Secondary Logo

Journal Logo

OASIS-C Importance of Accurate Pressure Ulcer Assessment and Management in Home Healthcare: Part II

FARREN, MARY RN, MSN, CWOCN; MARTELLY-KEBREAU, YANICK MSN, RN, CWOCN

Home Healthcare Nurse: The Journal for the Home Care and Hospice Professional: November-December 2011 - Volume 29 - Issue 10 - p 599–609
doi: 10.1097/NHH.0b013e3182345647
medicare matters
Free
CE

This is Part II of an article describing an educational initiative by certified wound, ostomy, and continence nurses to strengthen clinical and documentation skills related to the Outcome and Assessment Information Set (OASIS)-C M items. Part I, published in Home Healthcare Nurse in April 2011 (vol. 29, issue 4, pp. 233–245), reviewed the fundamentals of wound assessment, wound healing, and OASIS-C wound terminology. The focus of this article is to show the connection between the clinical assessment, interventions, documentation, and the impact on quality outcomes and reimbursement. Because of the scope of this topic and the emphasis given to the problem of pressure ulcers by varying sectors of healthcare, including hospitals and nursing homes, this article focuses on pressure ulcers and OASIS-C.

Mary Farren, RN, MSN, CWOCN, is a Certified Wound, Ostomy, and Continence Nurse at the Visiting Nurse Service of New York, New York, New York.

Yanick Martelly-Kebreau, MSN, RN, CWOCN, is a Certified Wound, Ostomy, and Continence Nurse, Visiting Nurse Service of New York, New York, New York.

For more than 200 additional continuing nursing education articles on home healthcare topics, go to nursingcenter.com/ce.

The author and planners disclose no financial relationships pertaining to this article.

Address for correspondence: Mary Farren, RN, MSN, CWOCN (mary.farren@vnsny.org) or Yanick Martelly-Kebreau, MSN, RN, CWOCN, 1250 Broadway, New York, NY 10001 (yanick.martelly@vnsny.org or 43977@VNSNY.org).

Back to Top | Article Outline

Overview

Figure

Figure

The Center for Medicare and Medicaid Services (CMS) measures and reports the quality of patient care in home care via the Outcome and Assessment Information Set (OASIS)-C data set. The OASIS-C data set incorporates process-of-care items related to evidence-based practices and outcome items, which report the change in the patient's health status at specific time points. OASIS-C data items are also the source of Potentially Avoidable Events reports, which display incidence rates for infrequently occurring untoward events (outcomes) (CMS, 2010b). Patients' outcomes are based on many variables, including some that are not under the home health agency's (HHA's) control. OASIS-C process of care items "allow for measurement of processes of care that are particularly relevant for HHAs and under agency control" (CMS, 2010a). Process measures in OASIS-C are classified into seven domains: timely care, care coordination, patient assessment, care planning, care plan implementation, education, and prevention (CMS, 2010a). Except for timeliness of care, a Medicare condition of participation, CMS does not mandate the adoption of process measures, but HHAs that incorporate them in the delivery of patient care are "given credit" for what they do to promote good outcomes (CMS, 2010a). Not all the process measures apply to every patient; therefore, a 100% score on the reports is not expected for every measure. There are 47 process measures that are calculated and included in reports to the HHA to be used for quality improvement/performance activities. Thirteen of these measures are endorsed by the National Quality Forum (NQF) and are publicly reported on the Home Health Compare Web site (CMS, 2010a). Of those 13, there are four measures that are integumentary or wound related. (For reference to the specific M items, please refer to Appendix.)

Back to Top | Article Outline

Focus on the Integumentary M Items

M1300: Pressure Ulcer Assessment

Best practice suggests that patients in all settings should be screened for risk of pressure ulcers, and the National Pressure Ulcer Advisory Panel (NPUAP) and the European Pressure Advisory Panel (EPUAP) recommend a complete skin assessment should be mandated in all healthcare settings "on admission, and repeat as regularly and as frequently as required by the individual's condition" (EPUAP/NPUAP, 2009, p. 11). M1300 identifies whether the clinician followed best practice and assessed for the risk of developing pressure ulcers by either using a standardized and validated pressure ulcer risk assessment tool or evaluating clinical factors such as mobility, incontinence, nutrition, and the like. CMS does not endorse a particular risk assessment tool. M1302 Risk of Developing Pressure Ulcers reports the results of the assessment (CMS, 2011). M1300 is a process of care item and measures the "percentage of home health episodes of care in which the patient was assessed for risk of developing pressure ulcers at start/resumption of care" (CMS, 2010a).

Clinical actions follow assessments. Depending on the area of the assessment that identified risk, interventions to reduce and prevent risk for pressure ulcer development or further deterioration of a pressure ulcer when present can include, for example, teaching patients or caregivers to recognize changes in skin color or temperature. Other examples are incontinence management strategies, placement of support surfaces, and referral to other disciplines/services. Documenting the interventions in the clinical record including the patient and caregiver willingness and ability to comply support evidence-based practice strategies in the delivery of skilled care. These clinical actions should also be reported in M2250 Plan of Care (POC) Synopsis at start of care (SOC)/resumption of care (ROC) and M2400 Intervention Synopsis at Transfer to Inpatient Facility and/or discharge from the agency.

Conducting a thorough skin assessment on the initial visit is crucial to collecting and reporting accurate data. Failure to identify the presence of pressure ulcers at SOC or ROC that are identified at a later time point will attribute the ulcer to the HHA and contribute to reporting an "increase in number of unhealed pressure ulcers"—which is a "potentially avoidable event"—an OBQI report, and it is a publicly reported outcome measure (CMS, 2010a).

Back to Top | Article Outline

M1306: Unhealed Pressure Ulcer at Stage II or Higher

Assess the patient's skin for the presence of pressure ulcers. Select YES if there is a serum-filled blister or an open Stage II, or a Stage III or IV pressure ulcer, open or closed regardless how long, and/or an unstageable pressure ulcer observed. See Figures 1–6 for examples of pressure ulcers reported in this item.

Figure

Figure

Figure

Figure

Back to Top | Article Outline

M1307: The Oldest Nonepithelialized Stage II Pressure Ulcer That Is Present at Discharge

This information is collected at discharge from the HHA but not upon discharge to an inpatient facility. Figure 1 depicts examples of Stage II pressure ulcers reported in this item: note the partial-thickness loss of dermis presents as a shallow open ulcer with red/pink tissue without slough or eschar or intact or open/ruptured serumfilled blisters.

M1307 tracks data about (a) the identification of the oldest nonepithelialized (open) Stage II pressure ulcer that is present at discharge; (b) the length of time that the ulcer remained unhealed during the episode of care; and (c) the identification of Stage II pressure ulcers that developed under care (CMS, 2011).

Stage II pressure ulcers (see Figure 1) that remain unhealed for more than 30 days are reported to the agency by CMS as "potentially avoidable events" (CMS, 2010b).

It is the responsibility of the clinician to provide accurate assessment and OASIS-C data collection information. To answer M1307 accurately, the clinician must know when the Stage II pressure ulcer first appeared and also know when the most previous OASIS assessment was conducted. The most previous OASIS assessment identifies the beginning of the quality episode for which this item is reported (CMS, 2011).

Back to Top | Article Outline

M1308: Current Number of Unhealed (Nonepithelialized) Pressure Ulcers at Each Stage

Refer to Figures 1–6 for examples of pressure ulcers reported in this item. This particular question has been the source of confusion for some clinicians as the terminology can be confusing. The term "unhealed" includes all Stages II, III, IV, and unstageable pressure ulcers that are open (nonepithelialized) and also includes Stages III and IV pressure ulcers that have closed (reepithelialized). The closed Stages III and IV pressure ulcers are also considered "unhealed" and they never regain full tensile strength. There is always an "aha" moment when clinicians finally understand this terminology. When the terminology is not understood, the clinician does not include closed Stage III or IV pressure ulcers when completing this item. Failure to identify and include these closed ulcers can have ramifications for clinical outcomes and reimbursement. OASIS data are also used to compute calculations for services and reimbursement that includes supplies for wound care, another reason why accurate assessment is imperative.

M1308 is used in quality reporting to identify an increase in the number of pressure ulcers. There are two columns in M1308 item. (See Appendix and Tables 1 and 2.) Column 1 is completed at SOC, ROC, follow-up, and discharge from the agency. In this column, the clinician reports the number of pressure ulcers at each stage. Stage I is excluded from reporting in M1308.

Table 1

Table 1

Table 2

Table 2

Column 2 is completed at the OASIS follow-up and discharge time points. When there are one or more pressure ulcers listed in a row of Column 1, the same row of Column 2 will be completed answering this question "How many of the ulcers listed in the same row of Column 1 were also present at the most recent of SOC/ROC?" It is irrelevant if the ulcer(s) represented in Column 1 was the same or a different stage at the SOC or ROC. What is relevant is the history of the ulcer(s) in the same row of Column 1. A pressure ulcer that was present at SOC/ROC that has either deteriorated or improved is still the "same" pressure ulcer and is not a "new" ulcer. If a row in Column 1 is "0," then the same row in Column 2 must also be "0." If the number of ulcers reported in Column 1 is greater than in Column 2, it indicates new pressure ulcer(s) developed since the SOC or ROC (CMS, 2011). See the sidebar for tips on completing M1308s.

Back to Top | Article Outline

M1320: The Status of the Most Problematic (Observable) Pressure Ulcer

All pressure ulcers except Stage I are considered in this item. Refer to Figures 1–3, 5, and 6. To identify the status or degree of closure visible in the most problematic observable pressure ulcer (CMS, 2011) requires the ability to identify tissue types and structures observed at the time of wound assessment, knowledge of and correct application of the WOCN Guidance on OASIS-C Integumentary Items document (WOCN, 2009), and critical thinking.

For example, a female patient is incontinent of urine and stool and has a Stage II pressure ulcer on the coccyx that is being treated with a hydrocolloid. Like the other dressings that the spouse said were used before, the hydrocolloid is not adhering and requires several changes in a day. The patient also has a Stage IV pressure ulcer on the right trochanter being treated effectively with Negative Pressure Wound Therapy (NPWT). In this case, although the ulcer on the coccyx is a lower stage, it may be the most problematic because it is more difficult to manage.

The healing status of an unstageable pressure ulcer except for one under a nonremovable dressing or device (M1308 d.1) can be identified. Following the WOCN Guidance on OASIS-C Integumentary Items, a pressure ulcer with more than 25% avascular tissue is statused as not healing (WOCN, 2009). A suspected deep tissue injury (DTI) (M1308 d.3) is not covered with new epithelial tissue and granulation tissue is not visible; therefore, the most appropriate status is "not healing" (CMS, 2011).

Accuracy when "statusing" wounds is important. This item affects the agency's Outcome-Based Quality Monitoring Program Carefully monitoring the healing status of wounds will reduce emergent care for wound infections, deteriorating wound status, which is also a Potentially Avoidable Event (CMS, 2010b).

Back to Top | Article Outline

M1324: Stage of the Most Problematic Unhealed (Observable) Pressure Ulcer

The stage of a pressure ulcer is based on the NPUAP (2007) updated staging system (http://www.npuap.org/pr2.htm), which identifies the definitions for each stage of the pressure ulcer. Stages I to IV pressure ulcers and closed Stages III and IV pressure ulcers are unhealed and can be observed/visualized. As the wound base of a pressure ulcer reported in M1308 d.1, d.2, and d.3 cannot be observed or visualized, it is "unstageable" and the correct response selection is "NA: No observable pressure ulcer or unhealed pressure ulcer." As the focus of this item is identifying the stage of a pressure ulcer, when there are both stageable and unstageable pressure ulcers present, the clinician will consider the stageable ulcer as the most problematic when completing M1324. Unstageable pressure ulcers are considered the most problematic when they are the only type present.

Back to Top | Article Outline

POC Synopsis

The POC synopsis as a process measure captures best practice and identifies if the HHA plans to include evidence-based clinical actions in the POC/485 that promote good patient outcomes. A best practice is reported when the clinician collaborates with the physician regarding assessment findings and plans for care, which result in a verbal or written order within the OASIS-C assessment time frame (within 5 days after the SOC and 2 days of the ROC) that becomes a part of the POC/485 (CMS, 2011). Examples of such "best practices" are establishing specific parameters to report changes in the patient's condition, foot care monitoring and education on proper foot care to patients with diabetes, specific interventions for prevention of pressure ulcers, treatment of pressure ulcers, and so on (CMS, 2011). Refer to Appendix for POC Synopsis M 2250.

Select "Yes" when verbal or written orders for the specific plans/interventions are received from the physician within the OASIS-C assessment time frame and subsequently included in the POC. Select "na" if the criterion in the "not applicable" column is met. Select "No" when you cannot select "Yes" or "na"; that is when the best-practice intervention from Column I is not included in the POC, or a physician's order for the best-practice intervention was not obtained or was not discussed and confirmed with the physician before including the order on the POC/485. Also select "No" when the orders were requested from the physician but not received within the assessment time frame (CMS, 2011). Documentation of the rationale for any "no" response is expected in the clinical record.

A "No" answer does not indicate best practice; therefore, it is important that the clinician select responses for M2250 considering if the item applies to that particular patient. If it does not, select "na"; if it is applicable, select "Yes" or "No," depending on whether orders for the best-practice interventions have been obtained and received. For example, an HHA patient with a Braden Score of 22 is not assessed to be at risk for the development of pressure ulcer based on the scoring mechanism of the tool; therefore, interventions to prevent pressure ulcers are not warranted. The clinician may be inclined to select "No" for M2250f because it appears as a first choice. However, when there are no physician orders obtained for the POC to reduce the risk of pressure ulcers, the correct response is "na" because the assessment indicated the patient was not at risk. Conducting an assessment to determine the patient is not at risk is an appropriate clinical action and also a best practice.

Back to Top | Article Outline

M2400 Intervention Synopsis

This item is also used to capture the HHA's use of best practices during the quality episode; it identifies if the POC included specific interventions and if these interventions were implemented by any agency clinician at the time of or since the previous OASIS-C assessment. "It is anticipated that processes of care implemented according to evidence-based guidelines will ultimately lead to better clinical outcomes" (CMS, OASIS-C Guidance Manual, 2011). Refer to Appendix, POC Synopsis M2400.

As with M2250 POC Synopsis, best practice is identified with "Yes" and "na" responses. Select "Yes" when the intervention is included in the physician ordered POC and implemented at the time of or since the previous OASIS assessment (CMS, 2011). Select "na" when the conditions in the "not applicable" column are met. When the intervention is appropriate for the patient, select "No" when you cannot select "Yes" or "na," that is if at the time of or since the previous OASIS assessment, the intervention was ordered and not implemented, or if the intervention was implemented but not ordered. Documentation of the rationale for any "no" response is expected in the clinical record.

Back to Top | Article Outline

Summary

OASIS data are used to produce quality reports for agencies and for public reporting on the Medicare Home Health Compare Web site, as well as to determine payment. "In any data-driven system, the quality of the output is only as good as the quality of the data input" (CMS, 2011). It was found that for the clinician to answer the integumentary M items accurately, they had to be knowledgeable in wound assessment and wound healing physiology, which was reviewed in Part I of this two-part article. In Part II, the focus was on the M items with clarifications about some terms and concepts that cause the staff to struggle. For years, HHAs were held accountable for not showing improvement in patients' outcomes when they had very little—if any—control on variables that can interfere with the achievement of these outcomes. Some of these variables can include the challenges of the patient's or caregiver's willingness or ability to adhere to the POC, obtaining approval from the insurance or healthcare provider for the need for DME items such as mattress support surfaces that would aid in reducing risk for pressure ulcer development and also the impact of comorbid conditions and clinical circumstances in which a pressure ulcer may be unavoidable (Wound, Ostomy and Continence Nurses Society Position Statement on Avoidable Versus Unavoidable Pressure Ulcers, 2009).

OASIS-C introduces process measures that are based on "best practices" aimed at promoting good outcomes. HHAs are not required to adopt these process measures at this time, but there is evidence that incorporating them in practice will lead to improvement in patient outcomes (CMS, 2010a).

The use of wound photographs with each of the M items was a successful technique employed to help clinicians "see what we were saying" and to use as a reference when reflecting on the critical questions developed to guide the assessment of the patient's wound. Clinicians are urged to remain abreast of changes in the OASIS-C guidance, which is frequently updated.

Questions and answers to OASIS-C questions are published quarterly on the CMS Web site https://www.qtso.com/hhadownload.html (QIES Technical Support office, OASIS Download, n.d.).

Back to Top | Article Outline

Acknowledgment

The authors acknowledge and thank Rhonda Will, RN, BS, COS-C, HCS-D, assistant director, OASIS Competency Institute, Fazzi Associates, and the many contributors at the Visiting Nurse Service of New York whose comprehensive and coordinated work on OASIS-C made this wound care education initiative possible.

Figure

Figure

Figure

Figure

Figure

Figure

Figure

Figure

Back to Top | Article Outline

Tips on Completing M1308

  • Perform a thorough skin assessment on all patients.
  • Do not just ask if there is a pressure ulcer—SEE FOR YOURSELF!
  • Inquire about all scars, especially the ones on/near bony prominences or suspected to be pressure-related.
  • Complete the assessment within the allotted time period for reporting OASIS data (within 5 days after the SOC or 2 days of the ROC) (CMS, 2011), and on a day that the wound is to be assessed.
  • Document all closed Stages III and IV pressure ulcers.
  • Enter "0" if there are no pressure ulcers at that stage.
  • At follow-up and discharge from the agency:
    1. First complete Column 1.
    2. If Column 1 is "0," Column 2 must also be "0."
    3. If there is a wound in Column 1:
      1. Find out if it was present at SOC/ROC or the date it developed.
      2. Include the ulcer in the "count" for the same row of Column 2 if the ulcer was present at SOC or ROC.
      3. A pressure ulcer that was present at SOC or ROC that has either deteriorated or improved is still the "same" pressure ulcer; it is not a new ulcer. For example, a Stage II ulcer on the sacrum at SOC that has deteriorated to a Stage IV at Follow-up (recertification) will be reported on OASIS-C M 1308 as in Table 1 and 2.

Note. OASIS = Outcome and Assessment Information Set; ROC = resumption of care; SOC = start of care.

Source: Authors.

Back to Top | Article Outline

REFERENCES

from Centers for Medicare and Medicaid Services. (2010a, March). OASIS PBQI/process measures. Retrieved
from Centers for Medicare and Medicaid Services. (2010b). Outcome-based qualitymonitoring (OBQM) manual. Retrieved
from Centers for Medicare and Medicaid Services, OASIS-C Guidance Manual (2011, January). Retrieved
from European Pressure Ulcer Advisory Panel and National Pressure Ulcer Advisory Panel. (2009). Pressure ulcer prevention quick reference guide. Retrieved
from National Pressure Ulcer Advisory Panel. (2007). Updated staging system, pressure ulcer stages revised by NPUAP. Retrieved
from QIES Technical Support Office, OASIS Download. (n.d.) CMS Q & A. Retrieved (find Wound Ostomy Continence Nurse Society. (2009).
    Wound, Ostomy and Continence Nurses Society Position Statement on Avoidable Versus Unavoidable Pressure Ulcers. (2009, July/August). Journal of WOCN, 36(4), 378–381.
    © 2011 Lippincott Williams & Wilkins, Inc.