Rehabilitation Team: Improve OASIS Scoring Through Collaboration

Overall, as healthcare professionals we should communicate or collaborate with other disciplines to fully identify the needs of a patient, accurately score the OASIS items, and to adjust treatment plans depending on the status of the patient as identified by each of the disciplines involved. We know this can be a challenge at times, especially when multiple disciplines are ordered. It can be difficult to coordinate treatment, and to communicate and collaborate when we have limited face to face encounters with one another.

We can agree that each discipline has its own scope of expertise. There is no one discipline that can be the expert in all aspects of healthcare or be the expert in all of the areas of intervention that a patient may need. Given this, it is most advantageous to match each of our patient’s needs to the discipline that is the “expert” for that need. Having multiple disciplines involved with a patient’s care is an opportunity that we need to take advantage of in order to achieve the optimal outcomes for our patients.

We can and should utilize the expertise of each ordered discipline to assist with patient assessment. CMS recently made this clarification in the OASIS Guidance Manual that will be effective 1/11/18: “Although one clinician must take responsibility for the comprehensive assessment, collaboration with the patient, caregivers, and other health care personnel, including the physician, pharmacists, and /or other agency staff is appropriate. For items requiring patient assessment, the collaborating healthcare providers must have had direct contact with the patient”. Given that each discipline has their area of expertise, collaboration can more accurately score the OASIS items as each discipline sees the patient from a different perspective and focus. Physical therapists from a mobility standpoint, occupational therapists from the perspective of daily living activities, speech-language pathologists from a communication and cognitive view, and nurses from a medical understanding. After a clinician performs the Initial assessment, collaboration can and should take place to assure that a complete assessment is conducted and that accurate data is collected. Examples of this would be an occupational therapist collaborating with a nurse on medication management issues for a patient with cognitive impairments, or a nurse collaborating with a physical therapist to accurately score items related to mobility and locomotion.

To minimize barriers for collaboration, to maximize efficiency in accurate OASIS scoring, and to enable clinicians to share their expertise in a meaningful way, it is helpful to have processes in place that will support a team approach. There are a couple of processes that have been utilized in our home care agencies that we will provide for your consideration.

OASIS Collaboration Process #1: Co-SOC assessments. For patients who are referred for combined multi-disciplinary interventions, it can be beneficial to have 2 disciplines present and overlapping at the start of care assessment in order to put together a collaborative care plan, and to also obtain optimal scoring accuracy. Agencies may utilize this Co-SOC opportunity with a majority of their orthopedic referrals, scheduling with 2 disciplines, where the case managing nurse or PT arrives at the visit 30 minutes or more ahead of the secondary discipline in order to get the patient opened to services. These visits may end up combining a nurse and a therapist(s) or two therapy disciplines at the visit. Generally, after the history and medical status is gathered by both disciplines jointly, the assessment tasks can be divided for completion by the most appropriate clinician. Significant findings are shared and observed by both clinicians. Keeping this visit fluid and interactive is a team skill which can have the added benefit of selling the patient on the value of a having an agency team working on her behalf.

You may find that your more seasoned clinicians have an easier time putting all of the pieces together during an assessment visit. There are some scoring concepts that are standard so that only individualized nuances may need to be discussed between the clinicians when validating OASIS scores. For example, it is common that a patient who needs training in safe mobility will also require assistance for safe medication management. This overarching effect of functional safety in OASIS scoring will be threaded through the OASIS items. For your newer clinicians, nurses or therapists, some of these concepts may still need to be taught or reinforced. The Co-SOC is a perfect opportunity to utilize the skills of the seasoned clinician for ongoing field training. An agency may use a paper document that can be handed off to the primary clinician at the end of a visit, or that can be e-mailed, for the purpose of sharing scoring recommendations and rationale when that is helpful for the team members. Having a template on the form which includes the Functional OASIS scores would be appropriate for standardizing the information gathering and sharing process.

OASIS Collaboration Process #2: Evaluation Template for Functional OASIS Scoring Feedback. This process promotes team care planning by providing all secondarily involved disciplines an opportunity to report their findings and recommendations back to the SOC (or ROC) clinician/discipline.
For an agency lacking an internal software system with which to share scoring feedback, one may utilize an e-mail template in which the appropriate rehab professionals (PT/OT/SLP) provide feedback to the SOC clinician based on their evaluation findings. The only feedback to be provided would be those items in which a discrepancy is observed. In such cases, change recommendations are provided, and the SOC OASIS scoring may be modified at the discretion of the SOC clinician. If further assessment is warranted by the SOC clinician, and it is completed within the 5 day window of a SOC, a change of the M0090 item, Date Assessment Completed, would be appropriate, in order to align with the date of the updated score(s).

An Evaluation template in which specific OASIS items are listed for the rehab clinicians to attend to in their assessments would offer a helpful reminder and a convenient location in which feedback could be entered when it is indicated. It may equally be appropriate for a rehab clinician to support the SOC clinician’s functional scoring, and to enter this feedback on the same template. How reaffirming for the team members! The following data points are ones that may be ideal to place on the feedback list:

    M2020 Management of Oral Medications
    Clinical Severity
    M1242 Frequency of Pain*
    M1400 Dyspnea*
    M1740 Cognitive, Behavioral, Psychiatric Symptoms
    Functional Status
    M1810 Dressing, Upper Body
    M1820 Dressing, Lower Body
    M1830 Bathing*
    M1840 Toilet Transferring
    M1850 Transferring*
    M1860 Locomotion*
    GG0170C 1. SOC/ROC Performance
    GG0170C 2. Discharge Goal
    M2012 a-g. Types and Sources of Assistance
    Service Utilization
    M2200 Therapy Need
*Publicly reported STAR rating outcomes

Your agency may already have systems and processes in place to help support team care planning and related OASIS scoring accuracy. If you do not have something in place yet, the new CMS guidance which supports collaboration may be the prompt you were looking for to set this opportunity in motion as, referencing an article from the APTA’s Home Health Section, there are some initial studies showing an improvement in OASIS outcomes and a reduction in re-hospitalization with implementing a structured collaborating interprofessional team.