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Staff training, automation helpful
Despite concerns about OASIS-related administrative hassles and patient privacy violations, for now Health Care Financing Administration (HCFA) regulations equally apply to all patients of Medicare-certified agencies, except for those under 18, receiving maternal-child, or housekeeping benefits. While pressing for relief from these OASIS provisions, Medicare-certified private duty providers have little choice but to comply with the regulations. Tips offered by other providers to ease the implementation burden include:
• Present OASIS as positively as possible.
"Don’t deliver the message that outcomes are bad. Acknowledge that it’s additional work, but that it also offers positive benefits," suggests Catherine Mallard, MEd, RN, director of clinical system design for the New York City-based Visiting Nurse Service of New York (VNSNY).
Managers on either side of the "too bad, it’s tough" or "isn’t this just awful" coin will only engender more staff discontent with the process. Allow staff to express concerns, but channel their energies by soliciting input on ways to streamline the implementation. (See article in this issue on effectively managing organizational change, p. 53.)
• Educate, educate, educate.
"Staff need as much information as possible about why OASIS is being done and that it’s not just an arbitrary thing to make people’s lives miserable," says Nancy Mongeau, RN, MEd, MSW, director of recruitment for Lynn, MA-based All Care Visiting Nurse Association.
Mallard agrees. "You’re going from a three- to four-page assessment to one that’s 17 pages. You have to show nurses why this has to be done." She recommends showing staff sample reports, picking one outcome improvement measure, and showing what it can mean to the organization and individual teams. "That way, it’s not too overwhelming or abstract," she says.
• Retrain staff.
VNSNY brought staff back for more training about two weeks after implementing OASIS. It helped them collectively identify ways to administer the assessment more efficiently, and also highlighted a few glaring problems. One nurse reported, "This is impossible! It’s taking me three hours to do it!"
"She literally viewed it as an interview and was reading all the questions and responses," Mallard explains.
Assessment efficiency is part trial-by-fire, part learning from others’ experiences.
"There is definitely a learning curve involved in the assessment process. Initially, it may take an hour-and-a-half to an hour per visit, but it decreases as they become more familiar with the instrument," Mallard adds.
Although it varies for each clinician, she estimates that most take around 15 minutes after they have experience.
"After a while, you get a routine and you get faster at it," Barbara Little, RN, MPPA, CHCE, agrees. Little is director of compliance for LifeCare Home Health Services in Delray Beach, FL.
"It’s just like the first time in nursing. It took a long time to do an assessment. But staff will come up with a conversational way to get questions," says Mongeau. To ease staff into a conversational approach and resharpen those skills first learned so long ago, use assessment training videos, Mallard advises.
• Involve other professionals.
Many agencies look to nursing staff exclusively to complete the OASIS assessment, but don’t forget therapists. Some argue that certain aspects of OASIS, such as a medication assessment, is outside their scope of practice. However, many therapists feel otherwise and believe that OASIS is the perfect vehicle to substantiate the impact of their interventions. At the VNSNY, they asked to be involved, Mongeau reports.
Schaumburg, IL-based personal care company LifeStyle Options has used OASIS for two years even though it is not Medicare-certified. "It makes sense for us because it’s a functional, rather than medical, tool," says Molly Miceli, chief executive officer.
Not bound by Medicare administration requirements, the company completes most of the assessment over the phone at the time of intake. Two staff support specialists — one a nurse, the other a teacher — verify missing and incomplete information at the time of case opening.
• Gain patient cooperation.
While awaiting clarification from HCFA about the proper course of action when a patient refuses to answer OASIS questions, don’t set up such a situation with negative explanations of the assessment.
"We explain that it’s part of being a Medicare-certified agency even though we’re not using [the patient’s] home care benefit," says Little. So far, no LifeCare patient has declined to participate in OASIS. Should one do so, Little’s not sure what will happen. "We’ll handle it on a case-by-case basis and ask our attorney and the company CEO."
Over time, patients will see OASIS as just part of the normal home care routine, Mongeau asserts. "It’s like when discharge planners first starting walking into patients’ rooms on the day of admission. People thought, This is absolutely absurd,’ but patients expect it now."
• Re-evaluate your data collection methods.
If you have not already made significant automation investments, with some OASIS experience under your belt, you may want to reassess your chosen data collection methods. LifeCare did a cost-benefit analysis of the estimated number of OASIS assessments per month, per branch. It also estimated the assessment and data entry times. The company uses an automated laptop system for Medicare clients, and a paper assessment followed by clerical staff data entry for private pay patients.
Nurses at the VNSNY use a pen-based tablet to directly enter OASIS responses. For now, therapists are using paper forms that clerical staff subsequently enter, but they will eventually convert to the computerized system.
The agency’s decision was based on its size, data entry expense, and existing information system, according to Mallard. With about 1,400 nurses, it already had a considerable data entry effort, and was concerned about meeting the required seven day OASIS "lock-in" period to enter, validate, and correct data before permanently transmitting it, she explains.
On the other hand, Great Lakes Home Health Services decided that scanable forms would create the least hardship, according to William Deary, chief financial officer of the Jackson, MI-based agency.
• Learn from others.
"Hook up with someone who’s been doing it and see them in action. Why reinvent the wheel?" Mongeau asks. Agencies that you contract with may be ideal real-time observation partners.
• Decertify or reorganize.
If you can’t make your OASIS implementation work either financially or operationally, even with extensive training and a positive approach, then consider decertifying from the Medicare program. Consider the licensure and regulatory climate in your state, as well as the credentials normally required by managed care organizations doing business there, Hogue advises.
Your strategic interests are also important. For example, if you want to expand personal care services — having managed care contracts and hence Medicare certification may mean less to you.
If decertifying seems too drastic, then evaluate moving your private duty operations to a separate corporation. While doing so will relieve you of certain regulatory burdens, it will add incorporation costs and other operational expenses. To pass HCFA muster, the two entities must truly be separate. That means neither Medicare-certified nor private duty administrative staff can assist their counterparts as their respective workloads fluctuate. Payroll taxes may also be slightly higher than they would be if the services were in one corporation.
• Mary Baker, RNC, MSN, MHS, FNP, President and Chief Executive Officer, Chicken Soup Plus, 1125 I St., Sacramento, CA 95814. Telephone: (916) 554-2444.
• Chandra Branham, Associate Director of Regulatory Affairs, National Association for Home Care, 228 Seventh St. S.E., Washington, DC 20003. Telephone: (202) 547-7424.
• William Deary, Chief Financial Officer, Great Lakes Home Health Services, 103 S. Jackson St., Jackson, MI 49201-2211. Telephone: (517) 796-1000.
• Elizabeth Hogue, Attorney, 15118 Liberty Grove Drive, Burtonsville, MD 20866. Telephone: (301) 421-0143.
• Barbara Little, RN, MPPA, CHCE, Director of Compliance, LifeCare Home Health Services, 800 N.W. 17th Ave., Delray Beach, FL 33445. Telephone: (800) 543-3491.
• Catherine Mallard, MEd, RN, Director, Clinical System Design, Visiting Nurse Service of New York, 5 Penn Plaza, New York, NY 10001-1810. Telephone: (212) 290-3553.
• Molly Miceli, President, LifeStyle Options, 1111 Plaza Drive, Suite 330, Schaumburg, IL 60173. Telephone: (847) 240-7330.
• Pat Stalica, RN, BSN, Director of Private Services, Outreach Health Services, 9415 Burnet Road, Third Floor, Austin, TX 78758. Telephone: (512) 821-2974.