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OASIS AvoidingACH

Fall Prevention

ManagingMeds

Care Coordination

How many days are allowed to complete an admission

OASIS?

Five days

Are Significant Changes in Condition (SCIC) OASIS

required to be submitted after Jan. 1, 2008?

Yes. Submitting SCICs is required per regulation but

there is no payment adjustment.

How is the Start of Care (SOC) determined?

It is the first billable visit, regardless of the discipline.

How many clinicians can author an OASIS?

One clinician must complete it, but all

disciplines may collaborate w/ the author.

What does the acronym “OASIS” mean?

Outcome and Assessment Information Set

What is a written, patient-centered plan with a range of

symptoms to report first to the agency, rather than calling

911?

A Patient Emergency Plan

According to the HHQI BPIP for reducing ACH, what

should be reviewed on every visit by every discipline

before leaving the patient’s home?

A Patient Emergency Plan

What assessment other than OASIS is a part of a best practice to reduce

ACH that is completed at the SOC?

Hospitalization Risk Assessment

What are the two most effective BPs that promote early ID of abnormal S&S, intensify patient/caregiver education, reinforce the

patient emergency plan and initiate best practices for medication management?

Front-loading visits and phone monitoring

True or False?

Hospitalization risk assessment should be completed on SOC/ROC and may also be performed at recertification or with significant change in condition (SCIC).

True

Who defines a fall as “an unintentional change in

position resulting in coming to rest at the ground or a

lower level?”

The Missouri Alliance for Home Care

True or False?

“Timed up and Go” screening is an effective assessment to identify persons at risk for falls.

True. Use this assessment as a part of your hospital

risk assessment.

Fall-related injuries accounted for 6%, 3% or

1% of all medical expenditures for people age 65 and older in the

U.S.

6%

What OASIS timeframes are suggested for doing a fall risk

assessment?

SOC, ROC, Recertification

What is the first step in the procedure for accurately

assessing orthostatic hypotension?

Place patient supine for five minutes, obtain BP and HR

This “Criteria for Potentially

Inappropriate Medication Use in Older Adults: Independent of

Diagnosis or Conditions” is

otherwise known as:

Beers Criteria

MO 780 states, “Management of Oral Medications: Patient’s ability to

prepare and take all prescribed oral medications reliably and safely,

including administration of the correct dosage at the appropriate

times/intervals.” The OASIS response selected should reflect the patient’s

ability to:

Take a majority of daily doses correctly on the

day of assessment

Name one element of medication review required by the Conditions of

Participation.

Any of the following are appropriate answers:

• Identify any significant side effects• Significant drug interactions• Duplicate drug therapy and

noncompliance with drug therapy• A process is put in place to ensure that

the patient’s medication regime is evaluated. The same process must be carried out for therapy-only patients.

To accurately assess the patient’s medications the clinician needs to use a combined approach of

interview and __________.

Observation

Your patient had a stroke and is unable to open the

medication bottles or open her pill box. To what discipline would you make a referral?

Occupational Therapy

Name two care providers involved in patient care

transition.

•Hospital to home health•Home health to self-care•Hospital to SNF•SNF to home, PCP or hospice

Any of the following:

When you think of patient transition, what is the purpose

of the handover?

Answers could include:• Exchange Vital Information• Communicate patient status • Exchange information and assume

or pass on responsibility*** Transitional care-coordination

should be the standard of care

True or False? Medication reconciliation only applies to

medications and prescriptions ordered by a doctor.

FalseFalse

Reconciliation includes all medications Reconciliation includes all medications taken by the patient including any taken by the patient including any OTC vitamins, supplements, pain OTC vitamins, supplements, pain

meds, etc.meds, etc.

Name at least one piece of information that should be

included in the Personal Health Record (PHR).

Answers could include:

• Caregiver’s name and phone number• Physician’s name and phone number• Advance Directives• Current Medications and Allergies

The four pillars of care transition activities are

described within the HHQI care coordination best

practice package. What are two of the four pillars?

Answers could include:• Medication self-management• Patient-centered record• Physician follow up• Red flags

Jeopardy Game Template adapted from the work of Susan Collins and Eleanor Savko, District Resource Teachers for Hardin County Schools: www.hardin.k12.ky.us/res_techn/sbjarea/math/MathJeopardy.htm

The End!

Tally up the points to see who your winner is.

Publication MO-08-87-HHThis material was prepared by Primaris, the Medicare Quality Improvement Organization for Missouri, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy