Quality may be key in new COPs, but HCFA still requires paperwork

OASIS seen as good start, but it has drawbacks

While most of the changes in the new revision of Medicare’s Conditions of Participation for home health agencies should not significantly affect quality managers, the OASIS (Outcomes and Assessment Information Set) requirement may be another matter.

Some of the experts interviewed by Homecare Quality Management expressed concern that OASIS would add additional documentation time to each home visit.

"If they [HCFA] do want home health care to make a difference, outcomes would be important," observes Jeannette Gronda-Kootsillas, RN, BSN, MSA, the clinical director for Henry Ford Home Health Care in Detroit. "I like the concept of OASIS, but they’ve got a long way to go. It does add time. There are 89 questions [sic] and from what I’ve read in the literature, 30 to 45 minutes are added to most visits."

From a quality standpoint, OASIS falls short in places by not requiring sufficient data, Gronda-Kootsillas says. "For example, the ostomy section focuses on only the prior 14 days of hospitalization, not the year before. There’s not a place to talk about any changes in the G.I. system.

"And for respiratory, there are only a couple of questions. It doesn’t give you all you need to carry through a plan of care. There are very few things on a medical assessment you could replace these [OASIS] with," she says. "I like the ADL section, however. There are a lot of good questions in it. But you still don’t get a complete picture of what’s going on with the patient."

Published March 10 in the Federal Register, the Conditions of Participation place the emphasis on outcomes of care rather than the processes. To achieve that, HCFA plans to mandate the use of OASIS, a standard core data assessment set, to help achieve a broad-based measurable improvement in quality of care. OASIS uses 79 data sets to evaluate the conditions of adult, nonmaternity home care patients. Mandating OASIS is the first step in comparing individual agencies’ treatment outcomes and patient satisfaction data to national data, says HCFA Director Bruce Vladeck.

"These proposals change the way we look at home health regulation," says HHS Secretary Donna Shalala. "We’re throwing out the old, process-driven approach and ushering in a new patient-centered system. We want patient satisfaction, not bean counting."

Although highly unlikely, the new COPs, including OASIS, could become final as early as June following the 90-day comment period required by the Administrative Procedures Act.

HCFA plans to implement OASIS in stages. Home health agencies must incorporate it into their current assessment processes when the proposed regulations are published as a final rule. Later, HCFA plans to publish another proposed rule requiring agencies to report OASIS data electronically.

Another problem with OASIS, some industry experts say, is the format for collecting data.

"I don’t see a big change from what we’re doing," says Gronda-Kootsillas, "but a change in the way things are packaged. We [Henry Ford] are heavily into quality improvement. A lot still has to be done by hand."

Says Cathy Nielsen, RN, CPHQ, "If the conditions of participation require OASIS, it will be burden." Nielsen is vice president of clinical services for In Home Health in Minnetonka, MN. "You may have collected data in a different way. If agencies have to use OASIS, that will be changed. It will take time for ramping up, staff education, additional forms, so it will have an impact on Medicare-certified agencies."

Karen Lajoy, PhD, director of training and quality management for Rehab Without Walls/Olsten Health Services in Portland, OR, agrees that OASIS "will be a burden in the start-up. You can’t expect to add something and there not be a learning curve. Unfortunately, there’s going to be a learning curve that will result in administrative costs."

But she says it will benefit home health agencies in the long run.

"Some of the [OASIS] demonstration sites we worked with say that once they start using OASIS, they see that they were doing some things they don’t need to be doing. OASIS can take their place. It doesn’t take any longer as long as agencies are flexible enough in their thinking to integrate it into their current system.

"Adapting a quality system like this is going to make the whole area of home health more credible. It’s going to allow for home health to really have some outcomes to report, and there’s not going to be any doubt about what we’re doing in home health," says Lajoy.

"Right now, outcomes are anecdotal. But these will be based on solid data, and that’s going to help the industry," she says.

Experts interviewed by HQM support the overall quality aim of the new COPs.

Nielsen compares the other revised COPs mandates with quality requirements of the major health care accreditation organizations.

"It’s similar to the language used in the [Joint Commission on Accreditation of Healthcare Organizations] standards for home care, emphasizing performance improvement. That’s good.

"If an agency is Joint Commission-accredited, then they’ve been exposed to all these issues," says Nielsen. This is the first major revision in Medicare’s home health conditions of participation since the rules were first issued in 1973.

A move to protect beneficiaries

The conditions of participation revision is based on four core requirements: patient rights, comprehensive assessment, patient care planning and coordination, and quality assessment and performance improvement. Among these are the following specific steps "to protect beneficiaries and improve quality":

• Medicare-certified agencies must conduct background checks of home health aides as a condition of employment.

• Current qualifications of home health aides should be expanded to include nurse aides who have completed appropriate nurse aide training or competency evaluation requirements.

• Agencies are required to discuss with patients the expected outcomes of care so the patients can be more involved in care planning.

• Agencies must coordinate all care that physicians prescribe for their patients, thus preventing the current practice of several agencies serving one patient without care coordination.

• Agencies are required to provide their staffs with continuous feedback on qualifications and performance as part of their continuous improvement programs.

While many of the changes represent a departure from the process-driven approach of the past, HCFA still is attempting to set time limits in some areas, including:

• the initial assessment (within 48 hours of referral, the patient’s return home, or the physician-ordered start-of-care date);

• the comprehensive assessment (no later than five working days after the start of care);

• updates of the comprehensive assessment (at least every 62 days beginning at the start of care).

As part of the comprehensive assessment, HCFA would require agencies to administer OASIS within every 57 to 62 days after the start of care. (A basic outline of the proposed COPs and OASIS rules is inserted in this issue of HQM.)

"I was really struck by the different mood that HCFA seems to be interested in creating," says Kathryn S. Crisler, MS, RN, senior research associate at the Center for Health Services and Policy Research in Denver. "This seems to be a real attempt to allow some flexibility on the part of home health agencies. I think agencies that are currently doing a good job should welcome it. It focuses on the endpoint; it’s where we all want to get to.

"In the past, HCFA has been very rigid," she says. "There’s a little of that in there still, but there’s less of Big Brother telling you how to provide care than saying, ‘OK, show us what you’re doing. You have the responsibility to provide good care. If you don’t, we won’t pay you.’"

The one feature that drew a lot of attention in the national press was a requirement for background checks of home health aides. Recent coverage of home care agency fraud and abuse of patients seems to have spurred the Clinton administration into addressing the issue, which experts agree is necessary and desirable. All agreed that background checks should be required, adding that their agencies have always done them.

"Criminal background checks is a very good idea," says Nielsen. "However, they are difficult to do right. Agencies have to be taught. They need to find out where an employee lived in all the prior years they worked, because there is no national repository. It’s all state by state. All they have to do on an application is leave out one state."

Cathy Frasca, RN, BSN, FACHCA, executive director of South Hills Home Health in Homestead, PA, sees the requirement by HCFA and HHS as something that is necessary. "Our state home care association has already developed a software package that’s available to members."

Frasca, however, does not believe criminal background checks should stop with home health aides. "I’d like to see it on all staff, not just home health aides. Of course, professionals have other types of monitoring systems."