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veryone who knows anyone working in home health knows about the implementation of the Prospective Payment System (PPS) in 2000 and its impact on how home health agencies are paid. What is less clearly understood is the assessment tool on which PPS is based, the Outcome and Assessment Information Set (OASIS). There are actually many similarities between OASIS in home health and the Minimum Data Set (MDS) in long-term care. Following the trail blazed in the "Ask Mabel" column about MDS by Karen Lou Kennedy and Elena Walls, we will attempt to answer your questions in hopes of clearing the clouds obscuring the OASIS from your view. You can call Renee Olszewski, Managing Editor, at (800) 237-7285, extension 209, with your question, or e-mail it to rolszewski@hmpcommunications.com and we will try our best to address it in a future issue.
       OASIS...it is not the sanctuary you once thought! For the home care industry, OASIS represents a comprehensive assessment completed several times during a patient's care (admission, transfer, resumption of care after hospitalization, recertification, and discharge). An example of an outcome measure for OASIS is the patient's ability to improve his or her ambulation throughout our care. This initial article will outline the history of OASIS assessment and review one of the most confusing aspects of OASIS, the significant change in condition (SCIC) reassessment.
       OASIS was developed for the Centers for Medicare and Medicaid Services (CMS) for use by home health agencies. The formulation of these data elements began over 14 years ago with the purpose of measuring patient outcomes and using this information to improve the quality of home healthcare. At its core, this change represents a shift by CMS toward outcomes-based quality management.
       For home health agencies, the implementation of OASIS meant a new type of comprehensive assessment that had to be completed and entered into a computer for transmission to each state. In 2000, these assessments became the basis of payment and are required in order to bill for services. Beginning in 2001, data from these assessments was analyzed by CMS and reported nationwide as adverse events and case-mix reports so home health agencies could use the information for quality improvement efforts.
       In addition to home health agencies using the adverse event reports to improve care, state surveyors are using the reports to target specific patients (with adverse events) for evaluation during surveys. In the future, these outcomes for each home health agency in a community will be made public so consumers (patients, physicians, and discharge planners) can use the information when selecting a home health agency.
       With 85 questions on the start of care, many home health agencies argued that OASIS was too long and too cumbersome and should be revised to decrease time clinicians spent completing forms and to increase time spent providing care. To address this issue, CMS appointed a Technical Expert Panel (TEP) to review all of the OASIS questions and to recommend which questions should be modified or removed from the data set. This process began recently and will continue for a total of 18 months.

Significant Change in Condition (SCIC)
       Under PPS, the payment received by a home health agency for providing all services and supplies to a patient for 60 days can range from $1,100 to $5,200 and is based on the OASIS assessments completed at the start of care and every 60 days thereafter. Under this PPS reimbursement methodology, CMS allows for adjustments in payment based on a change in the patient's condition. This adjustment is applied through the SCIC process and requires completing another OASIS assessment.
       There are three requirements to qualify for a SCIC adjustment. First, there must be a significant change in the patient's condition. This change can be a result of deterioration (a diabetic patient, for example, falling and breaking a hip) or an improvement. The change must be supported by documentation in the clinical notes, and a SCIC OASIS assessment must be completed.
       Second, the change must be unexpected. It cannot be an expected change as the result of the normal course of a disease or condition, an expected change due to deterioration in the patient's condition, or a change due to improvement in the patient's condition as a result of the agency's care.
       The last requirement is the receipt of a new physician order reflecting the change in the treatment plan for the patient. Not all orders received from the physician require a SCIC reassessment. For example, a change in medications or dosage usually is not enough of a change to require a SCIC reassessment, since this may not show a significant change in condition. If all three of these requirements are not met, you do not have a SCIC reassessment. When a SCIC is applied to an episode, the episode is paid in two prorated partial payments. The first payment, based on the original OASIS, covers the time from the beginning of the episode to the last billable visit prior to the date of the SCIC reassessment. The second payment, based on the SCIC reassessment, covers the time from the date of the SCIC reassessment to the last billable visit in the 60-day episode.
       For example, after admission for diabetes, a patient is receiving education. The agency follows this plan of care through a visit on day 27. On day 34, a visit is made, and it is determined the patient is having an exacerbation of his or her congestive heart failure (CHF). The physician is notified, and orders are obtained to modify the treatment plan by adjusting the patient's medications and ordering further teaching on CHF and close monitoring of vital signs and edema. The last visit in this episode occurs on day 54.
       The agency will receive 27/60th payment for the first portion (day 1-27) based on the original OASIS assessment and 21/60th (day 34-54) for the second portion of the episode based on the SCIC reassessment.
       Because of the gap created by using billable visits to determine payment, the adjustment can cause the payment to be less than the originally established amount. If the SCIC is due to a worsening of the patient's condition, CMS gives the agency the option of not applying the SCIC to the episode. If the SCIC is a result of a significant improvement, the agency is required to apply the SCIC to the final claim. Note that CMS has defined an improvement as a decrease in the case-mix weight based on the SCIC reassessment; it is not based on the clinical judgment of the nurse making the assessment.
       In the next issue, we will begin discussing specific OASIS questions based on feedback we receive from readers.