The Social Security Act’s section 1899B(b)(1)(B)(i) requires that post-acute care (PAC) providers submit standardized patient data for “Functional status, such as mobility and self care at admission to a PAC provider and before discharge from a PAC provider”. CMS tasked RTI to review existing PAC assessments, create the Continuity Assessment Record and Evaluation (CARE) Item Set to address the need, and analyze its accuracy. It was determined that these GG0130 and GG0170 would be most appropriate in addressing this requirement. So the home health GG-section was added to the OASIS-D data set.
Be in a suitable area to assess the patient for each activity. If you are testing walking, make sure you are in an area where your patient can safely walk the number of steps necessary. If there is no such area, talk with your clinical manager about alternate means to assess performance. Allow the patient the use of any assistive devices they would normally use to complete the activity.
Assess the level of assistance the patient requires to safely perform the activity. Use the most accurate score possible based on the following scale.
If your patient is able to perform the activity, start at the top:
Does the patient need any assistance (physical, verbal/non-verbal cueing, setup/clean-up) to complete the activity? If no, stop and select 06 – Independent. If yes, continue to next step.
Does the patient need only setup or clean-up assistance? If yes, then select 05 – Setup or clean-up assistance. If no, continue to next step.
Does the patient need only verbal/non-verbal cueing, or steadying/touching assistance? If yes, select 04 – Supervision or touching assistance. If no, continue to next step.
Does the patient need lifting assistance or trunk support with the helper providing LESS than half the effort? If yes, select 03 – Partial/moderate assistance. If no, continue to next step.
Does the patient need lifting assistance or trunk support with the helper providing MORE than half of the effort? If yes, select 02 – Substantial/maximal assistance. If no, continue to next step.
Does the helper provide ALL the effort to complete the activity OR is the assistance of two or more helpers required? If yes, select 01 – Dependent.
If the activity was not attempted, select one of the following reasons:
- 07 – Patient refused – The patient refused to complete the activity
- 09 – Not applicable – Not attempted and the patient did not perform this activity prior to the current illness, exacerbation or injury.
- 10 – Not attempted due to environmental limitations (e.g., lack of equipment, weather constraints)
- 88 – Not attempted due to medical conditions or safety concerns
Allow your patient to complete the activity with whatever assistive device(s) they would normally use. Score your responses based on the safe execution of the task with the use of the device and what degree of additional assistance is needed from a helper.
If the patient has cognitive impairments or limitations, take these into consideration when assessing the level of help required to safely complete the activity.
Collaborate with other clinicians on the care team and talk with the patient’s family and other caregivers. CMS encourages a multidisciplinary assessment. Just keep in mind that you are ultimately responsible for the responses you document.
Your scoring should be defensible, corroborated by other documentation in the chart and a consistent picture of the patient’s condition. Make sure your documentation supports your decision.
Strategies at Start of Care
At start of care, capture the patient’s baseline status keeping in mind the degree of assistance the patient requires to safely complete the activity. Thoughtfully choose discharge goals that are reasonably attainable, support your provision of skilled services and reflect how likely your patient will be to comply with your treatment plan.
If you are providing maintenance therapy, the performance level and the discharge goal may be the same number since your interventions are focused on preventing a decline in the patient’s function. If you are providing restorative/rehabilitative services aimed at that activity, your discharge goal should generally reflect improvement from the performance number. Remember that if performance is rated 1-6, improvement would be projected by choosing a higher number than the performance number.
If your patient had a recent facility stay, consider reaching out to the facility for information about the patient’s typical level of function. The SNF MDS, the IRF-PAI, the LTCH CARE, as well as the Home Health OASIS all contain items GG0130 and GG0170 so you can all “speak the same language”.
Since other facilities are using the same questions with the same scale to assess your patient’s function, CMS will probably review assessments across the post-acute care spectrum. If your start of care assessment paints a completely different picture than the facility’s discharge assessment, you’re going to get an ADR to review your chart. Again, make sure your documentation is defensible.
Strategies at Recertification or Resumption of Care
For assessments after the start of care, review your patient’s progress from the prior assessment AND from the start of care. If you have been providing interventions to address the activity and your focus has been rehabilitative/restorative care but there is no improvement, make sure your documentation explains the reasons for the lack of progress or even decline in function. Was there an injury, medical procedure or fall that effected the patient’s ability to perform the activity? Did the patient refuse to comply with the treatment plan? If so, what interventions did you provide to address the compliance problem?
For your convenience, therapyBOSS will carry over performance responses from the prior assessment. It is your responsibility to review these responses and update them as your patient’s function changes.
Strategies at Discharge
When you complete your discharge assessment, check back to the start of care discharge goals. Did you meet them? If you fell short, your documentation should include an explanation for unachieved functional goals. To make things a little easier, therapyBOSS will copy over the performance responses from the OASIS immediately before the current assessment. You will need to update responses as appropriate.
Keep in mind that the discharge performance includes the last 5 days of care so be sure to code the patient’s USUAL amount of assistance. This way your agency won’t be penalized if your patient is just having a bad day on their discharge visit.
How therapyBOSS Helps
therapyBOSS has long allowed to complete OASIS notes electronically on any device together with other pertinent notes for every treatment event, including assessments, follow-up visits, reassessments, supervisories, discharges, and more. Fast electronic documentation and quick access to previously completed notes helps facilitate accurate completion of the OASIS dataset for home health therapists and nurses.
Taking this further, therapyBOSS additionally loads responses from your prior OASIS! For GG0130 and GG0170 it carries forward the performance response, letting you know right away where the patient stood when last assessed. This will allow you to evaluate, at a glance, whether your patient has improved or declined since the last OASIS.
For More Information
Contact your home health agency or therapy company when questions come up – especially clinical questions. Chapter 3 of the OASIS guidance manual gives detailed strategies and examples for each OASIS question and QIES OASIS Q&As is a compilation of user questions and could provide help. As always, you can contact therapyBOSS support by clicking on Contact support on the web or the question mark in the app. To submit questions about this article, connect with us on Facebook.
The addition of GG0130 and GG0170 on The Skilled Nursing Facility Minimum Data Set (MDS), the Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI), the Long Term Care Hospital Continuity Assessment Record Evaluations Tool (LTCH CARE), and the Home Health Outcome and Assessment Information Set (OASIS) will ensure that CMS can track assessed patient function across the continuum of PAC settings. This will help to identify entities whose treatment plans provide greater improvement or decline in similar patient demographic populations. It will also help to identify entities who try to “game the system” by manipulating assessment data in an attempt to show greater improvement overall.