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March 2011Skilled In-service

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March 2011Skilled Inservice

Addressing Outcomes– Results & OASIS trainingCMS - Therapy Documentation Changes MedX - Procedures & PolicyAnticoagulation Safety in HomecareUPDATES & REMINDERS

Face To Face Encounters                Discharge Planning                 Case Conference                Equipment Cleaning        CPR

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SEE ATTACHMENT

Homecare CompareOutcome Data

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(M1730) Depression Screening: Has the patient been screened for depression, using a standardized depression screening tool?

⃞ 0 - No ⃞ 1 - Yes, patient was screened using the

PHQ-2©* scale. (Instructions for this two-question tool: Ask patient: “Over the last two weeks, how often have you been bothered by any of the following problems”)

Oasis Training- Depression

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(M2250) Plan of Care Synopsis: (Check only one box in each row.) Does the physician-ordered plan of care include the following:

a. Patient-specific parameters for notifying physician of changes in vital signs or other clinical findings ◦ ⃞0 ◦ ⃞1 ◦ ⃞na ◦ Physician has chosen not to establish patient-specific parameters for this patient. Agency will use

standardized clinical guidelines accessible for all care providers to reference

b. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care ◦ ⃞0 ◦ ⃞1 ◦ ⃞na ◦ Patient is not diabetic or is bilateral amputee

c. Falls prevention interventions ◦ ⃞0 ◦ ⃞1 ◦ ⃞na

Patient is not assessed to be at risk for falls

Oasis Training – POC Synopsis

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(M2250) Plan of Care Synopsis: (Check only one box in each row.) Does the physician-ordered plan of care include the following:

d. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for current treatment ◦ ⃞0 ◦ ⃞1 ◦ ⃞na ◦ Patient has no diagnosis or symptoms of depression

e. Intervention(s) to monitor and mitigate pain ◦ ⃞0 ◦ ⃞1 ◦ ⃞na ◦ No pain identified

f. Intervention(s) to prevent pressure ulcers ◦ ⃞0 ◦ ⃞1 ◦ ⃞na ◦ Patient is not assessed to be at risk for pressure ulcers

g. Pressure ulcer treatment based on principles of moist wound healing OR order for treatment based on moist wound healing has been requested from physician ◦ ⃞0 ◦ ⃞1 ◦ ⃞na ◦ Patient has no pressure ulcers with need for moist wound healing

Oasis Training –POC Synopsis

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(M2400) Intervention Synopsis: (Check only one box in each row.) Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented?

a. Diabetic foot care including monitoring for the presence of skin lesions on the lower extremities and patient/caregiver education on proper foot care

⃞0 ⃞1 ⃞na Patient is not diabetic or is bilateral amputee b. Falls prevention interventions ⃞0 ⃞1 ⃞na Formal multi-factor Fall Risk Assessment indicates the patient was not at risk for falls since the last OASIS

assessment c. Depression intervention(s) such as medication, referral for other treatment, or a monitoring plan for

current treatment ⃞0 ⃞1 ⃞na Formal assessment indicates patient did not meet criteria for depression AND patient did not have diagnosis

of depression since the last OASIS assessment

Oasis Training - Interventions

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(M2400) Intervention Synopsis: (Check only one box in each row.) Since the previous OASIS assessment, were the following interventions BOTH included in the physician-ordered plan of care AND implemented?

d. Intervention(s) to monitor and mitigate pain ⃞0 ⃞1 ⃞na Formal assessment did not indicate pain since the last OASIS assessment e. Intervention(s) to prevent pressure ulcers ⃞0 ⃞1 ⃞na Formal assessment indicates the patient was not at risk of pressure ulcers since the last OASIS assessment f. Pressure ulcer treatment based on principles of moist wound healing ⃞0 ⃞1 ⃞na Dressings that support the principles of moist wound healing not indicated for this patient’s pressure ulcers

OR patient has no pressure ulcers with need for moist wound healing

Oasis Training -Interventions

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Oasis Guidance Manual

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Release is April 1, 2011 Per Healthwyse, updates to

documentation will be available at this time

A qualified therapist (PT/OT/ST) must perform at 30 day service or the 13th visit, again at the 19th visit to write up a functional reassessment

PTA and COTA cannot make functional assessment visits at 30 day, 13th visit or 19th visit.

Reassessment must include summary of care, functional reassessment, and progress patient has made toward 60-day Medicare episode.

Medicare DocumentationChanges

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Assessment is clinical judgment that examines objective data

1. Gait: Must describe quality- what deficits you are seeing and why you are indispensible for that gait analysis

2. Tasks: Tasks should be individualized: Do not put IADLS and ADLs; what are each of them specifically?

3. Oral Motor: What does 65-80% improved mean to the patient’s function?

Movement away from quantity and move toward quality of functional tasks that are meaningful to patient in their home. (more free text)

Overall: In every visit, from first one to last, determine each time “why” the patient is being seen. If that question does not have a clear answer, the plan of care needs to be reassessed.

Medicare DocumentationChanges

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Policy is in review and will be available online soon. You will be notified when available.

MEDX manual available today for all therapists.

Key components of policy:◦ Therapist must complete competency on this

modality prior to using.◦ Order must include settings for duration, Joules,

pulsing, and console setting.◦ Cleaning log is required each Monday. MEDX

cleaning log available online –See Intranet.

MedX

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MUST put into 485 careplan.

Example: Intervention: PT to assess patient’s pain and use MedEx to decrease patient’s pain while improving household mobility.Goal: LTG: Patient to ambulate modified independently 150’ out to car using walker and pain <3/10 in R knee.

Mike Kerry has Operating Guide and Treatment Manual in his office in Supplies.

Must put protocol that is in the 485 under the “exercise” tab.

The Cleaning Logs: MedX cleaning logs must be

cleaned after each patient use.

MedX cleaning logs must be emailed of faxed to Mike Kerry every Monday and even if you DID NOT use, must write “not used for week of ‘x’” and turn that sheet in every Monday.

makerry@homecareforyou.com

MEDX

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An Estimated 3Million People in the US oral anticoagulant therapy annually.

Anticoagulation Therapy is delivered as Short Term (6 weeks or less) or Long Term

( frequently an indefinite timeline.)

Anticoagulation Safety In Home Care

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Adverse Events Related to inadequate or excessive coagulation include:◦ CVA◦ PE◦ DVT◦ VTE◦ Hemorrhage◦ GI Bleed

Anticoagulation Safety In Home Care

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The following Risk Factors may pre-dispose a patient for bleeding and should necessitate additional monitoring while on OAT.◦ Age 65 or older◦ History of CVA◦ History of GI Bleed◦ Recent MI◦ HCT <30%◦ Creatinine over 1.5mg/dL◦ Diabetes Mellitus

Anticoagulation Safety In Home Care

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Other Factors that may influence the therapeutic window include:◦ Other medications◦ Concurrent medication changes◦ Renal function◦ Body Weight◦ Age◦ Dietary Habits◦ Alcohol Consumption◦ Smoking Habits◦ Temperature Changes

Anticoagulation Safety In Home Care

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Generally Accepted TARGET INR based on DX.

Anticoagulation Safety In Home Care

Indication INR Range Target INR

Prophylaxis of Venous Thrombosis, Tx of Thrombosis, TX embolism, Prevention of Embolism, AMI to prevent systemic embolism, Non mechanical Heart Valves, Afib,

2.0-3.0 2.5

Mechanical Valves, AMI to prevent recurrence, Certain thrombosis and antiphospholipid syndrome

2.5 -3.5 3.0

Bi-leaflet Mechanical Valve in Aortic Position 2.0 -3.0 2.5

Orthopedic (THR,TKR,) 1.5 – 2.5 1.9

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Vegetables◦ • Broccoli◦ • Cabbage◦ • Brussel sprouts◦ • Green onions◦ • Avocado

Meats◦ • Beef liver◦ • Pork liver

Leafy Greens◦ • Iceberg lettuce◦ • Green leaf lettuces◦ • Spinach◦ • Turnip greens◦ • Parsley◦ • Endive◦ • Kale◦ • Collard greens

Other◦ • Mayonnaise◦ • Margarine◦ • Canola Oil◦ • Soybean Oil

Anticoagulation Safety In Home CareFoods High in Vitamin K

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Ibuprofen◦ • Advil® ◦ • Midol®◦ • Excedrin IB®◦ • Motrin®◦ • Haltran® ◦ • Nuprin®◦ • Mediprin® ◦ • Pamprin HB

naproxen◦ • Aleve®

◦ • Anaprox®

◦ • Naprosyn®

ANY PRODUCT THAT CONTAINS ASPIRIN.

cimetidine◦ • Tagamet HB®

famotidine◦ • Pepcid AC®

Herbal Products◦ danshen ◦ ginseng◦ garlic ◦ green tea◦ ginkgo

kava kava

Anticoagulation Safety In Home CareMedications that can affect INR

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The Safety and Effectiveness of OAT depends critically on maintaining the INR within a narrow therapeutic window.

Due to the importance of this therapeutic window, NGHHC requires strict adherence to this policy surrounding use of the INRatio devise.

NGHHC requires that PT/INR that are completed with the INRatio machine have laboratory validation if:

The results are greater than 4.5 The results are less than 1.5

Anticoagulation Safety In Home Care

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The Role of the Clinician…◦ Review SOC Call log from Intake. F2F information

will be found in this call log.◦ If a F2F appointment is needed – work with your

patient to schedule.◦ Communicate to your CC when the appointment

is scheduled.◦ Patient’s must understand without this

appointment and documentation of the appointment ~ Medicare services will end.

Face To Face EncountersF2F

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CPR that is approved by the American Heart Association/ American Red Cross is required by 3/31/2011. See Melinda Jewell if you want to sign up for a session at NGHHC.

Case Conferences Due every 30 days. Discharge Planning should be in every SOC

narrative and at least weekly in your note. Equipment Cleaning Logs ( MEDX. PT/INR)

due every Monday.

Updates & Reminders

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All Skilled Staff Thursday, May 19th Pre-work on Nightingale University will be required

prior to attending. Skills “check off” will be scheduled individually

Beginning May 02nd.

Annual Skills FairCompetency Evaluations