Home Care Under Fire
Home care experts split on value of OASIS data
Home care plays catch-up in the numbers game
(This is the second in a two-part series looking at home care agencies and their efforts to "tell their stories with data." In the first part, we examined some of the regulatory efforts that are forcing agencies to start the benchmarking process for the first time and their impact on many agencies. This month, we look at what two agencies have done as a result of the new regulations.)
Greg Solecki, vice president of home health at the Henry Ford Health System in Detroit, refers to the Health Care Financing Administra-tion’s (HCFA) OASIS (outcome and assessment information set) data collection initiative as "trying to kill a mosquito with a blowtorch."
The initiative has some 89 questions covering sociodemographic, environmental support system, and health/functional status of patients.
According to Solecki, OASIS is a punishing endeavor that is burying his agency in paper. "Yes, a shortfall of our industry has been our lack of data and our failure to tell our story in numbers. But I think that we are going in the wrong direction.
"We can add a thousand more questions and have a bunch more data, but we don’t need it all. Not every one of these questions has value. We are going to end up with warehouses full of data and nothing to do with [the information]. Do we really need to know if the patient lives in a house or a mobile home? Does it matter if he rents or owns? We could live without knowing this."
The result at Henry Ford is a huge turnover in staff. "In the past, for every home care nurse who left, there was always one in the wings. Now, even non-home care nurses know about OASIS and they don’t want to be here. I find it difficult to convince nurses that this is a good thing, and I don’t want to damage my credibility by saying it is a plus," he adds.
Solecki acknowledges there is value in data and benchmarking but adds he is not yet realizing any benefit from his OASIS data collection efforts — especially not any that equal the investment he and his staff have put into it.
"We are still trying to collect and transmit this information to the state in a timely manner. We are still doing this manually and have added over a million pieces of paper to our coffers doing this. I have taken pictures around our office to show graphically how we are drowning in paper. If someone bestowed a gift of 200 laptops to our nurses, there might be a light at the end of the tunnel. For now, we’re still in the dark," he adds.
Instead of using OASIS and its potential for external benchmarking, Henry Ford has concentrated on internal comparisons. The home care group has looked at clinical outcomes such as infections from catheters and how total joint replacement patients fare over a long period (nine years). Staff look at rehospitalization rates, functional data, and educational visits. "But we have not formally benchmarked with other providers except for our patient satisfaction surveys," he says.
There is some informal chatting with other like agencies around the country — much of which lately has concentrated on how much they all hate OASIS. "We contact our peers and compare notes on issues like how to handle after-hours on-call issues, field safety, and primary care nursing," says Solecki. "And this does help us to improve our processes."
Along with these informal studies, there have been a few more formal efforts, such as a wound care project at Wayne State University in Detroit that involved some 30 agencies. There was a diabetic care benchmarking project with 25 agencies in the Michigan peer review organization. Both of these efforts provided information that was important to Henry Ford in revamping processes, procedures, and documentation.
In addition, Henry Ford has made use of the Freedom of Information Act to request financial data from the Medicare Fiscal Intermediary about local and national agencies. Solecki says that information has been used to compare utilization, visits per admission, the number of admissions per full-time employee, and Medicare business as a percentage of total.
One external benchmarking program Solecki undertook on his own was a mystery shopping program in which he called other agencies, as well as internal departments, to see how they responded to questions, how polite they were in answering calls, and whether staff followed existing telephone procedures. "That was fun, but the staff got hip to it, so we stopped," he says. "We’ll resurrect that in the future."
But what about OASIS? Forget it, says Solecki.
There are those, however, who disagree with Solecki’s admittedly biased view against OASIS. Sharon Johnson, RN, MSN, RNC, CNA, director of Jefferson Home Care in Bryn Mawr, PA, says she is one of OASIS’ biggest cheerleaders. Part of the pilot-testing group of 50 agencies around the country, Jefferson Home Care has already had enough data feedback from the program to be able to use it to improve care.
"Before OASIS, we had done patient satisfaction surveys and we had done research projects on re-hospitalization rates. But really, our benchmarking was internal," she says.
OASIS supports improvement
Now, along with the patient satisfaction survey, there are outcome reports that the agency can use. "This has become our way of life. It is our process improvement program. All of our clinical improvement goals are based on OASIS and how we look compared to other agencies."
In the last four years, the agency has tackled several outcomes: acute care hospitalization rates, stabilization in cardiac patients, improvement in urinary incontinence, improvement in pain interfering with activities for all patients, and a suboutcome focused on orthopedic patients. Those five have improved to a statistically significant degree.
This year, two others were added: stabilization in bathing and stabilization in oral medication management. Those programs have just been implemented, but Johnson sees no reason they won’t show improvement, too.
"When you have the data, it really helps," she explains. "It makes it easy to pull together the right people to work on the problem. With pain, we used a pharmacist and clinicians. In cardiac patients, we had occupational therapists who worked with staff on how to help patients balance exercise and rest."
For Jefferson Home Care, there has been an issue of getting all the information into the computer system. In that area, she sympathizes with Solecki. But her agency will be getting laptops this year, which will ease the input burden.
"We did work hard to make sure that our assessment was comprehensive, yet easy for staff," Johnson says. "We got rid of areas of duplication. For instance, we had nurses putting vitals on three pieces of paper. Yes, the start of care form is 20 pages long. But the narrative note is shorter than it used to be, and I think it is manageable."
Like Solecki, Johnson is also a champion of data and their uses. "I am an administrator but also a clinician. When you sit down with nurses, therapists, and aides, and you ask how you can help patients get better, the clinical people can tell you what to do. And then when you see it improve over 12 months, you can’t not be excited," she explains.
But Johnson was part of the pilot project that received outcome reports. For many others, the data are being sent in, but nothing has come back yet. "To them, I have to say, Be patient,’" she says. "Get hooked up with a vendor who can give you an outcome report and work with the clinicians to use the data. I think OASIS does help us tell our story with data."
Solecki admits that OASIS and benchmarking are a reality for home care now. "This is our darkest hour. But benchmarking is critical from a business perspective. And it’s fun. I’m not a data geek, but it is fun to get the data, learn from it, and see how we compare to others. Data in a vacuum are misleading."
[For more information, contact:
• Greg Solecki, Vice President for Home Care, Henry Ford Health System, One Ford Place, Detroit, MI 48202. Telephone: (313) 874-6539.
• Sharon Johnson, RN, MSN, RNC, CNA, Director of Clinical Practices and Outcomes, Jefferson Home Care, 130 S. Bryn Mawr Ave., Bryn Mawr, PA 19010. Telephone: (610) 526-3837.
To learn more about OASIS, see Healthcare Benchmarks, August 1999, p. 89, or visit the HCFA Web site at www.hcfa.gov.]