Webinar: OASIS D Part 2: Are You Ready for the Changes? New Items

Disclaimer: This transcript is intended to provide an overview of the main topics discussed in the original version of this webinar. Because it has been auto-generated, it might contain errors (including to proper names, industry terminology, numbers, and punctuation) that result in altered meaning. To hear the webinar in full, please view the archived recording.

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Thank you. I want to welcome each and every one of you to our session today, whether it is listening to the live version or participating in the recording. I am glad that you’re here. For many of you though, I am probably more glad to be here than you are because the OASIS usually doesn’t make us super excited. It tends to make us more feelings of dread and apprehension. We tried to alleviate a good portion of that in part one, where we looked at the items that are being removed and took a moment of silence to remember them. And then celebrate that there were 28 less things we needed to answer and then looked at the ones that were changed things that were tweaked or adjusted and try to help you prioritize and organize your thoughts around what to really focus on in terms of preparation.

And if your review, if your part of your job involves reviewing other people’s work things to hone in on going into early 2019 here, we’re going to spend some time on the brand new items. And those tend to be the ones that get the most attention because they look so much different. They’re asking different things potentially in different ways. And so these tend to get people to sit up and pay attention. Although that’s a good thing, there’s been some interesting dialogue. I’ve been a part of about these items because so much of what’s being added to OASIS D is functionally related. I’m getting calmer, getting pulled into conversations about this is a conspiracy that therapy is, is trying to put more functional questions in here for some sort of reason. Growing concern on the part of nursing as far as, how am I supposed to answer these, these look more therapy question than nursing question?

I’m not sure what I’m supposed to do with this. I’ve I heard things kind of running the gamut in terms of the reaction to this particular course of action and what they’ve added. So what I really want to do is help people step back a little bit, look for the common ground, because we always have to remember as we tried to stress and part one, OASIS is a data collection instrument. It is not a therapy tool. It is not a nursing tool. It doesn’t pretend to be, it never said it was yes, there are times when clinically sounding words show up in questions or in the guidance, and they may resonate with you differently depending on if you’re a nurse or a therapist, but that is more of our projection onto the item, not the way the item was actually created. And it’s important for us to recognize that that this is not some sort of therapy expansion or a attempt to take over larger portion of the OASIS, but really what I think it is, is an emphasis on the importance of patients’ functional ability, because I think we can agree.

You can have your medical status well-managed to be completely comfortable with taking all of your own medication, not have any wounds on your body, but if you’re not able to get up and get around and take care of your basic self care issues, or get yourself something to eat, this is going to be a problem in terms of your ability to remain safely in the home environment. So function is hugely important. So we want to make sure we spend our time today looking at the new items and reminding folks, if you get stuck, if you’re not sure if you’re out seeing a patient and it’s like, well, it’s kind of partway between this answer or that answer, please, please be familiar with the OASIS guidance manual. That is the place to start in terms of getting a question resolved. Yes, there’s always going to be that patient who doesn’t quite fit and we have to pick the best answer from what we’re given, but we always want to stick with the authoritative source.

So when we look at today’s handout and you go, well, some of these slides are like kind of boring or they’re just kind of what I tried to do was pull out those key pieces directly from the manual because nobody has the time or has the interest in my opinion, to sit around and listen to my opinion about what’s going on with OASIS D we need to stick to those core documents and make sure that we’re comfortable with them leading up to implementation and are very familiar with using them. As we start to assess patients with this document, as we start to review the work that’s coming in after patients are assessed. So we can look at the new items really as they’re six. So you can’t do the math and go, well, we lose 28. We have six. Wow. We’ve we’ve gained well.

I would say that some of these questions, if you’ve been looking at them are rather large, and that would be specifically GG one 30 and GG one 70. Those are multi-part questions. So I think to try to calm us down a little bit as an industry, yes, these are six new questions, but I would argue that four of these are pretty darn straightforward. It really is a question of reading the item, knowing the guidance and moving on. So let’s start with those. I’m looking at the issue of prior status. We know that OASIS in the past has had items trying to capture some semblance of prior status. But what we see in OASIS D is an expansion of it in a couple of interesting areas. We are looking more specifically at issues around mobility and cognition going forward. So we have a, which is looking at self care and we need to make sure when we’re looking at these items that we are familiar with, what’s included.

So we have some examples listed for self care. And I think regardless of our level of experience on this call, we are pretty consistent and understanding what self-care means. When we look at mobility, we have to understand that for ambulation in terms of prior level is being looked at as indoor mobility only. So their ability to get from room to room in their home with, or without a device. So you don’t really have to say, well, is it one way with or without is that assistance? No. The, the piece of equipment involved is not part of the consideration of your response choice when it comes to stairs. We want to make sure we don’t miss the fact that stairs is indoor or outdoor. So you may have a patient who doesn’t have stairs in the house, but has stairs to exit or enter the home that will have to be taken into consideration in our response option here.

And I am super excited. Oh, it might be kind of sad to admit, but the inclusion of functional cognition in this particular item. And I know if we brought out our speech language, pathology, friends, they would not find this to be an adequate representation of this important activity. I totally get it. This is why it’s data collection. And it’s a basic overview. And I think really being able to look at from a prior level of functioning, their need for assistance, when planning regular tasks like shopping or remembering to take medication, this is really not a full-blown cognitive assessment and it does not pretend to be, but it also helps to balance and give us insight in terms of what was this patient like before this happened? Is this really a significant change compared to recent activity? Or has this been going on for a while?

So we know that determining prior level of function is incredibly important. And to our therapy folks, we cannot just assume that GG 100 takes care of the depth at which we need to be looking at prior level of function on our therapy specific assessments. What do I mean by that? Well, sometimes it frustrates us because prior level of function we overwhelmingly were not there. We didn’t lay eyes on these activities. So we’re dealing with patient report information from caregivers. And we know that that’s not always the cleanest picture of what’s been going on. But when it comes to the therapy evaluations, we know that the expectation that prior level of function is included, I would argue the critical piece that needs to be there very often is the issue of how long has it been Judy 100 for the sake of standardized data collection is talking about this prior to this illness, exacerbation or injury on a therapy evaluation, we would want to be a bit more time-bound in relation to was that two weeks ago, two months ago, two years ago, again, I know that’s patient report, but I’ve also noticed as I review therapy, evaluations and therapy documentation there’s times where the prior level of function is basically just independent or needed assistance.

And doesn’t really talk about task or how long. So that’s a sidebar that isn’t directly about answering the OASIS, but indirectly a reminder that we need to make sure we’re getting that information in our therapy evaluations. But prior level is an important piece of determining how long has this been going on? What are areas that are brand new problems for this patient? What are things that are longstanding or have been around for awhile? When we look at the issue of prior device use my biggest advice here is simply read the question, because if you read the question, it’s going to come out very quickly. What about a cane? Cane is not a response option. So if my patient has been using a cane, I’m going to mark down Z none of the above that is explicitly coming from the manual and we could go way off topic and try to debate why isn’t cane included.

Cane is a piece of equipment. Why would you not have, you know what? This is where we get ourselves more anxious than we need to be about a lot of things with OASIS. It is what it is. So cane is not an option. We would not try to shoehorn it in there. And none of the above is where you’re going to go. But again, this gives us some context about, is this brand new equipment that this patient is going to have to learn to incorporate into their daily routine, or is this something they have been using prior to this most recent issue? So as you can see those two items lend themselves to being pretty darn straightforward, where we start to get more anxious as we look at the next two questions of, wait a minute, I’m having a little bit of a flashback because I’ve seen some of this before you are correct.

GG one 70 C currently in OASIS. C2 was the tip of the iceberg in terms of our ability to reorganize our data collection around function. I believe that GG one 70 C is the perfect opportunity to practice these principles leading up to go live on December 1st, because where are these other questions? We can look at them. We could practice them. We could talk about them, but we can’t use these new questions until always this D is live. So it becomes, okay, this is great. I’m going to get educated, but now I got to try to remember it through the holiday season and then try to recall it. When I see my first patient in January, I believe [inaudible] is a great way to know whether or not we’ve got the basis covered because the guiding principles here that we’re going to look at are the same guiding principles for just that one row.

All at it becomes an in January is take what we know to be true about that one row and simply apply it to different tasks. The concepts are the same. So we want to spend some time on those concepts in order to kind of gauge folks reaction and where people are in their head about some of this stuff. We’re going to use a couple of polling questions today. This is the first one. So as I kind of read it aloud and not saying that you can’t read, but you really don’t want dead air during the poll. And you definitely don’t want me to sing. So please answer the following question when determining a patient’s ability to complete a functional task, the clinician can consider information verbalized by the patient or caregiver. So yeah, we went with a true false, and I know some people, those aren’t their favorite questions. But just to get an idea about, can we consider what the patient is telling us or what the caregiver is telling us when it comes to function?

All right, let’s take a look at the results here. Well, we have about 70% airing on true, but a significant percentage looking at false. I would say that if I could, you know, exercise my spidey skills for a minute, that falls may be a little bit more toward the therapy side of that. Because when we look at this issue of patients and caregivers, verbally telling us about how well they’re doing, we tend to be a more skeptical. And I think as we look at the complexity of the functional assessment in OASIS D there’s a lot of anxiety about, oh my gosh, did you see how many tasks are in there? We’re going to have to make this patient, do all this stuff. There is no way as an admitting nurse, I can do what I need to do to manage this patient’s medical status deal with getting their medications all straightened out, get through the rest of an admission process and have them do all these things that are listed.

Okay. Let’s take a look with the instructions, really tell us and how that factors into the polling question. Yes, it is always going to be preferred that we base our response on direct observation, right? That is preferred. That’s the word straight out of the manual. What you see on these slides? I did not add to or change the wording. Okay. Although it’s the preference. It does not mean we don’t take report from the patient, the clinician, other staff, and their caregivers. I wanted to highlight that in the poll, in the polling question, because I think there’s so much emphasis on the observation. And although that’s the preferred method, we can’t approach this by saying, oh my gosh, OASIS D wants to make me do every single thing on this list. Now let’s just be fair therapist. Why don’t we just disclose it to the nursing side of the conversation, put away this aside for a second on therapy evaluations in particular occupational therapy evaluations, that patient is not completely demonstrating every single thing on that list.

They are not taking a shower, getting dressed, doing household management, making meals. They don’t do all of it on a visit. It is a combination of observation of their abilities or challenges combined with those verbal pieces of information, looking at what came with the referral. It is a combination, but the problem we’ve had in the past with OASIS is we can’t default to verbal only. And that is because when it comes to areas of function, patients are prone to not tell you the truth because they want to stay home. And I don’t really care how nice your brochures are or how sweet of an individual you are. Patients are concerned when we enter their home, that we are going to end up sending them to a nursing home if they can’t functionally stay there. So if I have a wound, sure, I want the nurse to come look at it and take care of it and, and take my medicines are messed up.

Yeah. I want my nurse to come and straighten that out, but you start asking me about falling. Can I get my clothes on? Can I get to the toilet? Just asking me, I am going to tell you everything is great because I, I don’t want you to use that as a way to end up trying to send me to a nursing home, or you’re going to rat me out to the doctor or worse yet. You’re going to tell my kid, because I can tell my kid over the phone who lives three states away. That I’m all good. You start telling them that I’m having trouble getting myself something to eat, and then I’m going to have to deal with all that drama. And I just don’t want to. So I’m going to tell you everything is okay. This is why it has to be a combination.

Not always going to observe every little thing in here. Exactly, but we need to be comfortable in our own clinical skin and looking at what factors affect safety. And what I really love is the second bullet to this therapist, pay attention here really carefully when possible CMS invites a multidisciplinary approach. That is now my new favorite word for OASIS D. We are being invited. They previous discussions of OASIS have suggested you could collaborate. Talked a little bit about collaboration. We said in part one, how the original functional items now have a consistent statement around collaboration with other disciplines you get to GG. And it’s a flat-out invitation. The question we have to answer therapist is are we going to accept this invitation or continue to sit in our swim lane going? I only deal with OASIS when you make me do an admin, or when I get stuck with a discharge or I don’t do it at all, I don’t want to do it at all.

That’s a nurse’s job in light of the final rule for home health that dropped ironically on Halloween. PDGF the new payment model will be a reality in 2020, and in 2020, that means the number of therapy visits will no longer be an ATM machine. It will not be a factor that directly shapes reimbursement. Our value has to be more than making visits. And our value opportunity here is to step up to that invitation and collaborate on collecting functionally related data. And the key issue is collaboration. We are not suggesting that nurses can’t answer these questions. So the therapist should, no one is suggesting that this portion of the assessment be dumped over to therapy and we stick their answers in there and say, it’s a complete assessment. Absolutely not. The responsibility will remain with the individual signature on that assessment, but that has never met that individual is the only person involved.

So what we see in the GG language, that’s slightly different than what we’ve typically seen in the N items is not only is there an invitation, but there’s a discussion that that report can include and should include other clinicians care staff, family. It’s a broader view of where am I going to get my information from? So individuals that are going to be seeing this patient making visits in that first five day window from the start of care can absolutely contribute information to secure the most appropriate response. That also would mean folks that are PTA’s and OTAs that currently do not fill out a way this at all, and OT and the not able to do admissions for the Medicare part, a population, okay, that’s a technical issue, but those disciplines need to be aware of what’s being collected to be able to contribute valuable information.

Again, this is not a divide and conquer dump job who can do what better? No. This is a recognition that trying to get our arms around accuracy at times for our patients is going to take longer than 90 minutes. How are we going to capture that? Because as we look through the original, the additional information we’re supposed to be looking at them, scoring them as independently as possible. Now, before we jump all over that, what does it say? As long as they are safe, we are back into common language with respect to the M items of function. Safety remains the core element, but the patient lives alone and he doesn’t mind nobody’s here. Oh my gosh, can we please let that go? The issue is, is it safe for them to do it? We seem to think that independent is synonymous with they do it on their own.

No, that’s not what independent means. Independent means they do it on their own anytime of the day or night that they want to do it. And there’s no safety concern at all. You are not interested at all when he takes a shower or what he does, because he’s perfectly fine. If that’s the level you’re at, we can talk about independent, but more often than not, we’ve identified a risk for falls. We have concerns. This patient just got home from a facility. That safety piece is part of this. And the fourth bullet talking about cognitive impairments may that affect the physical assessment. This should feel very familiar. It is not just can he get from point a to point B and not fall down, do his arms and legs move. Know that that is part of it, the physical aspects of it, but the cognitive issues, the environmental issues all remain in consideration here.

When we’re trying to grasp the idea of safety timing, that’s some people look at the timing recommendation and say, that’s kind of weird. I mean, wouldn’t you be doing this? Like at the beginning of care. I mean, why would you have a timing issue? But we have to remember is the reason we have GG and J is the impact act GG and J are not about getting an OASIS update or let’s throw something in interesting for 2019. It is a mandatory issue to harmonize data collection across post acute care. So now we are seeing a larger body of did GG beyond [inaudible] and that already has been getting collected in inpatient rehab and in skilled nursing facilities. So the issue of timing, although reads a little weird to us, make sense when you think about facility-based care, when you’re in a facility and there’s different professionals accessible to this individual, basically around the clock in some capacity, then when are you assessing them?

What is the cutoff? And the recommendation here simply is you need to assess function as early in this episode as possible. I will say it does crack me up that it says, and I quote when possible the assessment should occur prior to the start therapy services to capture the patient’s true baseline status. This is because therapy interventions can affect the patient’s functional status. Yay us. Okay. We’ve got a mini shout out there that what we do might do something with their function, but it reminds us of a critical element. Even with the current M items. We are assessing baseline, not after you’ve made a recommendation after you’ve adjusted a cane after you suggested he moved this, this chair a little bit closer, those are all skilled. Interventions are true performance at the beginning is baseline. That’s true for the entire always. It’s not it’s before I make a suggestion, before I move your pills, before I rearrange your bathroom, before I adjust the that’s all skilled care baseline is what they’re capable of doing before you make any sort of intervention.

Okay. And it’s interesting to note. Now we have some language around the discharge assessment that the five days prior to the discharge is the timeframe for reassessing this function. At the end. That’s an interesting concept for us in home care, because a lot of times that discharge has been how do I make sure I don’t get stuck with the OASIS I’ve I’ve been in organizations and I wish I was making this up where the disciplines give each other fake discharge dates in order to avoid the discharge, because they’re afraid that if they say, you know, I’m going to be done with occupational therapy on Friday, or some sort of magic happens. And every other discipline discharges by Thursday, and now suddenly the, the discharge OASIS has to be done on the OT visit, which was not the original plan. So yeah, that’s an app.

That’s an example of a certain degree of dysfunction, but I’m not sure we’ve necessarily owned a coordinated discharge. We’ve struggled to get the five day window working right from the start of care. Now we’re looking at a five day window with respect to discharge. What does that mean if I’m discharging out of that care within five days prior to the end? And I’m particularly, I’m a therapist and I have some thoughts to share about what their final ability level is here. I can contribute. I should contribute as part of my discipline specific district. When we look at ability, what I think is interesting and specific to our environment is the idea of the environmental impact, but being specific about having the patient perform in different locations within the home. I haven’t seen that before. I think that’s pretty cool because it’s been a long time concern of, okay, he can go from, sit to stand, but from where, I mean, we’ve all gone into that home and you’ve seen the command center cause it’s the one and only chair they can’t actually get out of.

And it’s typically positioned right at the television set. It’s got the trashcan next to, with a little tea stand with the most recent mail and the, in a remote control and Afghans off the back because this individual is not getting out of that chair unless absolutely necessary. And it is the only one that can. So if we’re going to be assessing how they get from sit to stand, they’re saying, don’t make it just one spot. You saw them in, how do they do throughout the home? That’s why it’s walking room to room. That’s why you can’t just say, well, he walked across his living room, but his hallway is full of all kinds of junk that he’s been using as a temporary storage unit. Yeah. How’s he going to get down there? How’s he going to navigate that? That is a huge opportunity in home health to really address the environmental piece.

And we know the patient’s availability can vary from time to time. And so they go back to language. We should be very familiar with at this point of what is true, more than 50% of the time when it comes to quality reporting, that role of what’s your goal has been causing anxiety in terms of how are we going to answer it, but on a larger scale from a home health quality reporting program, the minimum is that one self care or mobility goal must be coded. Now, do not walk away from this webinar saying, I went to this webinar and it says, I only have to put in a goal for one, no, this is language from the guidance manual about the reporting requirement. I would strongly advocate. We put down a goal for every single one of them, but I want to be careful here of how we’re understanding goal.

Okay. Because the goal issue is not that what we put in there is a complete goal statement. It would never, ever pass muster as a therapy goal at all. And not even anybody’s goal because it’s simply a number. Well, what if I’m wrong? I don’t want the nurses putting down a goal that is about something I’m working on as a therapist or I’m a nurse and the therapist are the ones who should put the goals. Okay. Just because it uses the word goal. I really wish it kind of would have used something more about projected outcome or anticipated outcome because that’s really all it’s asking for is for the admitting clinician and collaboration with others as needed to say, what do we realistically think is going to happen going forward? They’re not set in stone. They’re not absolutes. That’s why it specifically says, and I get so excited when I read it that you can put a goal that the patient will be better at discharge.

You can also put a goal number that indicates they stay the same. And yes, you can put a goal number that says that they’ll be at a lower level of function at discharge. Oh gosh. Why would you make a goal? Because it’s not a goal the way you’re trying to make it be from a clinician perspective, this is trying to get inside your head to say, let’s reasonably project. What we think is going to happen. Why does this matter? Other than for, I sound like a crazy person getting this excited about it, because one of the biggest concerns, looking at how we measure the value of home care is how home health compare and value based purchasing and all that. When it comes to function gives the impression that the discussion is all about improvement, only improvement matters. And having sat in some of those conversations and said, well, what about stabilization?

I mean, sometimes getting them stay where they are is a hugely positive outcome. And sometimes decline is not a shock. We knew this was going to happen. We were trying to slow it or delay it as much as possible. Well, our current OASIS doesn’t measure anything that way. There’s nothing in there that allows you to say what you think will happen. Now we will have it. Do I think you’re going to get better at this. Then I’m going to put that kind of number down. Do I think you you’re going to stay the same and I’m going to have therapy involved in therapy is going to bust out the maintenance program so that we stabilize this number. Yes. And in some patients I am realistic and experienced. And I believe that by the time we’re done in some of these areas, it’s very likely that they will be worse than put it.

Why does it matter? Because if we anticipated decline and there is a decline, that makes sense. If we anticipate stabilization and there is stabilization good, okay. If we say stabilization, they improve. That’s interesting where we haven’t been able to capture is, and that’s why they can’t separate it out in our current model very well is how do I know that that decline was anticipated or unanticipated was this someone you really thought was going to get better? And despite everyone’s efforts got worse, that’s a completely different conversation than an anticipated decline. So that’s why these numbers are not about somebody writing therapy. Goals are only therapists can answer these, but really are about, can we be reasonable and put something out there as a placeholder of what we anticipate will happen? Are we going to be a hundred percent, right? I would say, no. Would I challenge you?

If you feel like you always put down improvement or as a reviewer, every time you look at it, I always put improvement. Then we’re going to have to have a conversation because I’m hard pressed to believe we are going to improve every functional thing we find on every one of our patients, forevermore, there are going to be patients that stabilization is the target. There are going to be patients where some of these tasks and decline is going to happen. But what about these non attempted codes? Some of them are pretty straightforward. I mean, patient refused his patient refused. But when you get into non applicable versus not attempted due to medical condition, those two can get a little fuzzy. Code 10, have not attempted due to environmental impotent limitations. I want you to be very cautious here. Okay? If you’re going to choose that response, be prepared to document specifically what those environmental limitations are.

What is going to be very hard to sell is if you put an answer in an em item and then a similar item and GG is now on attempted due to environmental conditions, wait a minute, how did we do it here, but not do it here in the same assessment? Part of my concern is I don’t want the environmental reason to be home health go-to answer because when we start looking at the ambulation assessment and it gets into certain distances, I’m already hearing the, but the patients don’t have that kind of room, or they’ll never going to be able to. Yeah, there’s going to be situations where the environment legitimately precludes this. That’s why we have to speak to the patient specifics as to why, but that can’t be our default. Oh, this looks way too complicated. I’m just going to put that. We don’t want to do that.

We also need to remember that if a patient needs two or more helpers, they’re dependent, that’s straight out of the manual. That’s not a debate 0.2 helpers. You are dependent and yes, we could still use dash. It should be extremely rare in the words of CMS, because we should be able to get enough information, but let’s take a minute and just spend another second on that. Not attempted business about code nine versus code eight, eight. So code nine, the non applicable code is if you have a patient who could not perform the activity at the time of the assessment and could also not perform the activity prior to the current illness, exacerbation or injury. So think about it this way. You go to the home, the patient is a two-story home. They’re stairs, plain as day. The go up the stairs, the patient, no cannot do.

This is unable to do this. I’m not going to do this and tells you, honey, I have not been upstairs in five years. Not applicable is simply saying, there’s no reason to measure a task that we aren’t even going to work on. The patient has no intention of doing it. They didn’t do it before the code eight eight says, if we have a patient who could not perform the activity at the time of the assessment, but could perform it before. So this is where we’re going to have to have a component of this. Be patient report and caregiver report and information from other clinicians and individuals who interacted with this patient. Were they able to do this before? Yes. Are they unable to do it now? Completely unable? Well, we’re not attempting it due to a safety concern or a medical restriction. You can imagine if it’s a medical restriction, you’re going to have to document specifically, you got physician orders restricting it.

If it’s a safety concern, oh, happy day, your documentation can also meet the requirements of the conditions of participation. By speaking very patients specifically about what those safety concerns are. So again, if we’re going to pick the non attempted we need to be prepared to provide additional documentation, to support our response as well as to be able to get a better handle on what are some of those issues, making things ending up in the not attempted category. So you may say, oh my gosh, that was long. And we still haven’t touched the questions. No, there’s a reason. Again, we have GG one 70 C right now, everything we just talked about is the framework of that loan item. We have to make sure we are so familiar with that. That if anybody goes over it again, you’re bored because you already knew all that because all of that is directly applicable. When we start looking at a specific item before we do that, let’s deal with a little tidbit about assistance with our second polling question. If a patient only requires verbal cues to complete a task listed in a GG item safely, which are the following responses apply. So verbal cues only are what’s required. Would they be independent that upper cleanup assistance supervision or touching assistance or partial slash moderate assistance, keep in mind data collection, not clinical. So these are not therapy definitions of these things. Where would verbal cues land?

All right, let’s take a peek at the results. Very well done supervision or touching assistance. I, I always gotta make myself kind of laugh at the choice of touching assistance. To me, that is absolute proof that therapists did not sit in some room and write therapy, sounding questions to add to OASIS because there is no therapist that could, would, or should use a term called touching assistance. My new example that pops in my head is could you imagine if an OT notes said patient bathes with touching assistance? This sounds like call the authorities. This is a special victim unit episode. Ooh, no good. But yes, that is correct. The verbal cues land in that response. Why does that matter? Because if we can get these response levels nailed now again, when we flip the switch to OASIS D, then it becomes only an issue of which task are we looking at.

So what are these levels? And we have to make sure, again, we started, we already invented what the non attempted means. When we look at the ones about it, we need to keep in mind, independent is fully independent. It doesn’t matter when they do it, how they it’s all good and it’s safe, run person, go do it. It’s perfectly fine. Set up or clean up is where we do something ahead of a task or after a task. But the task itself is still independent. It’s kind of the equivalent in the current M items to those responses for grooming and dressing about laying things out for them. So, yep. You can get dressed if I bring you your clothes and put them here is the equivalent here of setup so that I, if I’ve moved the blanket out of the way, if I brought your Walker to you, but you can sit to stand on your own.

And again, safely, that is what set up or clean up is for supervision or touching is where we see rear verbal cues has landed. And then we have the corresponding partial substantial and dependent. And again, as therapists, we know what a substantial, we don’t have to have substantial. Again, data collection, not a detailed therapy assessment. The other thing we noticed is categorically missing from these items as it should be, is it doesn’t have anything about the why the patient needs any sort of help at all. It doesn’t specifically get into the depth of why they couldn’t attempt it either. That’s why our documentation is critical in outlining the reason behind their level of assistance. Because that reason that there’s a challenge is what defines a patient-specific plan of care. It’s not just that you need help, but figuring out why you need help and what we need to do about it.

So once we master the, the framework guidance, once we measure master the response options, now it’s just a question of looking at task. And some of these we have to call out because there’s a few risks involved and the risks are some overlap or potential duplication with currently existing M items. Now you may say, well, there you go, lady, why didn’t they just dump the M version? Why am I answering the same question twice? I knew this again, this is where we take a deep breath in out, and simply let it go. What we have to understand is that impact, put these in here for data collection harmony with post acute. Many of the M items is there in there today have to stay because they’re payment related. So it’s a bad timing and essentially on a much larger scale that put these two things into our tool at the same time, it is what it is.

We just have to watch for risk areas. Eating is straightforward. Oral hygiene is straightforward. Toileting hygiene almost looks for Beetham to the M question. All of this, just breathe. What you’re going to have to make sure here is that we are consistent in our response, not identical because we have completely different scoring guides, but you can’t be putting it down in the M version that the patient, you know, manages it if something’s laid out to them. And then in this version put down not attempted due to safety or medical concerns. Wait a minute, wait a minute. We want to see that consistency. Then we look at showering or bathing self. The one that, that I would circle with a big yellow marker because in GG, it excludes the tubs, the transfer you include the transfer on the inversion. You exclude it on the GG version.

Does that mean I could have different answers? It is, but I wouldn’t expect to see independent in one and completely messed up in the other. Okay. You might see some variation in the responses because of the different scales, but we have to keep in mind, we exclude the transfer here, upper body enroll or body. Well, why didn’t we already did that? Okay. This is getting dressed. It isn’t talking about gathering and getting, because the gathering and getting would be handled by your set up response. Keep that in mind. If I got to bring you your clothes for you to put it on, that’s called set up. That is not independent. And we finally got a separate line item for footwear about time, because we know that this can be challenging for some of our folks that factors in and how they check their feet if they have diabetes.

So it’s good to see that we have a separate role for that. When look at mobility again, I think it’s going to be so much better with these items that we have standardization around the scoring guide. What’s so frustrating and dealing with the OASIS version of the functional items is there is a scoring guide and then it’s a different, and then there’s this many responses and then there’s bed, fast options and chair, fast options. It’s like, could you just make up your mind and go across the board? That’s what we see in GG, that it is once I’ve got this down, it is simply a task specific issue. Now simply a task specific issue means we got to look at what these tasks are and the first few don’t feel so terrible. Rolling to the right and to the left, going from lying to sitting, lying from sit to lying.

Sorry, lying to sit at the side of the bed. That should look familiar. There’s our GG. [inaudible] Sit to stand the ability to come to a standing position from sitting in a chair wheelchair or on the side of the bed. Again, keeping in mind, just cause you can pop off off one surface doesn’t necessarily mean you’re going to be equally good off all these surfaces in your house. Then we look at the chair to bed transfer. We’ve already been dealing with a similar issue on the N items, the toilet transfer. Yep. That is specifically here. It’s not embedded in toileting. Like our other one. This is the toilet transfer issue of just the on and off. So we got to make sure we’re looking at that consistently. A car transfer. Oh, I feel liberated because many of you who I’ve encountered over the many years have heard my orientation to home health seriously was don’t ever document the patient walked on grass because that meant they went outside.

And if they go outside, they’re not home-bound okay. We finally put that to rest by putting car transfer with a goal on this assessment, our patients were never intended to be home hostages. If we eventually are trying to get them out there, this is what we’re going to have to look at. But again, to those who are starting to drift back to look at all the things I’m going to have to have them do, I’m going to have to have them roll in, stand up and get in the shower. Okay. Well, if your person can’t hardly get off the couch, what do you think is going on with the car transfer? Can we take a combination of the struggle of the couch against the daughter’s report of how difficult it was to get him in and out of the car and use that to make a decision about car transfer?

Not an immediate, oh, not attempted, not attempted wait a minute. It was attempted. How do you get home? Do I feel I have enough information? Do I want to on this admitting visit, say, wait a minute. I know PT is coming out within the first couple of days. I want to get with them about it. I know where I’m leaning, but I like to get a second opinion. Yes, you can do that. When you look at the walking though, that’s where I think we’re going to have to unpack this a little bit more because it gets very frustrating to look at 10 feet to 50 feet hundred and 50 feet a stab may through the heart of all the numbers to take, to put in here. It had to be 150. Let’s just clarify for the universe. Again, there is no magic distance that if you walk further than X number of feet, the patient is suddenly no longer.

Home-Bound your note into flame and everybody gets in trouble. Okay? I wish it would have been any other number. Then this emotionally charged version. And I’ve heard people telling me, oh, it’s fine. Cause it’s 150 feet or more whatever we’re going to have to remain diligent. That just because the biggest number on this item is one 50 does not mean it’s the furthest that they can walk with therapy. You need thousands of feet to be functional in the community. There’s research behind it. This is simply capturing snapshots of information. Then we look at going up steps one step four, step 12 steps. Yeah. Okay. In a facility they can have their little areas. Here’s our one step. Here’s our four step here. So our 12 steps, are we going to have to be a bit more creative in home care? You bet. But that doesn’t mean I can’t answer the question.

And then my favorite picking up an object. Why is that my favorite? Cause here I’m already hearing it. Oh, does this mean we’re going to have to have patients pick objects off the floor every time it says a spoon, are we gonna have a spoon? Yeah. I, and I say, well fine. We should have an agency issued spoon. Maybe it should be in the color of the company. We can put a logo on it and carry around these spoons and walk into every home and throw a spoon on the floor and say, go get it. Yeah. I know you can hear the sarcasm in it. You know where I’m going with this, but let’s not go down the ramp to the theater of the absurd. If your patient can barely get out of the chair has failed your fall risk assessment. Do you honestly think it’s a good idea for them to go around, picking up stuff off the floor?

That is part of your judgment. That is not, I have to be a therapist to have that opinion. You couldn’t even get up to let open the door to let me in. You hollered at me to come in to see you. There’s mobility issues already. Now for some patients, oh honey. I pick stuff off the floor. Are you going to want them to demonstrate so you can see, are there some patients you’re going to want them to demonstrate? So you can say, did you just see what happened? Please don’t do that anymore until we work on some other things first. Yes, but this is not. Medicare is sending out standard issue spoons that you must throw on the floor. Or the only answer I’m going to use is not attempted use our contextual judgment about what’s going on with our patients. And then we have wheelchair responses that kind of fall in line with the assessment of the gate issue.

So let’s unpack the gate assessment. First of all, assist assistive devices and adaptive equipment. Don’t affect the code. Okay? There’s no differentiation about this is the response with a piece of equipment, this response without, but it does affect coding. If you think about it in terms of, if I have to go get the equipment for you, if I have to move it out of your way, once you’ve sat down. Now we are looking at set up or cleanup. So I know that there’s been a lot of discussion. That equipment is not a driving force to your answer, which is true. But the management of that equipment, that management of the support of a piece of device absolutely can impact whether or not you’re going with independent or at minimum set up or cleanup. If you have to help manage that. So the assessment of ambulation starts from a standing position.

We’ve already had a separate item about how they stand. So from a standard, can you go 10 feet? This is not going to work. Wait a minute. Aren’t we, the industry that was a huge fans of the tug. I mean, when we were trying to deal with the fall risk assessment, tug was all over the place. Okay. Everybody’s using the tag, use the tug it’s in the EMR. It’s wonderful. If we’re doing the tug, there is no reason we should, we should be immediately going to some sort of environmental, not attempted for 10 feet at a minimum. That one should be doable. 50 feet with two turns. Well, what better place to do that in the home? They got to turn there. You don’t have 50 straight feet. Well, they’re not supposed to for this question. How are they getting into a different room? How are they getting back out?

What are those different directions look like? You can turn twice in the same direction. You can turn in different directions. This is me and I have to measure 50 feet. Oh yes, please do. Because if we use our eyeball, we are going to be, ragingly inconsistent on what this is supposed to be. Then 150 feet or more. Thankfully we’ve had clarification that based on environment, you can turn as much as you need to turn to get to that 150 feet. But again, if the patient can’t do more than the time you did the timed up and go, they barely survived that then we can extrapolate and look at it or we can collaborate and look at it of what we’re going to do with the other questions and then issues about how they do on uneven, how they do on a one step four steps, 12 steps.

Again, it could be that 12 steps is not applicable to them. They don’t have stairs in a home or to leave the home. They do, but they’re not 12. Yeah, I can use non-applicable for those. But we have to stop looking at this list is, oh my gosh, we’re never going to be able to accomplish this. Yes we are. And if we’re unsure as the admitting clinician, we can come back and work on this on a different visit. We can collaborate with another discipline and be able to get to that answer. So as opposed to kind of, oh my gosh, we’re dead. Let’s look at it and say, let’s be reasonable. And let’s remember our clinical judgment is absolutely part of this in terms of how we look at what’s going on with our patients, the final piece. Cause we spent a good chunk on those middle two.

And there’s still more, two more new questions. Yeah. They kind of come as a combo and they’re on transfers and discharges. So these are not a start a care issue. This is all about falls. Have you had any falls and did you get injured by the false seems very clean and it’s very clean at the first glance because I think we’re good with the definition of a fall unintentional change in position coming to rest on the ground floor or onto the next lower surface. Boom. We know this. Okay. We’re all good with that. We know it’s been a challenge in home care environment for years because they may be witnessed or unwitnessed. And if you think patients are fibbing about their function, they’re flat out lying about the falls. I mean, come on, you’ve gone to the home. They had a big old bump on their head.

Oh, nothing happened really. Then the daughter’s there. Do you want me to tell you what happened? I found around the floor. Then they start arguing again. This factors into falls feel like the direct route to the nursing home. So I’m not necessarily going to tell you. So we’ve really had to work hard with our patients to say, listen, I know I’m not asking you this because I mean, or I’m going to rat you out. We are trying to better manage this serious issue. We need to know when you fall. The problem for many, as we look at OASIS D is this expanded definition of a fall that you don’t have to like it. You don’t have to agree with it, but you do have to know what it is and you have to follow it when you’re putting down the number of falls and that’s this intercepted fall business.

So the patient didn’t actually meet the criteria of a fall, but they would have, if they hadn’t grabbed the doorframe, the daughter hadn’t put her, put her hand on his shoulder that you were there on the visit and grabbed the back of their pants. They didn’t technically fall by definition one, but they’re being called an interrupted fall. And those are to be reported in the JJ items. You can see where you go. Hmm. There you go. How are we supposed to manage that piece? Well, falls is a huge issue for our patients. We know this and I think a lot of it is we have to kind of demystify that we’re not worried about your fall risk, because we’re mean spies for your doctor. We are trying to get a better handle on this issue. And so I think we’re going to have to educate and educate hard internally and externally about this interrupted fall idea and not with a, this is dumb.

Okay. It’s frustrating. But it is what it is. And we always have to make sure our concern about falls. Do we see it permeating our functional assessment? I’ve said for years we should do a fall risk assessment before we touch any functional question. I expand that now and did GG. If you are a fall risk, how can you be independent and safe? Would we ever look at a patient and say, yes, you are at risk for falls. I think is your shower by yourself? I just met you. This is baseline. You just got home. My tool says you’re at risk. I think you should go get yourself dressed, get in the shower. And then you’ll make me something to eat and go, no we wouldn’t. We need to take this issue. Seriously, fall risk as a factor in how we score those OASIS items. And we’re going to have to make sure our patients understand that this tracking of falls is not a police state activity.

It is an attempt to better capture data to intentionally work on reducing falls. So we have some strategies here for these new items. Again, focus on GG one 70 C ASAP. If we can get the structure under our belt, it’ll be so much easier under OASIS de emphasize those foundational instructions. Make sure we understand what we’re looking at from an assessment, from a timeframe, how are we going to manage this invitation to collaborate goal setting? Let’s do get away from the who writes, which goals therapy goes, no, what are we projecting? And how comfortable are we in projecting those things for our patients, practicing activities. Now, how are we going to assess it? That reach across the aisle between the nurses and the therapist about tips and strategies and what I look for and what helps in trying to figure out what these patient’s risks are.

And then really drilling in the definition of falls for staff, for patients, for caregivers. Because again, if we were struggling to have patients report, when they actually hit the floor, when they’re left to, can you tell me when you almost hit the floor, if you wouldn’t have grabbed the door, that’s going to take some work to make sure they understand. But the key element here on this section is collaboration, except the invitation, look at how we’re going to manage this because we will be much, much better at this together. So what we’re going to do now is open up the Q and a box. And I actually am the one who opens these to take a look at and see what questions we have. And we have quite a few. So I am going to work my way through these in the time we have.

And if by some chance as you keep putting them in, you go, oh gosh, we’ve run out of time. I am happy to follow up with those outside of this. So if you want to keep firing away in the box while I address them, go ahead. Okay. Is there a timeframe for prior the timeframe in the question does reference that the prior is prior till this illness exacerbation or injury, they have not put any sort of days, weeks, or months to it. That’s the data collection. The timeframe issue comes into play on therapy, specific evaluations to further drill down what this patient’s been dealing with and for how long but the OASIS item does not put any dates or times on it. It’s prior to this illness exacerbation or injury, the term R S I on those slides. And forgive me for not mentioning that specifically, but I wanted to not make so much clutter of the words on those, his response specific instructions on that is the language directly out of the manual governing essentially those particular items in terms of response, specific instructions, as it would imply.

If you have a patient who is unable to pick up an object, because they can barely ambulate safely, do you rate them as eight, eight due to unsafe or, oh, one dependent again, it’s going to be a judgment call. If you are the thought of them picking something up off the floor, horrifies you from a safety standpoint, then I would feel confident in putting down safety concern eight, eight is your reason and elaborate why I wouldn’t say, Hey, you got to pick that up anyway. I think you can do it now. I can deem it’s completely unsafe for you to try if it’s, well, you did it. And if you had some help, like if you drop something and your daughter’s here, and if she helps you it’s safe, then you could put something else. So it really comes down to how severe you think that particular concern is about them doing those things.

Can the patient pick up items from the floor with adaptive equipment? Again, equipment is, is really not a direct factor in any of these items. The question would be then if you’re going to use a Reacher for that kind of thing, that’s fine. We would want to see documentation of the Reacher, but then it becomes the question of, does someone need to bring them the Reacher? Does someone need to put it out of their way? When they’re done? We may be getting into set up or cleanup is the designation because of the access to the piece of assistive equipment that they’re using. But the item guidance is consistent for the sections that it doesn’t necessarily live or die. Only off the equipment issue. If the patient can do the 50 feet, but with rest, how would you rate this physical assistance would be contact art again, in terms of the actual level of assistance, we’d have to actually see the patient to see what it is, but there isn’t any timeframe on them completing that distance.

So we have to look at two, they made the 50 feet with the two turns. They had a pause a couple of times. Then we have to look at this and say they completed it. What level of assistance did they need, if any, to do so. And if it is just, you felt someone needed to be there to supervise. Supervision is a response, and that is still assistance, just like OASIS and the AML items, lumps assistance together. GG spreads them out, but supervision is still a level of assistance. If I have to be there in case or this contact guard piece, you are not independent. So the time it takes you to do it, if they have to take rests or anything is not a penalty, essentially, in terms of choosing a response, I’m unclear on the one question I’ll have to cycle back on that one.

Yes. Okay. It appears with the new OASIS D we are seeing a lot of alignment with the ICF model, specifically G items that reflect activities and participation and environmental factors. Yeah. You’re definitely starting to see the planets come into alignment on some pretty big things in relation to how things are asked, what we’re looking for and the ICF structure, because it is falling into place that this is not about, did you just do this one thing and not kill yourself in the process? It is looking at their, what was their level before? Is this even an applicable task? Was this part of their routine? What did they participate in prior? What are their normal roles and responsibilities? I think by extension, that kind of language needs to start to find its way. If it hasn’t already landed there into our documentation, I think GG opens the door even further to what was this patient doing prior?

What is reasonable for them to expect going forward? What is the patient wants to go back to doing becomes an extension of questions that are framed the way GGR much, much easier than some of the M items? What I’m just going to call a clumsiness of response options that don’t seem to fall very well with some things these really speak toward a vision of going forward and ICF definitely is the, the name of the game in terms of being able to speak to the needs of the home health population in a very structured and formal way, right? Discharge answers are based on the last five days of care. Does this mean that the discharge waste is discharged? Answers could be based on the treatment performed by a PTA. Okay. The answer itself again, when we’re, whoever’s doing the discharge, that person is responsible. So we could not directly say that a PTA visit would be the basis for that discharge assessment.

Okay. That would still be driven by the assessment conducted by that individual on the last visit, by a person who is capable and designated, capable to complete an OASIS. What it does mean is information collected by other team members in that last five days is up for consideration by the discharging clinician. So I would never say a PTA visit two days prior is what the nurse should just use for her answers or his answers, but it can be a consideration. Part of what’s been going on with this patient in the last five days in order to pick the best possible response going forward. So that’s, that’s where we have to be very careful on this collaboration. It’s it’s not going to be a divide and conquer. It is not going to be a look at my note and just figure it out from there. We really need to think about how are we handing off a patient if we’re getting out sooner than another discipline, what are those pieces of information that would guide GG responses?

How do we embed that into a discharge summary? I think it would be valuable to really look at from the therapy side, what goes into that last visit to that summary for the discharge? Could it include pieces of information specifically designated to highlight at that point in time where we believe the answer is because the other piece we have to consider is I may do a therapy visit three days prior to discharge and see this level. And then something happened that I’m unaware of because I’m discharging and the final clinician finds out something different than what I had documented that could happen. So those are things that we want to look at, not just assuming that we can just pull it from other people’s notes, but how are we using it as pieces to consider as opposed to the current model, which very often kind of leaves the person whose name’s on the OASIS, on their own little island and no one else wants to swim over there and help them because it’s all your job. We want to be able to do better at providing consistent information between and amongst disciplines.

There is one only one question still in here. I did not answer because I’m not quite understanding the question, the question as it reads right now, if the individual wants to type it back in is GG one 30. Why is D item missed or skipped? I don’t, I can’t flip it back in front of to look at it. So if you can clarify that or you also can reach out and we’d be to address the question offline, if it’s something that I am just not understanding at the moment. So if there are other questions people would like to type in or thoughts you have about this I know we’re at the end of our time, and even if you were remotely entertained over the course of this, there are other things you have to go do today. So I think this is going to be a discussion that continues as we develop and refine strategies to collect this information. But I want to challenge my peer therapists again, we’ve got to really think about accepting that invitation to collaborate in light of PDGM, because if, if we decline it, we could see ourselves in a much more difficult position in justifying our ongoing involvement with patients when the financial piece is no longer part of the conversation. And I really would like to avoid as much of that as humanly possible. So with that, I’m going to turn it back over to our host. So she can wrap things up for us today.