Since 1999, the Centers for Medicare and Medicaid Services (CMS) has required certified home health organizations to collect extensive patient assessment data with more than 100 questions. Over 20 years later, clinicians are still struggling with time constraints in assessing and completing the Outcome and Assessment Information Set (OASIS).
However, with a “show me” rather than “tell me” approach to this problem, not only are the results more clinically accurate, much of this rigorous process can be completed in just 15 minutes.
In this two-part series, we will learn what clues to look for and how to use the OASIS Walk, enabling clinicians to easily obtain OASIS information while performing the comprehensive assessment.
The First Set of Clues: The Medical History
The OASIS starts at intake, made easy by using an electronic medical record (EMR) system that seamlessly integrates patient demographics, healthcare indicators, medical and physical history, treatment notes and medications in the home health record.
By reviewing this information before calling the patient, the home health clinician gains valuable clues on where to dive deep into the assessment.
For example, patients with prescribed pain medications to be taken daily are most likely experiencing daily pain regardless of what is reported. The assessing clinician will want to watch these patients for guarding and grimacing during the assessment process.
The Second Set of Clues: The First Phone Call
Further clues come during the first phone call to schedule the assessment appointment. It is considered best practice for the assessing clinician to make this call personally. The clinician can gain insight into the patient’s ability to understand and process information by asking the patient to have their medications, discharge planning instructions and insurance cards ready on the day of assessment.
Clinicians can also discern other clues about the patient’s living situation and if others are involved in care. A trained listener may even be able to determine functional ability and homebound criteria by asking how the patient was transferred from the hospital.
The Third Set of Clues: The Patient’s Living Situation
The third set of clues occurs when the assessing clinician drives up to the home.
Piled up newspapers, broken shutters and overgrown grass suggest limited mobility. The time it takes the patient to answer the door and observing their gait as they walk to and from the door gives further clues to not only mobility, but also pain, use of assistive devices and ability to dress and groom oneself independently as evidenced by appearance and condition of clothing.
Missing buttons, snaps or a disheveled appearance are immediate clues that require further investigation to determine functional ability.
As you enter the home, engaging in conversation and asking for the items discussed the day before provides clues into hearing functionality, as well as cognitive abilities. Identifying these clues will save the clinician time and provide a better indication of the true state of the patient, rather than only relying on what is said.
The next blog in this two-part series will delve into the OASIS Walk, and how that, coupled with the identified clues, will enable the clinician to complete the OASIS assessment in 15 minutes.
At Axxess, we are dedicated to enhancing care in the home and providing you with multiple resources for success. In addition, we have developed a short video that presents the OASIS walk-through in a realistic, patient-centric approach.