W

hile most home health agencies are well versed in the relationship between accurate Outcome and Assessment Information Set (OASIS) assessments and reimbursement, many clinicians and administrators are unclear as to how OASIS data can affect important new quality indicators.
       Both federal and state regulations require home care agencies to make ongoing efforts to improve the quality of the care they provide. Typically, agencies call this their quality improvement program. Historically, many agencies focused their quality improvement programs on internal processes rather than on the effects of care on patient outcomes, such as improvement in clinical and functional condition. Part of the reason this was done was because before OASIS, there was no easy way to measure our impact on an individual patient’s health and independence. The Centers for Medicare and Medicaid Services (CMS) understands this and has been saying since OASIS implementation that one of the most important benefits will be objective measures of the quality of care home care agencies provide¹.
       Four years have passed since OASIS data collection and transmission were first required, and by 2004, CMS has described its quality improvement plan in detail. We now know that the CMS plan for quality improvement includes three already fully implemented phases:
• OASIS data collection by home care agencies for all CMS patients
• Outcomes-based quality management (OBQM) reports created for regulators to use when planning surveys
• Outcomes-based quality improvement (OBQI) reports to be used by the public when selecting a home care agency.
       This column will describe the OBQM and OBQI reports and what they mean to your home care agency and to the industry as well.
       CMS generates both the OBQM and OBQI reports by using computers to analyze OASIS data submitted on every patient. To describe it simply, computers compare answers to selected OASIS questions on admission to answers on discharge. Any change is called an outcome measure. Outcome measures can be positive or negative, reflecting patient improvement or decline.
       For the OBQM, the Case Mix, and the Adverse Event reports, CMS selected adverse event indicators, such as the development of a new pressure ulcer or emergent care for injury due to a fall. A list of all 13 adverse events that are monitored can be found at the following CMS site: http://www.cms.hhs.gov/oasis/obqm.asp. CMS generates these reports quarterly for each home care agency and makes them available to the agency’s managers as well as state and federal regulators.
       Although adverse events are sometimes unavoidable, research has shown that they happen less frequently in well organized and motivated home care agencies. For this and other reasons, CMS directed state and federal regulators to download the reports for each agency before visits and to use the information contained in the OBQM reports when shaping the review plan for the agency survey. CMS also suggested that every home care agency review these reports and use the results to shape their quality improvement program.
Because these reports represent an incomplete picture of patients, CMS emphasizes that the aggregated data represents potential adverse events and that agencies should review each case when an adverse event rate on the OBQM report is higher than the national norm. If an agency’s review warrants it, integrating this outcome measure into quality improvement programs would be what the surveyors would likely expect to find when they visit your agency.
       For the OBQI reports, CMS selected outcome measures to help consumers start considering the quality of care when selecting a home care agency. Many OBQI outcome measures are derived from the OASIS dataset and fall into three basic categories:
• Improvement in medical condition
• Adapting to illness and disability
• Avoiding emergency care and hospitalization.
A full list of the OBQI indicators is available at http://www.cms.hhs.gov/ quality/hhqi.
Though integrating these outcome measures into quality improvement programs is not a statutory requirement, CMS is advocating public use of OBQI reports and is making every effort to compare agencies in a community so that quality can be more easily considered when selecting a home care agency.
In the next few columns, we will describe how home care agencies can analyze the OBQM and OBQI reports and integrate the results into quality improvement activities, reduce the risks of survey deficiencies, and use these indicators to grow their business.

Frequently Asked Questions
Question: Should I list a fracture for the home care episode when treating a patient post-fracture repair?
Answer: In most cases, no. If the patient is admitted for surgical aftercare, list the relevant medical diagnosis only if it is still applicable. If it is no longer applicable (e.g., the surgery eliminated the disease or the acute phase has ended), a V code is generally appropriate as the primary diagnosis. The importance of this principle can be seen in the example of hospitalization for the surgical repair of a hip fracture. Coding guidelines stipulate that the acute fracture code may only be used for the initial acute episode of care and is no longer appropriate once the patient is discharged from the hospital to home healthcare.
Question: Can you use V 58.3 (attention to surgical dressings and sutures) for a dehisced wound?
Answer: No. If there is a complication of medical or surgical care, such as infection or dehiscence, select a code specific to the condition rather than a V code. V codes for surgical sites should be reserved for routine post-op surgical care, such as dressing a well approximated incision or care of post-operative Jackson-Pratt drainage tubes.
Question: If the patient is only receiving water flushes to keep a G-tube patent, should M0250 (therapies the patient receives at home) be answered with response #3, “Enteral nutrition (nasogastric, gastrostomy, jejunostomy, or any other artificial entry into the alimentary canal)”?
Answer: No. Response #3 indicates a patient is receiving nutrition via artificial entry. A flush of a feeding tube is not considered to provide nutrition, thus response #4, “none of the above,” would be appropriate.
Question: I have two questions regarding surgical wounds. First, are orthopedic pin sites considered surgical wounds?
Answer: Yes.
Question: Second, when is a surgical incision fully granulating?
Answer: A surgical incision closed with sutures or staples (healing by primary intention) should be called fully granulating when it is fully epithelialized if there are no signs of infection or necrosis and when there is a well defined healing ridge. A surgical incision that has dehisced or was left open to heal by granulation and contraction (healing by secondary intention) should be called fully granulating when it has filled with granulation tissue to the level of surrounding skin if there are no signs of infection or necrosis and if the wound edges are not closed (closed wound edges have the top layers of epidermis rolled over covering the bottom layers, blocking epithelial migration from the edges).
Question: How should M0482 (does this patient have a surgical wound?) be answered for a patient with a post-op vaginal hysterectomy? Since the incision is internal, there are no skin lesions to observe. However, there is a surgical procedure that may require follow up on signs and symptoms of complications that should be monitored on elderly or cognitively impaired patients².
Answer: M0482 should be answered “yes.” Consider this wound “not observable” even though this provides an exception to the rule of what “nonobservable” means (covered by a nonremovable dressing). This option makes the most clinical sense, which will mean (providing that this is the only surgical wound) that M0484 is “zero,” M0486 is “yes,” and M0488 is “NA.”