Design stellar competency and assessment program for therapists

Expert describes how to meet all requirements

Medicare’s Outcome and Assessment Information Set (OASIS) requirements have made it more important than ever that your entire home care team be capable of performing and documenting consistent and accurate assessments of patients.

A comprehensive OASIS assessment requires that a patient’s medical, nursing, rehabilitative, social, and discharge planning needs be met. Since home care patients could be referred for therapy only, this means all therapists should be capable of performing a comprehensive assessment because a nurse might not be involved in a particular case, says Linda Krulish, MHS, PT, president of Acworth, GA-based Home Therapy Services, a home care consulting company that provides therapist training. Krulish spoke about improving therapist competence at the 18th annual meeting of the National Association for Home Care held in San Diego last October.

Home care quality managers and administrators first should review their state regulations and agency policies, as well as the competency level of each therapist, before deciding whether to require therapists to perform those comprehensive assessments, Krulish suggests.

Then, if therapists are going to be expected to conduct those assessments, quality managers should develop a training program that will ensure their assessments produce high-quality data. (See related story on improving assessment documentation, p. 39.)

Under the Medicare prospective payment system, the case mix will be determined by the OASIS data that home care agencies submit to the Health Care Financing Administration (HCFA) in Washington, DC.

"Poor OASIS data could result in under- or overpayment, and neither is good," Krulish says. "This is a critical time because we’re looking at data collection from both the quality of care and reimbursement."

If an agency’s staff collects poor OASIS data, this could lead to patients being assigned to an inappropriate case mix group, which means inappropriate reimbursement; or in a worse-case scenario, it could result in a federal fraud investigation, she adds.

Follow these guidelines

Poor assessment data will also affect patient treatment planning. "We also have HCFA’s program memorandum to state agencies, which came out in November, that suggests that part of the Medicare survey process should have surveyors determine if an agency has appropriate program training in place to make sure all therapists and nurses who are performing comprehensive assessment are competent to do so," Krulish says.

Krulish provides these guidelines for assessing competency training needs:

1. Educate staff on regulatory requirements.

Quality managers could begin by discussing the Medicare Conditions of Participation, reviewing what HCFA requires of a comprehensive assessment. This inservice should include:

— What is the scope of the comprehensive assessment?

— How will it identify the patient’s medical, nursing, rehabilitative, social, and discharge planning needs?

— What has the agency determined is a suitable comprehensive assessment?

— Which items on the assessment must be completed each time, and what are the different time points for conducting an assessment?

2. Obtain staff feedback.

Once therapists and the rest of the staff understand how to conduct the assessment, the quality manager should ask them for feedback, Krulish says. "This can be an informal process with a staff discussion of ongoing issues the staff brings up, or you can use a questionnaire asking, What are the things I can do and what are the things I need more training in?’"

3. Prioritize problem areas.

Competency assessments should provide a quality manager with a good idea of where major problems lie. For example, if certain questions on the OASIS tool are completed incorrectly by several clinicians, then the problem could be with the way the question is interpreted. Or the entire staff might need some updated education in that area.

Once a quality manager determines which are the problem areas, it’s time to prioritize them and proceed with a plan to correct them.

Top priorities should include the areas in which clinicians have the most difficulty, as well as areas that have a high risk if they’re not handled correctly. For instance, medication assessment is a high-risk area, so a quality manager might desire to make it a top priority.

Priorities also might be areas that most concern the staff. But as the priority list is made, quality managers should keep in mind that low-volume areas, even if they are high risk, might not be near the top of the list. For example, if an agency only has one wound care patient a year, then competency training in wound care treatment probably would be a low priority.

4. Train staff and develop solutions.

After drawing up a priority list, a quality manager could select the competency and assessment issues for selective training, inservices, peer training and mentoring, or other problem-solving strategies.

Solutions might include a stronger checks and balance system. For instance, some home care agencies have a nurse review all drug profiles documented by therapists, and that sort of agency policy could improve regulatory compliance, Krulish says.

5. Reassess staff competency.

Once staff training and education are complete, it’s time to administer the same competency tests that were used previously.

If the staff’s skills were assessed through a simulated lab, and problems were identified and handled with additional training, then the reassessment should also be a simulated lab.

"When a surveyor asks how you determined therapists were competent in competency assessment, you could go back to your files and show their improvements in testing," Krulish explains. "When you look at competency assessment in that way, it’s very second nature, and it’s common sense."