OASIS quandry

Libby1987 · Feb 9, 2017

"Taking into consideration their strength, balance, endurance, vision/hearing and cognition, what amount and type of assistance and/or equipment is needed to remove their fall risk?"

and/or

"What amount of assistance to eliminate their fall risk are you willing to lay your license on the line?"

bbritton_64 · Feb 9, 2017

I have tried to explain it in just that way. What would the patient need to no longer be at risk? But they have a mental block on the availability of assistance. If we say they are at risk yet have no caregiver, and don't want a caregiver for that matter, how do you answer the question? They have trouble separating the way things really are from the way they should be. Does that make sense?

Libby1987 · Feb 9, 2017

I have tried to explain it in just that way. What would the patient need to no longer be at risk? But they have a mental block on the availability of assistance. If we say they are at risk yet have no caregiver, and don't want a caregiver for that matter, how do you answer the question? They have trouble separating the way things really are from the way they should be. Does that make sense?

Yes, and in my experience it is a universal issue for nurses. We have some who continue to struggle no matter how many inservices with different angles, but most of them are getting it.

They should be collaborating with their therapists' assessments as well to reach the correct response.

bbritton_64 · Feb 9, 2017

Not the fall risk part, but the ADL responses.

JustMeRN · Mar 2, 2017

I do admits exclusively, and when I'm training someone new I always tell them adl questions should not be about what the person can currently do, but what is the ideal situation that would result in the best care of the patient. Regardless of wether or not someone is there to help what is the safest way for someone to do adl's. So grandma joe might be bathing and dressing independently, but is that safe and manageable? Very rarely should someone needing homehealth be rated 0 on adl questions.

So, if grandma joe is able to get her clothes from the closet or dresser, but walking to get there, managing balance while reaching and pulling drawers makes her unsteady, she's a 1 (at least). Even though she can do it, it is not the safest situation. If she is showering independently, but it's so exhausting she only does it once a week then needs a nap after she's not a zero. If I feel the need to guard her as she walks she's not independent. If she has a walker that is necessary for ambulation she needs meal set up (you can't hold a walker and carry your plates).

I think we hate to feel like we are judging patients. If I answer grandma jo needs help with everything, but there's no one to help her, is answering accurately going to get her taken out of her house, or me in trouble if I say she needs help and then something happens to her I couldn't prevent? Those are the resistance I hear. But, oasis is not judgemental, in many questions we are not judging intent, just collecting data. I think that's the disconnect many people have with oasis.

Beeda · Mar 16, 2017

So remind your nurses that there is often no relationship between what a patient does and what they SHOULD do. On initial evaluation you should make your evaluation based on the situation before any teaching is done. For example, Ms Total Hip is 79. She greets you at the door dragging her walker (which is too low) through the hall because it is too wide to fit past the grandfather clock and the pile of mail. Her dog is yapping at her feet and she is wearing untied shoes (because she can't bend to tie them.). Just based on this at minimum she requires assist with dressing because she SHOULD have someone to lay out her clothes. She can't safely get them, clearly can't dress her lower body While observing hip precautions, has a major trip hazard (dog) Incorrect use of the walker, and environmental hazards. Additionally, she should have assist with lower body dressing to observe hip precautions. She later takes you into the bedroom where she shows you how she gets her shirt on (while standing up - an automatic safety fail) I would score her as totally depend for safety. Ok, she lives alone and does it daily, but it is not SAFE. By the end of the vs you have moved the clutter, fixed the walker, and moved the wheels to the inside of the walker. She sits in a chair to get dressed, and she found the dressing aids she got from rehab. Score her a dependent on soc BEFORE teaching and by the end of the visit you have improved her to clothing must be laid out for upper body and assist for lower body. BINGO! You have also improved your outcomes and made her safer

Tell your staff that low oasis scores help with risk adjusting and with reflecting accurate patient conditions that can often be improved with pt/ot/sn instruction and justify additional visits. If someone is a 0 on start of care they are probably not homebound and should not need any therapy!

if that fails, remind your staff that people are not safe if they are texting while driving...just because they don't have someone else in the car to text for them doesn't make it any safer.

AnOldsterRN · Mar 18, 2017

I worked in Home Health 22+ years. It's not what it used to be. The "per visit pay" does not account for all the "free" drive time, gas, phone calls, and homework (the extensive amount of paperwork). Home Health agencies pop up everywhere fighting to contracts and fighting to stay open. The last straw for me came when I discovered the owner breaking into my OASIS to edit, backdating items and orders expecting RNs to sign, upcoding and sending LVNs to do unneeded visits.. all reported to the proper authorities to deal with. So please excuse me if I come across as harsh.

RN's are trained professionals who are perfectly capable of assessing the ADLs portion of the OASIS. While I realize that a change in functional status would necessitate a change in coding, sending out OT, PT and CHHA which will give a bigger per episode rate with Medicare, having nurses change the way they assess functional status is not right. It does not sound like your nurses are having a "hard time with the ADL questions." It sounds to me like the owner is having a hard time accepting the answers.

The OASIS is to reflect the patient's condition and functional status at the time of the assessment. If the patient is able to groom self unattended, the OASIS should reflect such. There is also the 2nd option that grooming utensils must be within reach.. or clothing needs to be laid out. If there is no caregiver as you state, then how do you justify having the nurses mark that the patient needs extensive help with no one there?

The Medicare fraud in Home Health has reached such an extensive level that task forces to deal with Home health have opened around the country. The Feds have put a moratorium on the opening of Home health agencies in some areas.

Your nurses are are perfectly capable of assessing the appropriate functional status. Let them do their jobs without a boss trying to think of ways they can change their answers to what would be more profitable.

Again, my apologies for coming across as harsh.

AnOldsterRN · Mar 18, 2017

They have trouble separating the way things really are from the way they should be. Does that make sense?

No, it does not make sense. The OASIS assessment should reflect the patient's functional status AT THE TIME OF THE ASSESSMENT. There is nothing to separate on "how things should be." Respect your nurse's clinical judgement and find another patient you can send PT, OT, and CHHA to who actually needs it.

Libby1987 · Mar 18, 2017

No, it does not make sense. The OASIS assessment should reflect the patient's functional status AT THE TIME OF THE ASSESSMENT. There is nothing to separate on "how things should be." Respect your nurse's clinical judgement and find another patient you can send PT, OT, and CHHA to who actually needs it.

What she is saying, and if you have the experience you claim then you know what she meant, is that nurses in general struggle with separating what the patient performs out of necessity and what level of assistance is needed to eliminate their fall risk outside to that of any fully independent person.

If you work for an agency that improves patients' functional status and raises them to a higher level of independence then that improvement must be demonstrated by the only means possible which is through OASIS. That's what it's designed for, measuring 2 points in time and reflecting improvement, no change or decline.

If your interventions aren't improving the majority of your patients to some degree then I would question your practice and those you work with, more so than then the OASIS issue. If you work amongst blatant fraud then shame on them but there are a lot of us out here providing excellent care with intergrity.

AnOldsterRN · Mar 18, 2017

What she is saying, and if you have the experience you claim then you know what she meant, is that nurses in general struggle with separating what the patient performs out of necessity and what level of assistance is needed to eliminate their fall risk outside to that of any fully independent person. .

i do have the experience I claim and I know exactly what she meant. She wants pointers on how to get the nurses to change their assessment questions to reflect a lower functional status.

The questions on the OASIS are pretty clear cut.

Libby1987 · Mar 19, 2017

i do have the experience I claim and I know exactly what she meant. She wants pointers on how to get the nurses to change their assessment questions to reflect a lower functional status.
The questions on the OASIS are pretty clear cut.

She wants pointers on how to get the nurses to assess the level of assistance needed to perform that ADL safely. I don't know why you are accusing her of trying to game the system because that is exactly how they are supposed to be answered and nurses do in fact commonly answer the question based on what they see, or even more commonly are *told* that the patient tells them how they perform their ADLS without taking into account the safety risk.

The team should be collaborating anyway, in the 5 days allowed to assess and answer the OASIS questions. If the patient has fact improved, the nurse's assessment should not have prevented that reflection by scoring the patient with a fall risk as independent.

And the questions on the OASIS are not pretty clear cut to the majority. I literally see a patient marked as having no pain under M1242 while having M2250d marked yes. Something has simple as that is answered inaccurately. Or M1400 marked 3 while ADLS marked independent. Perhaps it's because nurses are trained differently, I certainly see every new nurse, after being instructed how to document medical necessity and skilled service, still chart that the patient is A&Ox3 sitting comfortably with FFW within reach as their skilled service. Or maybe it's because the admission visits require the collection of so much information, a lot of teaching and maybe a procedure or two that it's just a lot to capture comprehensively and accurately. Attempting to educate after comparing the therapist's evaluation is not an attempt at fraud.