Since the release of version 6 of PPS Plus - Home Health Edition, the technical team has been hard at work handling installations, support requests and customer suggestions. If you've had an opportunity to speak with one of our technical team members, I hope that the experience more than met your expectations. We strive to provide our customers with the highest level of support to go along with, what we consider to be, the premier tool for clinical data analysis and reporting in the home health industry.

The release of version 6 was a significant milestone, in that it was a return to the drawing board for us. We looked at where the application was and where we wanted it to go. Version 6 is the first step in that direction. Look out for some exciting new features and services from PPS Plus in the future.

With that out of the way, if you're reading this, you're probably wondering what's new in the application. This list isn't all-inclusive, but it does cover the major additions, fixes and improvements to the application since its initial release in December.  If you've been waiting on or looking for a specific feature or bit of functionality that you don't see below, please contact your account manager or a member of our technical staff (find our contact info here). We always welcome your suggestions and critiques.

 - Brad

In my last blog post I discussed some strategies for answering M2250 correctly. I feel as if line item d needs special attention, as it is often scored incorrectly.

The latest set of Q&A's released on January 20 clarifies that "NA" is only appropriate if the patient has NO diagnosis of depression AND the clinician completed an assessment that indicated that the patient has no symptoms of depression. If the patient DOES have a diagnosis of depression, only responses "no" and "yes" are appropriate. If a depression assessment was NOT completed, only responses "no" and "yes" are appropriate. Is it acceptable to have a diagnosis of depression, not be symptomatic and have interventions on the plan of care related to this? Absolutely! Even if your patient does not have a diagnosis of depression (or if he/she does have the diagnosis and is not symptomatic) you can implement depression interventions for monitoring. Again, I cannot emphasize enough the importance of referring to the OASIS manual and OASIS Q&A's for guidance on these OASIS items.

If you have been around home health at all in the past three to four years, there is no doubt that you have heard about P4P (pay for performance). P4P has been in place in other areas of patient care for a couple of years and now it is homecare's time to be rewarded for providing outstanding care to its patients. What has been proposed is that bonus payments be awarded to HHA's (in their respective states) that ranked among the highest performance level in certain patient outcomes.

The HHP4P demonstration was done from January 2008 through December 2009 in seven states: Illinois, Connecticut, Massachusetts, Georgia, Alabama, Tennessee and California. Agencies choosing to participate in the demonstration did so on a voluntary basis. Incentives were made available based on improvement in patient status and actual monetary savings to Medicare.

The results: All participating agencies received their regular Medicare payments without any reductions. Additionally, incentive payments (a total of $15.4 million), is currently being awarded to HHA's that ranked in their respective state's highest performance level or highest level of improvement in patient outcomes. The $15.4 million was based on actual savings to the Medicare program because of better patient outcomes for 2008 only. Additional money will probably be available for outcomes in 2009 also.

What criteria were used in deciding on disbursements? Outcomes from OBQI data were used to evaluate this data. Since this data is automatically submitted for agencies that already submit OASIS data, there was no additional work required for participating agencies. These seven outcome measures were used in the demonstration:

1. Incidence of Acute Care Hospitalization
2. Incidence of Any Emergent Care
3. Improvement in Bathing
4. Improvement in Ambulation/Locomotion
5. Improvement in Transferring
6. Improvement in Status of Surgical Wounds
7. Improvement in Management of Oral Medications

The plan to go forward is currently being formulated whereby P4P will be instituted nationwide for all Medicare HHAs. So if you have wondered why CMS "makes such a big deal" about evaluating your agency's outcomes, wonder no more. $15.4 million looks like a big deal to me.

For more information on the demonstration, click on www.hhp4p.info.

One of the new OASIS-C items that is frequently answered incorrectly is M2250. One of the most helpful tips I have heard is to start on the right and work your way to the left when answering each of the line items in this question. The common mistake is to answer "no" when the appropriate response is "na." Let's take a couple of line items to use as examples:

Let's first look at line "b." If you start on the right, you will see the first option is that the "patient is not diabetic or is bilateral amputee." The next column over is response "yes," indicating that the patient is diabetic and the physician-ordered plan of care does include interventions for diabetic foot care and monitoring for skin lesions. And the last option would be "no," indicating that the patient is diabetic and the physician ordered plan of care does not include diabetic foot care. The common mistake is to start on the left. Clinicians see response "no" and select it for non-diabetic patients, knowing that the plan of care does not include the above mentioned interventions, when the more appropriate response is "na." Misunderstanding the responses in the item can affect process measure data.

Let's take a look at line item "f." A common mistake is to answer "no" for patients that are not at risk for developing pressure ulcers. If you start on the right, the chances of answering incorrectly are minimized. You will find that the first response on the left is that the patient is not assessed to be at risk for pressure ulcers. This is a much more appropriate response if a screening was completed and no risk was found. You then move on to "yes" and "no," indicating that the physician-ordered plan of care includes or does not include prevention interventions.

Again, misunderstanding the responses in the item can affect process measure data. I cannot emphasize enough the importance of referring to the OASIS manual and OASIS Q&A's for guidance on these OASIS items.

Through many years of practicing the profession of nursing, I have learned that one of the best ways to teach is through the process of story telling. So here is our story. The saga began in December of 2008. My husband suffers for frequent gout attacks primarily in joint of his left great toe bunion. He decided he had had enough and wanted to get the bunion fixed, so he went to a local podiatrist who determined the circulation to his left foot was not the greatest. There was no palpable pedal pulse. My husband was referred to a vascular surgeon for further evaluation.

In early 2009, the vascular examination was done, with ultra sound exams of both legs: the left leg had a blocked popliteal aneurysm and the right leg had an open popliteal aneurysm about 4 cm long. Since his body created co-lateral circulation on the left, the doctor focused on the right aneurysm for further treatment: a fem-pop (femoral popliteal) bypass was planned for early August. During the pre-operative assessments and evaluations, a stress test was performed. Results showed an ejection fraction (heart function test) of 35% so further tests were ordered. An angiogram done in August 2009 revealed one coronary artery that was 100% blocked and one that was 95% blocked. With no acute cardiac symptoms whatsoever, it was hard to believe that my husband was scheduled for open heart surgery on September 1, 2009 instead of a bunionectomy!

My husband has been treated for high blood pressure for several years and has prided himself in the fact that he only had to take two medications a day, both for hypertension. After the surgery and the four day hospital stay, my husband came home on Friday to begin the healing and recovery process with all 21 of his new medications!

Having been a home health nurse for several years, I thought I could care for my husband until I ran into the biggest brick wall I had ever faced. He absolutely refused to take his medications. He vehemently said, "I don't need all these pills and I'm not going to take them." In fact, I found pills in his pants pockets and on the floor. I was very anxious for the home health nurse, Mike, to arrive on Sunday. Maybe he could talk some sense into my husband.

At the time, I was the Agency Supervisor for the home health program that was ordered to provide nursing and therapy services. Mike arrived at our house, introduced himself and began creating a miracle. I sat quietly in the room observing, hoping to not intimidate Mike by my presence. Clearly, Mike knew exactly what he was doing and what my husband needed.

First, he listened. He listened to the frustration my husband was feeling about his health decline and about the medication extravaganza. Mike did not make any judgment statements, he just listened.

Then he began to teach: each medication on the list, what its function was and why it was important for the healing process. He used terms such as "pipes," "garden hose," "engine," "spark plugs," "roto rooter" to name a few. I sat in amazement as I witnessed the transformation in my husband, watching him and listening to him, as he verbalized total understanding of the importance of each medication. Mike taught him using language and terms he could understand. Since that Sunday, my husband has been very diligent about taking each medication that has been ordered. I have celebrated with him each time one of the medications is discontinued and encouraged him if another new medication is ordered.

The best practices care plan for oral medication management includes providing a comprehensive medication review at the home health start of care: review the proper administration, side effects, contraindications, food and drug interactions, and adverse reactions; assess the client's ability to self-medicate and compliance with medication use; instruct on correct medication administration including information about the drug, time/frequency, dose, route and what to do if a dose is missed, and storage issues; instruct on signs and symptoms that require immediate attention; instruct on the importance of using one pharmacy and instruct on the importance of taking an updated medication list to each doctor's appointment. Our addition to the best practice care plan for oral medication management:

Listen to the concerns and fears of the client/patient and family in regard to their medications. Teach in terms the client/patient and family can understand, don't read from a drug book or expect understanding from pharmacy printed materials, though these can be used to guide your teaching. Teach using real life examples.

As Brian Parsley wrote in the Newswire article last month, "You can make a difference," and Mike certainly made a difference in my husband's healing journey. The use of best practices and attending to the real life needs of clients/patients and families fosters the creation of a world class service organization.

P.S. My husband's blood pressure is not responding to the medications very well, so a renal ultrasound was ordered. Guess what? Yep, a blocked renal artery. Getting ready for a stent!

Copyright© 2010 LK Publications and Consulting Services. All rights reserved.

Lois Kinsella, a diploma nursing graduate and forty-year veteran of the nursing profession, has extensive experience in long term care program development. After graduating from the University of Wisconsin School of Nursing, Lois developed Cedar Acres Adult Day Center in 1987, one of the original sites in the Robert Wood Johnson Dementia Care and Respite Services Program. A pioneer in Alzheimer's adult daycare, Lois provided leadership as President of the Wisconsin Adult Daycare Associaton for several years and had many opportunities to speak at state and national conferences. Lois is the author of "The Hundred Mile Road," a parable about the acceptance of hospice care. Lois developed and managed Alzheimer's assisted living facilities, an Alzheimer's special care unit in a nursing home, hospice programs, and most recently assisted with the development of ABLE Home Health in Rockford, Illinois, a HomeCare Elite top 500 agency. As Agency Supervisor, Lois provided leadership and guidance for the staff, always emphasixing service excellence through the use of best practices to produce quality outcomes. Currently, Lois is an independent contractor providing forms development, coding and data entry services for home health and other long term care programs.

To learn more about Lois Kinsella and LK Publications and Consulting Services, email l.kinsella@comcast.net.

With the implementation of OASIS-C, reporting of pressures ulcers has changed. Today, I want to focus on the reporting of closed stage III and stage IV pressure ulcers. These two stages of ulcers are considered "full thickness" ulcers, which according to the WOCN guidelines, means there is total loss of epidermis and dermis and damage extends into the subcutaneous tissue and possibly into the muscle or bone. An important point to remember is that stage III and stage IV pressure ulcers can be considered closed when they are fully granulated, but never "fully healed." M1308 asks the clinician to report the current number of unhealed (non epithialized) pressure ulcers at each stage. Because stage III and stage IV pressure ulcers never fully heal as discussed above, it is still appropriate to report closed stage III and stage IV pressure ulcers in M1308. Also remember that reverse staging of stage III and stage IV pressure ulcers is not an appropriate clinical practice according to the National Pressure Ulcer Advisory Panel (NPUAP). Stage III and stage IV pressure ulcers should continue to be reported at its worst stage, even if re-epithelialized. The next items on the OASIS ask the clinician to report the measurements of stage III or stage IV pressure ulcer with the largest surface dimensions. Guidance in the OASIS manual tells the clinician to report 00.0 for all of these items for closed stage III and stage IV pressure ulcers. The final question asked relating to these pressure ulcers addresses the status of the ulcer. Again, the OASIS manual should be referenced for guidance. It tells assessing clinicians that response 0 (newly epithelialized) is the appropriate response for pressure ulcers that have re-epithelialized. As always, the key to ensuring OASIS accuracy is being familiar with the guidance in the OASIS manual and other OASIS resources.

A large part of OASIS-C B1 was revised to reflect comments, suggestions and changes we have seen since its inception in 1999. With the exception of the process measures that were added to account for changes made in research and other studies, most of the OASIS looks as it always did. A clinician that did an OASIS in December last year should have very little difficulty with the layout of the new form. On the other hand, there are several items which were revised to reflect comments and suggestions from the same clinicians. These items (i.e. pain, bathing, transferring) were expanded to include additional options.

• M1220 (Pain) separated option 0 into one option for "pt has no pain" and one option for "pain does not interfere with activity"
• M1830 (Bathing) added an option for a patient unable to utilize tub or shower but could bathe independently at the sink
• M1840 (Toileting transferring) totally removed hygiene and clothing from the previous toileting item
• M1860 (Ambulation/locomotion) separated option 0 into an option for "one handed" device and "two handed" device
• M2020 (Medication) now includes wording for all medications as opposed to all prescribed medications

All of these items have some effect on either reimbursement or outcome measures, so if your clinicians are not yet aware of these changes, now is the time to bring these to their attention.

A detailed review of your OASIS data before submission has always been vitally important. Undetected coding and OASIS errors dramatically affect a homecare agency's reimbursement and outcome percentages.

With the advent of OASIS-C we now have process measures that will be publicly reported in addition to the quality measures previously reported. These new measures will require monitoring as well. Even the most n=highly trained OASIS review professionals are unable to find and correct every mistake in documentation.

Fortunately, there are tools to enhance the review process. Electronic OASIS review software is available that will quickly and thoroughly review your OASIS assessments for coding errors and clinical inconsistencies. It will direct you to specific OASIS items with suggestions for corrections. Review staff can then determine what corrections should be made.

This can dramatically reduce the amount of time it takes for the review process and will make a significant impact on Medicare reimbursement, outcomes and other quality measurs.