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SHOW ME: Enhancing OASIS Functional Assessment

Vol. 27 no. 1 January 2009 Home Healthcare Nurse19 SHOW ME: Enhancing OASIS Functional AssessmentMARY CURRY NARAYAN, MSN, RN, HHCNS-BC, COS-C, JOISE SALGADO, OTRL, AND ANN VANVOORHIS, PT, HCS-DHave you ever felt that thesearch for Outcome and Assess-ment Information Set ( OASIS )accuracy is endless? In 2007,the administrators and clinicalmanagers at ProfessionalHealthcare Resources, Inc.(PHRI) looked at the agency sfunctional outcome indicators(improvement in bathing, trans-ferring, ambulation/locomotion,and management of medica-tions) and shook our again, the outcomes didnot seem to capture our intu-itive sense of the degree towhich our patients actually didfunctionally improve under ourcare. Why were these outcomesnot better?Our home health agency has8 offices in the Maryland, Vir-ginia, and the metro DC week, our administratorsand clinical managers meet todiscuss quality issues via aconference call.

vol. 27 • no. 1 • January 2009 Home Healthcare Nurse 19 SHOW ME: Enhancing OASIS Functional Assessment MARY CURRY NARAYAN, MSN, RN, HHCNS-BC, COS-C, JOISE SALGADO, OTRL,AND ANN VANVOORHIS, PT, HCS-D

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Transcription of SHOW ME: Enhancing OASIS Functional Assessment

1 Vol. 27 no. 1 January 2009 Home Healthcare Nurse19 SHOW ME: Enhancing OASIS Functional AssessmentMARY CURRY NARAYAN, MSN, RN, HHCNS-BC, COS-C, JOISE SALGADO, OTRL, AND ANN VANVOORHIS, PT, HCS-DHave you ever felt that thesearch for Outcome and Assess-ment Information Set ( OASIS )accuracy is endless? In 2007,the administrators and clinicalmanagers at ProfessionalHealthcare Resources, Inc.(PHRI) looked at the agency sfunctional outcome indicators(improvement in bathing, trans-ferring, ambulation/locomotion,and management of medica-tions) and shook our again, the outcomes didnot seem to capture our intu-itive sense of the degree towhich our patients actually didfunctionally improve under ourcare. Why were these outcomesnot better?Our home health agency has8 offices in the Maryland, Vir-ginia, and the metro DC week, our administratorsand clinical managers meet todiscuss quality issues via aconference call.

2 As we re-viewed the most recent HomeHealth Compare outcomes foreach office, we considered pos-sible causes for outcome re-ports that did not match clini-cians reports of clinical managers ofPHRI review their teams pa-tient outcomes at patients do not improve,the managers frequently dis-cuss the outcomes with the cli-than a therapist would atadmission. Nurses tend tooverestimate patients Functional abilities at ad-mission, whereas thera-pists seem to capture thepatient s Functional statusadequately at interrater variabilityleads to an erroneous noimprovement when pa-tients Functional abilitiesactually have improved identifying these prob-lems, PHRI selected a smallperformance improvementteam consisting of a nurse, aphysical therapist, and an oc-cupational therapist (the au-thors of this article) to developaperformance improvementplan.

3 This article describesSHOW ME, the 1-page tool andprocess we developed to ad-dress these problems. But first,let s frame our solution interms of why Medicare be-lieves Functional assessmentand outcomes are so crucial togood patient ofFunctional Assessmentand Care PlanningTo have a high quality of life athome, home health patientsneed to perform their ADLs andIADLs (Table 1). Functional inde-nicians involved in the care ofthose patients. Now theyvoiced their opinions aboutpossible reasons for inaccu-rate outcomes. Comments in-cluded the following: Nurses are not skilled atperforming Functional as-sessments. They still relymore on interview than ob-servation despite beingtold they must ask the pa-tient to demonstrate his orher activities of daily living(ADLs) and instrumentalactivities of daily living(IADLs) before answeringOASIS M0640-M0810.

4 Even therapists fail to per-forman adequate assess-ment in some functionalareas, especially neglectingto assess patients abilityto select and administeroral medications safely. When admitting a patient,some therapists do not ad-equately assess patients ability to ambulate safelyon all surfaces they needto transverse in the homeand to transportation,which they do capture atdischarge. Nurses frequently admitpatients who are dis-charged by often score patients Functional status higher 20 Home Healthcare is associated withhealth and well-being (Graf,2006). Yet, many of home care spatients come to us with a re-cent decline in Functional one third of all hospi-talized patients older than 70years are discharged from thehospital with a decline in theirability to meet their ADL needs(Brown, Friedkin, & Inouye,2004).

5 Because of the limitedmobility imposed on patientsfor their illness/injury while inthe hospital, patients can be-come rapidly , a significant decondi-tioning (decrease in musclemass causing muscle weak-ness) can occur within 2 daysof a patient s hospitalization(Hirsch, Sommers, Olsen,Jullen, & Winograd, 1990, as re-ported in Graf, 2006).Home care nurses and thera-pists have a professional andethical responsibility to iden-tify Functional deficits accu-rately so they can appropri-ately develop careplans thatreturn patients to the highestfunctional level possible. Toidentify Functional deficits,nurses and therapists mustperform an appropriate assess-ment of patients abilities sothey know what rehab servicesand exercise programs willhelp them reach their patients deserve goodassessments, which lead togood care planning and thus ul-timately to good outcomes.

6 Al-though our agencies adminis-trators and performanceimprovement directors want usto achieve good outcomes, ourpatients are even more in-vested in the outcomes its recent series on bestpractice geriatric assessmenttools, the American Journal ofNursinghighlighted the value ofassessing the ADLs and IADLsof older patients. When pa-tients show signs of functionaldecline, the authors suggestthat clinicians use the KatzIndex of Independence in Activ-ities of Daily Living and theLawton Instrumental Activitiesof Daily Living Scale to helpthem intervene appropriately(Graff, 2008; Wallace & Shelkey,2008). The OASIS Functional as-sessment incorporates the as-sessment parameters of thesebest practice ME Tool To resolve the inadequate func-tional assessments and theproblems with interrater relia-bility our managers identified,we developed SHOW ME (Fig-ure 1).

7 With the SHOW MEmnemonic, clinicians can eas-ily remember what they actu-ally must observe patients dobefore they answer the variousOASIS Functional Activities of Daily Living (ADLs)M0640 Grooming M0650 Dressing upper body M0660 Dressing lower body M0670 Bathing M0680 Toileting M0690 Transferring M0700 Ambulation/locomotionM0710 Eating/feedingOASIS Instrumental Activities of Daily Living (IADLs)M0720 Meal preparation M0730 TransportationM0740 Laundry M0750 HousekeepingM0760 ShoppingM0770 Telephone useM0780-800 Medication management M0810 Equipment management Functional Quality Indicators Exhibited on Home Health Compare Web Site M0670 Bathing M0690 Transferring M0700 Ambulation/locomotionM0780 Oral medication management Table 1. ADLs and CMS, 27 no. 1 January 2009 Home Healthcare Nurse21 SShirt & Shoes Observe patient don/doff shirt and a shoe/sock M0650 M0660 HHike to bathroom Observe transfer on/off bedside commode/toilet Observe transfer in/out tub/shower Ask patient to reach head, lower back, & toesM0670M0680M0690 OOrganization and use of grooming utensils Shaving equipment Comb/brush ToothbrushM0640 WWalk through home to all areas needed for ADLs/IADLs Bedroom, kitchen, laundry, access to transportation Include all surfaces even & uneven surfaces, stairs & steps Note cleanliness of clothes/home & ask who does laundry/ housekeepingM0700M0740M0750 MMedications Observe where meds kept & device/techniques used to take meds as ordered Observe ability to select right med, right dose.

8 Right timeM0780M0790M0800 EEating and making meals Access to/use of refrigerator and microwave or stove Carry meal to table Chew and swallow adequatelyM0710 M0720 Figure Assessment : SHOW ME tool. 2008 Professional Healthcare Resources, Supervision watching performance Verbal cueing watching and talking through Assistance Physical contact Minimal: 25%-50% (touching) Moderate: 50%-75% (holding) Maximal: 75%-100% (carrying) Ability to perform during an entire 24-hour period,in patient s own environment,as influenced by Physical factors (endurance, strength, pain, fatigue, dyspnea, vision/sensory, etc.) Cognitive factors (memory, orientation, etc.) Psychological factors (fear, depression, psychosis, etc.) Environmental factors (arrangement of home, stairs, clutter, facilities available) Medical contraindications (restrictions on driving, stair climbing, etc.)

9 SAFELY!!!!!(If performing the activity, but not safely, increase Functional deficit) If Functional Deficits, Plan Care! Achieve better outcomes for our patients with referrals!!! Functional AssessmentSHOW ME Deficits in ambulation or transferring PT Deficits in ADLs or IADLs OT Deficits in IADLs, no caregiver MSW Deficits in eating, related to swallowing SLP Deficits in medication management RN Difficulty with grooming, dressing, bathing HHA22 Home Healthcare tool describes the activ-ities the clinician must observefor each Functional OASIS ques-tion. We included observationrequirements for almost all theM0 questions, from the groom-ing question (M0640) to themanagement of medications(M0800).To cue clinicians further con-cerning the elements of a goodfunctional Assessment , we in-cluded several other elementson the 1-page SHOW ME we discovered thatmany nurses do not know thedefinitions therapists use for supervision, verbal cuing, and assistance, we includedthe definitions of these terms inthe tool.

10 We also included a re-minder about the many factorsthat can impair a patient s func-tional abilities: physical, cogni-tive, and psychological disabili-ties or deficits as well asenvironmental barriers andmedical contraindications. Westressed the importance of giv-ing a patient who is doing an ac-tivity, but not doing it safely, alower Functional score (highernumerical score)because to as-sess and truly capture a pa-tient s needs, the lower func-tional score is indeed theappropriate , we reminded our cli-nicians that if the patient hasdeficits in any of the functionalassessment areas, especially inperforming ADLs and medica-tion management, the clinicianshould request an order fromthe physician for a referral toappropriate team members. Ifwe do not get the right teammembers involved, the patientwill not have the benefit of theservices that would help himor her achieve maximum func-tional introduce our staff tothis new quality improvementtool, we printed the SHOW MEtool, placing it in a page pro-tector sleeve for each held in-services duringteam meetings at each of ouroffices, at which we explainedhow to use SHOW ME and illus-trated its use with patient sce-narios.


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