practice considers the relevance of the evidence and the consistency in research findings, looking for ways to improve or modify the application. Qualitative research is being used more frequently in this regard.

To further encourage evidence based practice in home health care, CMS is seeking standardized tools to be used in the OASIS C Integrated Assessment. These tools, such as the Braden and Norton used for skin integrity assessment are readily recognizable, not only in home health but, in other levels of care in health care. Thus, if the patient is transferred to another care level, a reliability of skin assessment can be maintained because the tool is a recognizable standardized instrument.

Evidenced-based processes are also being encouraged because the patient population is requiring more from their health care practitioners, having increased knowledge, empowerment, and access to information, and expecting predictable outcomes from care.

Evidenced – based practice is not a new concept. It is documented in Daniel 1:6 in the Bible where “controlled trials” were used in comparing dietary benefits for families. In the 1700s, James Lind used randomized trials to show that scurvy could be prevented by citrus fruit. In the 1800s, Semmelweis studied the transmittal of puerperal fever, an infection occurring in females post partum. Semmelweis was able to document that physicians and medical students would perform aurtopsies, and in the same clothing (dirty aprons and all), frequently, merely wiping their bloody hands on their aprons, then perform gynecologic examinations on the new mothers. By instituting hand washing with chloride of lime prior to examining the females, the infection rate dropped over 80%. Evidence-based practice is soundly grounded in research.

The Agency for Healthcare Research and Quality, the National Guideline Clearinghouse, and the Evidence-based Medicine Resource Center are just a few organizations involved with the practices of EBP. Discipline specific associations impacting medicine, nursing, and the rehabilitation oriented therapies are also actively involved in research.

Evidence-based practice in nursing is seen with a new model called Guided Care Nursing (GON) being researched in Maryland, to examine seven chronic care interventions, including disease management, patient self management, case management, lifestyle modification and geriatric management. The nurses involved in the program have completed a specific educational program that looked to enhance their skills in these areas. Predictive modeling software was used to identify patients for the study. The study has been so positive further clinical trials have been funded..

Researchers at the University of California San Francisco Medical Center have undertaken a prospective study to look at incongruencies in practice standards across specific disease lines.

Evidence Based Practice is now being applied in the health care education and training setting. Data has been evaluated on over 109 medical schools in the country.

Government has a strong belief that evidence based practice will positively impact both on the quality and financial outcomes in health care. It is an exciting time in health care. It is truly the time for strong data driven practice.

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

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Evidenced Based Outcome Improvement

Wednesday, March 24th, 2010

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

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OASIS-C

Thursday, February 11th, 2010

OASIS-C is making agencies more aware of the needs of the depressed patient. Recently, I was speaking with an agency that wants to expand their psych team. We discussed adding an Occupational Therapist to the predominately RN team.

So much of successful therapy requires healthy displacement of internalized anger. The RN therapist frequently uses words, supportive counseling, or cognitive restructuring action plans. The OT leans toward activities. Adults enjoy activities, especially when they build ego strength or divert or displace hostility in a more acceptable manner. Plus, did you ever notice that it is sometimes easier (and sometimes safer) to talk when active? OTs can assist with stress management, anger/conflict management, basic living skills, relaxation strategies, and grief counseling. They are usually comfortable using the mini-mental status exam and the geriatric mood assessment. Of course, the team must agree on which tools will be used and be certain all members are proficient in their use to reduce inter-rater reliability issues and promote optimal effectiveness. Both RNs and OTs model relationship skills with patients and families to promote patient goal achievement. Both disciplines model interpersonal and communication skills and respond effectively to conflict and complex issues in coordinating services. So, when you are considering your home health psych team, consider OT. They add another dynamic dimension.

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

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Posted in OASIS-C | No Comments »