Use OASIS data as springboard to QI

New England agency offers tips for its use

It may be years before you receive benchmarking information from the Baltimore-based Health Care Financing Administration (HCFA) about your Outcome and Assessment Information Set (OASIS) data.

And it will be a while before any private companies are able to provide you with valid comparisons with agencies in your area. But it's still possible to put together some great quality improvement projects with the OASIS data you collect.

Affiliated Community Visiting Nurse Association in Rockland, MA, has used its OASIS forms to create several QI tools. One tool measures a patient's functional status and gives nurses objective information to help determine how many hours a week a patient will need home health aide visits, says Joanne O'Regan, MS, RN, vice president of admissions for the agency, which was formed last year when eight separate VNAs merged. Affiliated Community VNA serves southeastern Massachusetts.

After using the tool for less than a year, the agency already has some important data that compare the patient's needs with the kind of services the patient is receiving, says Kathleen Hernon, BSN, RN, performance improvement coordinator.

The agency also has used the aide's visit tool to assist with its utilization review process, which is a requirement of Medicare's interim payment system (IPS), says Joanne Dalton, PhD, RN, CS, program development manager.

The OASIS data also were used to create a tool for patients with cardiac problems and patients with Parkinson's Disease. O'Regan says the goal for each patient group is to achieve better outcomes by identifying whether patients improved on several different measures.

HCFA plans to use OASIS data while implementing a prospective payment system for home care agencies. HCFA will require Medicare-certified home care agencies to begin reporting OASIS data Jan. 1. Once OASIS data are collected nationwide, then it may be possible for HCFA or private companies to use the data for benchmarking home care outcomes on a variety of measures. The data already have been used for limited benchmarking purposes in national pilot projects, including HCFA-funded studies that focus on outcomes-based quality improvement.

Agencies that only collect OASIS data for Medicare requirements and then wait a year or longer for feedback from HCFA are missing out on a good opportunity, O'Regan says.

A good guide for staff

"You can manipulate data in-house and come up with quality improvement reports, marketing reports, and HMO reports based on the OASIS data you're already collecting," O'Regan explains. "That's why we're doing what we're doing, and we think every other agency should be doing it too."

O'Regan, Dalton, and Hernon explain how they've created these tools using OASIS data and what they hope to accomplish with them:

· Aide's visit tool. The tool uses nine OASIS data set items that are each scored with numbers according to how high-functioning the patient is. The lowest score of zero would mean the patient is very high-functioning, Dalton says.

These data set items are pulled manually from the 25-page OASIS form. However, once the agency scans a version of its OASIS tool, nurses will be able to access the aide's visit tool on the computer, Dalton says.

Items measured are:

- the patient's cognitive functions;

- ambulation;

- transferring ability;

- bathing ability;

- toileting ability;

- dressing upper body;

- dressing lower body;

- bowel incontinence;

- urinary incontinence.

The tool adds these individual scores into one aggregate score relating to the patient's level of functioning. Patient scores range from zero to 36.

Then the agency assigned a value to score ranges. This value relates to how many home health aide hours would be appropriate for a particular patient. It has not been tested for validity, Dalton says.

For example, for scores of 30 to 36, the patient might be given five or more hours each week of home health aide services.

"It's a good guide for the staff," Hernon says. "It allows nurses to quantitatively look at whether they're meeting the needs of a patient."

Nurse input taken into account

Nurses may suggest a patient needs fewer or more hours of aide services than the tool suggests. Their input goes into the final decision as well because a patient might have significant social factors or other variances that are not measured on the tool, Dalton says. For instance, the patient might have a caregiver who is chronically ill and cannot provide assistance with bathing.

When nurses discuss aide services with family members, they do not have to mention the tool. Dalton suggests they could say, "It seems to me your mother or father requires this many hours of home health aide assistance. What do you think?"

· Cardiac Patient OASIS Outcomes Report. This report pulls OASIS data items on patients in the agency's cardiac program. Specifically, the tool looks at patient outcomes in functional ability, learning ability, pain management, and a number of variables that could affect outcomes, Dalton says.

"To analyze the data, you want to be able to compare these patients, and in order to compare patients, you have to know factors that vary the outcomes," Dalton says. These variables might include whether the patient has a caregiver or comorbidity factors.

The report will soon help the agency obtain better outcomes measurements for its cardiac program. The program has included a study of congestive heart failure and chronic obstructive pulmonary disease patients, and it looks at how often patients are readmitted to the emergency room, O'Regan says.

"HMOs have an advantage in working with our agency because the outcomes reports validate what we do," O'Regan adds. "So they're able to see patient-specific data on how we are able to progress a patient from point A to point B in X amount of visits and dollars, and what was the outcome."

Using the cardiac report, the agency can even give HMOs aggregate data that are physician-specific. Dalton says the agency plans to compare its aggregate outcomes for internal improvement. For example, suppose the aggregate report shows that most of the patients improved in medication compliance but did not do as well in ambulation. Then the agency might start a QI project to change its cardiac teaching tool.

· Parkinson's Disease Patient OASIS Outcomes Report. This report is in the preliminary stages, Dalton says. It has the same format as the cardiac report and also includes some variables from the OASIS data set. The data pulled includes items pertaining to functional ability, the patient's ability to bathe, cognitive status, bowel incontinence, urinary incontinence, and others.

"We collect information on cost per episode, monitor what patient outcomes are, and show how much it cost to provide this service," Dalton says. If the management sees it is costing the agency more money than the HMO is paying for treatment, a QI team could investigate whether the same outcomes could be achieved with fewer visits, perhaps by calling patients more often, Dalton adds.

"The data is extremely valuable," Dalton says. "The performance improvement person could look at the data and set goals and objectives, and an administrator could look at the data from a marketing perspective."