P R O C E E D I N G S

(Whereupon, the proceedings commenced at 9:05 a.m.)

CHAIRMAN WOOD: Good morning. This is the first regional hearing by the Secretary's Advisory Committee on Regulatory Reform, the second meeting of this group. The first meeting was in Washington in January, at which time I think we had an extremely good start on this large task in front of us.

Since then, the Committee has broken into subcommittees. There are four of those subcommittees, they're making very good progress in identifying solutions to regulatory problems.

We're pleased today to be in Miami and we have on our agenda for this hearing three important topics. Our goal is to hear about the issues related to each of these, but also to derive a set of recommendations for reduction in the regulatory burden related to these.

I'm particularly pleased to begin this meeting with comments and the ability to welcome senior leaders from the Department of Health and Human Services. The Secretary has given us his strong commitment to the activities that we have in front of us and has actually articulated his expectations that we will have recommendations for him as we move throughout our activities over the next several months.

To begin this morning I'm very privileged to introduce to you Ms. Josefina Carbonell, the Assistant Secretary from the Administration on Aging from Health and Human Services.

For those of you who are from Miami I probably don't need to make any other introductions, but I was quite privileged to hear from her earlier about her career, and so I'm especially happy that you'll begin by sharing some comments with us this morning.

MS. CARBONELL: Thank you, Mr. Chairman, members of the Advisory Committee, it's indeed a pleasure and wonderful to welcome you to sunny Miami, particularly for those folks that are -- I know that have been a little bit frigid out there, but this is my home town, and it's a pleasure to come back here as a member of this team and this administration to welcome you to Miami.

Again, Secretary Thompson is very much interested in this administration and having his team meet and speak with the people we serve and the people who work on the front lines to provide care and services to our patients and to our consumers, and he's passionate about providing the best in health and human services to people in all walks of life, and he's more than interested in hearing comments and thoughts about issues that are important to real people, and he's truly committed to forming partnerships at the federal, state and local levels.

I come from the local community. I spent over 29 years in fact right here in Miami providing services to many seniors in this community, and I know firsthand of the importance of having regulations that are not burdensome, but helpful; regulations that enable states and local providers to provide more effective and efficient services to our consumers and to the people that we're serving.

At the Administration on Aging I have been conducting a series of listening sessions across the country to hear how we can make our programs more effective for our elders. The administration is conducting a comprehensive review and update of all our current regulations in order to implement the provisions of the recently reauthorized Older Americans Act.

In fact, next week I will be accompanied by Secretary Thompson in Denver, Colorado for my eighth listening session, and in April we're looking forward to being in Boise, Idaho for a rural listening session in that part of the country.

This administration, again, the Department of Health and Human Services, are doing things differently, and isn't that a fresh idea. Listening sessions I've conducted present a really distinct opportunity to better serve our consumers and to implement our services in rural, urban and suburban areas by listening to the concerns and challenges faced by them. Through the listening sessions we look to insure that all of our consumers, including states, area agencies on aging, tribal organizations, service providers and older persons and their caregivers are invited and are heard.

As a former service provider in this community I understand the significance of being heard, and that's what this Advisory Committee's hearings are all about. We want to assure we're developing and implementing regulations that will serve their intended purpose, while at the same time improving the quality of those services.

We have a new way of doing business to best meet the needs of our consumers. At the Department of Health and Human Services we're one department, and we're breaking down barriers across the department, across the government and across the nation. We're working to integrate health and social supporting services to build bridges between the two systems to enhance coordination among ourselves and to make access easier for the consumer. We're working to coordinate better at the top level so that we can better integrate services down to the local level, which is really where the action is.

At the Administration on Aging we're redirecting our efforts away from being regulatory in the traditional sense of the term to providing more technical assistance and guidance. We have entered into partnerships with states and providers to enhance quality and performance outcomes while maintaining accountability. This approach will certainly result in improved services for older people and their caregivers. This approach is consistent with the one being used for the President's new Freedom Initiative, and it has involved a comprehensive review of the barriers that existed and prevented accesses to services for disabled individuals. This regulatory reform initiative is really designed to remove those regulations that are burdensome and barriers to the provision of quality healthcare across our communities.

The aging programs and those under the Department of Health and Human Services involve the deliver of home and community-based social and supportive services. As we work to build those bridges in healthcare and social services, we will apply the same principles used in the regulatory reform initiative.

The approach of these listening sessions and throughout the department is consistent with the Secretary's goal for this initiative, to reduce rules that burden healthcare and actually are unable to respond faster to the concerns of healthcare providers, state and local governments and individual Americans and families who are affected by those Health and Human Service Rules.

This is the right approach to restore common sense to the provision of healthcare and services. I know how frustrating it can be for dedicated service providers who want to do a good job for the consumer to be impaired because of the paperwork or because the rules are just too much to handle. It produces the opposite result that none of us wants. It causes the focus to be on the paper and not on the people.

Secretary Thompson, in light of September 11^th, has charged all of us with looking to eliminate barriers that interfere with the public and private sectors' ability to respond to and prepare for emergencies.

On February 11^th, just a few weeks ago, I testified in New York City before the Senate Special Committee on Aging. The hearing was designed to explore what improvements can be made to prepare better for responding and caring for older people in future disasters or emergencies. The comments from the hearings included the need to be able to cross-program and agency lines, to bypass paperwork requirements and to be flexible enough to provide what individual consumers need. In short, the message was that in extraordinary times we need extraordinary responses.

At the Administration on Aging we're working with our National Aging Resource Provider Network, many of whom are Medicaid providers, also, to identify regulations for review by this Advisory Committee. Again, the goal is to improve quality, service and access for consumers.

At the Administration on Aging and all our HHS partners we are here, and we have a tremendous opportunity to address missed opportunities to improve quality care for older adults and their caregivers in home, community and facility-based settings.

We're focusing on providing information for older adults, and about improving that information about health and healthcare in a culturally proficient way to help ensure better understanding, given the ethnic diversity of the older population, as well as the increasing numbers of older adults with limited English proficiency.

We support research to document the outcomes of direct nutrition interventions, such as the new medical nutrition therapy benefits under Medicare for diabetes and renal disease prior to dialysis. We want to highlight the importance of adequate nutrition and hydration to help keep older adults functional, whether in a community setting, such as providing one or two meals a day and access to medical nutrition therapy, or in a nursing home to effectively manage chronic diseases, prevent pressure ulcers or minimize hospitalization.

It is also of great importance to improve training to nursing home personnel, especially certified nursing assistants, and in communities like Miami where diversity is prevalent in the workforce we must consider the opportunity to provide training in other languages to ensure quality of services ultimately to our elders.

It is an honor to address your first regional hearing in my hometown, and I join you today in listening to the public comments so that together we can merge health and human services into a seamless system that provides really high quality services for all people of this nation.

Thank you very much. Gracias.

CHAIRMAN WOOD: And I will remind Committee members to not to do what I did. Make sure when you speak that your microphones are on.

I'm also pleased to welcome Mr. Ruben King-Shaw, also a homecoming of sorts, and, again, I don't need to make for members of the audience from Miami a great introduction, but I'm pleased that he's here today in his role as the Deputy Administrator and the Chief Operating Officer of the Centers for Medicare and Medicaid Services.

He has been with us actually in our first meeting in Washington, and I know that his efforts in this regard will help us to be productive as a Committee.

So, Ruben, I'm happy to have you along with us today.

MR. KING-SHAW: Well, bienvenidos, Miami. For those who've not heard that -- I hope you hear that a lot while you're here. Welcome to Miami. I'm told that -- that there are instant interpretive services available here in the room. If you would want one of the receivers to get the interpretation on an instantaneous basis, then please see the folks here in the room who are in the back.

But I really do hope that you take advantage of your time here in Miami, not just, you know, to enjoy the fine food and the beautiful scenery and the great weather and the music and all the things that make Miami special, but you also get a chance to see some of the delivery system and the character and the personality and the culture of the place. It's a fascinating city that's a rich blend of rhythms and people and histories and culture, and the way that effects healthcare is a very powerful thing, and I think here in Miami and South Florida people have learned that it's not just a matter of caring for the sick, it's responding to people according to the needs of the body, the condition of the mind and, with respect, for the soul, and it's that last part that I think Miami has excelled in, understanding that people have a soul and a culture and traditions that affect their view of healthcare and of family and of institutions and of care and caregivers.

And so when you think about a regulatory reform discussion and you're thinking about what rules we have, I would ask you to think, and I think the Secretary would appreciate us thinking about where these rules came from, and are they not just consistent with the standard practice of healthcare or of social service or of reimbursement, but do they also connect -- do they also support this sense of caring with dignity and aging with dignity and imparting not just health, but understanding and wellness.

And to the extent that our rules do all the great things that we need them to do in program integrity and outcome measurement and financing of care and all those things that you would expect a government to do, let us also make sure that those rules that we discuss, that we review, that we change or that we propose also connect with the individual, the patient, the beneficiary, and in so doing, the caregiver or the practitioner, without whom we could not deliver these services, we could not achieve our mission.

At CMS we have quite a number of priorities, as does everybody else. The Secretary has been quite clear on, you know, what he expects from the CMS, and it's clearly to continue to protect the program from, you know, fraud and abuse.

It's also to reinforce and redefine and expand our ability to care for people as they age to the entire long-term care delivery system which is beyond the resources of any one institution, to look at the issues of home and community-based waivers, to clearly map the way for a prescription drug benefit in the Medicare program in some meaningful and cost-effective way, to push the envelope in terms of demonstrations and new initiatives to find better and different ways to do things and to improve the service that we render to beneficiaries and our providers.

And these are not things that nobody else has thought of before. These are things that have been on the table for a very long, long time. I think part of what makes your initiative so special, so powerful, is that we reach out to you to help us map the way to these destinations.

And to the extent that we have rules and regulations that stand in the way of us achieving our mission in addressing these issues, we would hope that you'd be able to point those out to us, and the ultimate trick is give us some guidelines on how you would like to see them changed, not just what is wrong with them.

I hope that the time that you spend together here in this room and around this great community is time well spent for you individually and collectively. You'll have an opportunity to go see some of the services being delivered in the field, and you have the opportunity to hear from folks who will come before you to talk about how the rubber meets the road in their everyday lives, both through forums and initiatives, and clearly, as you, you know, wrap up the session tomorrow and you hear some folks talk about one of the more pressing issues, EMTALA, if you don't know what that means; you will. Like HIPAA, if you don't know what that means, you're too late, jump on the bus as quickly as you can.

But as we go through the discussion, I will be here for as much of it as we possibly can. Again, greetings from our administrator, Tom Scully. He hopes to join you in future meetings. I will make as many of these as I possibly can.

The folks here from CMS who will be sharing with you are among the very best at what they do, so I hope you challenge them with questions, and they've guaranteed me they can answer any question you could possibly answer -- possibly ask with great integrity.

Always a pleasure to be with my friend and hero, Josefina, and for many of you here in the room, all the very best for a great two-day session and enjoy Miami, please. Thank you.

CHAIRMAN WOOD: Thank you very much, Ruben.

The first item for us today is to begin to look at how regulation manages to achieve the intent of program design, and for that we have chosen to begin to explore OASIS, and some of you are quite familiar with OASIS.

The way that we will do this is to actually see what the intent of OASIS was and then see the data collection in action, and the rationale for that was to really begin to see how providers have to translate program expectations and regulations into real everyday practical activities, and so I anticipate that we'll learn a great deal from that.

We're privileged to have with us today several people who are going to help us with this important task. We're going to begin actually with an overview from CMS, and Jennifer Boulanger is going to do that for us, and then we're going to do a demonstration, and the demonstration will be done by Ms. Barbara McCann and Ms. Karen Carnes, and for the first part of the morning then I hope that that will give us a great start for what we're going to do in the next day and a half.

So with all that being said, I would be happy if Jennifer could begin to lead the discussion, and then we'll set up the demonstration after that.

MS. BOULANGER: Not following your advice and see if we can get the microphone set up here. Thank you very much.

I'm Jennifer Boulanger. I'm the Acting Deputy Director for the Center for Beneficiary Choices in CMS, and I have a loud voice, so I hope not to blast anyone out of the room.

I think -- I mean this is, I think, a really fabulous opportunity, today's session on OASIS, especially getting a chance to see an actual assessment occur. I'm going to talk briefly -- I can hear my voice booming, so pardon me.

I'm going to talk briefly about the history of OASIS, what it's used for, what it was conceived -- conceived for, how it's really used and then some of the quality results that we've had to date and then get right into -- turn it over to Barbara McCann and Karen Carnes so that they can get right into the real meat of the assessment process.

OASIS is the Outcomes and Assessment Information Set. It's not a questionnaire. It is what all of our staff call a data set, which is certainly not a very sexy title and one that I still can't quite wrap my head around. It was begun some 14 or 15 years ago in a way to explore integrating continuous quality improvement into home care beginning to focus on outcomes, outcomes of care.

But then in 1987 Congress passed the Omnibus Budget Reconciliation Act of 1987, which I'm sure a number of you are familiar with. It -- one of the things it's probably best known for is the provisions it has on nursing homes. From that MDS was born, which I know you're going to be addressing at a subsequent meeting, and the whole point of the nursing home provisions were to -- were to address a lot of the problems that had been well documented in nursing homes to strengthen the requirements for providing quality care and enforcing the requirements. OBRA 87 contained similar provisions to protect patients in home care. Medicare had a longstanding requirement at that point on -- in the conditions of participation requiring that home health agencies evaluate patients and establish plans of care.

What OBRA 87 mandated, and I'm going to read this, it mandated that Medicare monitor the quality of home care and services with -- now here's the quote -- "A standardized reproducible assessment instrument, the extent to which the quality and scope of items and services furnished by the agency attained and maintained the highest practicable functional capacity of each individual as reflected in such individual's plan of care and clinical records." That's really the heart of what we're getting at here.

To try to implement this requirement Medicare then contracted with the University of Colorado with researchers and clinicians there to develop this very instrument that we believe was contemplated in OBRA 87.

Now in designing this assessment instrument the clinicians and researches looked at the kind of information that's obtained during this whole assessment of a patient's condition to develop the plan of care, and they tried to take those elements that were common in all assessments across a wide variety of providers and incorporate that into the standardized reproducible format prescribed by law, and what they came up -- they started with, oh, it was an iterative process. They started with some 300 elements and then over time winnowed it down to the 79 core elements that are currently in OASIS.

Now, the actual number of elements you'll see it kind of varies, but we really consider there to be 79 core elements across the different time frames of assessment.

Now, the real big change in OASIS came with the Balanced Budget Act of 1997, 10 years later. That Act, as I'm sure many of you are intimately familiar with, contained numerous provisions -- everyone's kind of laughing here -- numerous provisions that had very far-reaching consequences in the healthcare community across all kinds of providers. Home health was certainly very strongly affected. I think that would be an understatement for those of you in home care.

One of the requirements was that Medicare develop and implement a home health prospective payment system within two years, which is kind of a tall order because while there had been a lot of research, there still was no measure of case mix, and when you're developing a prospective payment system, which is essentially a capitated kind of payment to a provider, the key is having a case mix system because otherwise you can't adjust for the conditions of the patient and pay appropriately.

And so at that point CMS, then HCFA, began looking and thinking what do we do about this, and looked at the state of the research, the state of play, and decided wouldn't it be great if we can use OASIS, which is out there, has been tested for many years at this point, to also use that as the case mix measure for prospective payment, and research began on that, thankfully came in, thankfully from the CMS perspective, came in showing that OASIS could be used for payment purposes, but this is a later -- a later evolution of the instrument because, as I said, it started out for quality purposes.

OASIS now is -- has multiple uses; payment, quality, also is used in the conditions. And so for those uses it is administered at a number of different intervals; when a patient begins in home care, there's a couple for different kinds of starting, when a patient is transferred to a hospital, when a patient returns from the hospital, when the patient is discharged from home care, and you can see just from the outcomes point of view why you would want to measure at some of these time frames because they're indicative of major points in a patient's care cycle.

It is also a really terrific link from a policy perspective having payment and quality on the same instrument because the incentives in both can oftentimes work to opposite ends. So for payment purposes the incentive is for providers -- for any provider, not just home care -- we've certainly seen this in the hospital world, as well as other areas, other settings, for providers to what's called up-code, try to -- to code the patient in the very sickest possible category in order to get the maximum possible payment.

On the quality side the incentive is to show what the patient really is, because if you start them out in sort of a funny place, it could really screw you up on your quality measures, and surveyors may want to come and take a look at what's going on inside your agency. So there's a tension here that actually, we think, does a good job of helping everyone code properly.

The other incentive in any prospective payment system is to provide less care. In the hospitals we saw this in the late >80s with discharging quicker and sicker, people called it. In home care as with any other prospective payment system, providers, agencies get paid the same general payment if they provide seven visits to a patient or they provide 30 visits in that 60-day episode.

So, again, the policy view is that it is a good thing to be able to monitor quality as you're instituting prospective payment systems, and the old system for home care payment was a per visit payment so agencies were paid for every visit.

So, if anything, the opposite incentive existed previously, which was to provide as much care as you could. So there was a, again, a concern moving to this new payment system, what it would mean for patients, for beneficiaries.

But that's the segue into quality, and because this was developed for quality purposes, it was developed to measure the outcomes of patients' care, and in the mid->90s two demonstrations began to look at whether OASIS could in fact be used to measure outcomes and then help agencies with continuous quality improvement and improve the quality of those outcomes, and so there was a national demonstration that began in 1995. It had 54 home health agencies in 27 states. That lasted three years. New York State embarked on a demonstration that involved 57 agencies.

In both of these demonstrations they used targeted hospitaliza- -- they targeted hospitalization, decreased hospitalization as an outcome they were seeking to influence. They also then let agencies pick another outcome measure to use to try to improve, and those would be things like wound care, urinary incontinence, things like that. And the result of the demonstration was really quite startling, quite phenomenal, quite amazing.

In the national demonstration, the three-year demonstration, hospitalizations decreased 23 percent in three years. In New York State in a four-year demonstration, hospitalizations decreased 26 percent, and this -- talk about a profound impact on agencies, on their costs, on beneficiaries, who wants to go back into the hospital. So that is the big news from OASIS on the quality front.

The title for this particular activity is called Outcome Based Quality Improvement, which has the unfortunate acronym of OBQI. I keep thinking it's Obi Wan Kanobi, but it -- it is actually delivering some results here. What -- the reports that are generated for OBQI using OASIS data are in your notebooks at Tab 2.c. I've included some of the reports for three different agencies.

One is an agency that needs a fair amount of work, and that doesn't mean that they can't take on this work and make changes, because that's the point, and that's Agency X, Agency Y is an agency kind of in the middle in terms of their quality, and then Agency Z is a stellar performer. When you look at these graphs, you can see how they stack up compared to the nation.

These reports began to be able to be downloaded by agencies across the country this past Friday, and at that point CMS held a satellite broadcast, and it's also Webcast, and you can access it from HCFA.gov, but that Webcast to tell agencies about the reports and how to use them. That is the OASIS at a sprint.

I want to stop now to turn it over to Barbara McCann and Karen Carnes. We're going to actually do the assessment and talk about how they do OASIS in their agency and across all of their agencies and any other remarks, but I'm happy to answer any questions.

CHAIRMAN WOOD: Let's have questions first for Jennifer while we're getting ready for the demonstration.

There's several that I have that I'll come back to after we see the demonstration >cause it might change actually how I ask the question. So let's have a look at it.

MS. McCANN: Let me give you a brief introduction.

CHAIRMAN WOOD: We need a microphone for you to use.

MS. McCANN: I'm Barbara McCann. I'm the Chief Clinical Officer of Interim Healthcare. We have about 300 offices nationwide.

Those of you on the panel, on your right-hand side behind the brief overview of OASIS you actually have the initial assessment that we would like you to use a piece of it today with us.

Just to give you a brief overview, OASIS has 79 questions. What we have done, as many other agencies have over the last few years, we have integrated those questions into an initial assessment trying to integrate an appropriate question following a head-to-toe assessment that a nurse would do in the home, So, for instance, we always ask about shortness of breath. There was an OASIS question on shortness of breath so we used that instead of a traditional question.

You do not have to do this as an interview totally, and you do not have to use the questions in the exact order all the time that they appear as printed out by the government. So you'll see it's interspersed throughout here.

This is 20-some pages long. This is the assessment that we must use at admission, upon return from a hospital stay of more than 24 hours, every 60 days and at discharge. There are different data sets that we use upon admission to an inpatient facility of more than 24 hours and upon death at home. So in essentially our heads we keep track of five.

Now, this is on paper. It will always be on paper, and because I am now a HIPAA convert, it's going to stay on paper for awhile >cause I have to spend most of my money getting ready for that, but you did a great job last week, thank you, in the Sharp conference.

Our nurses take one and a half to two hours to do this assessment. You are only going to see a portion of the assessment today. That is a little bit longer than we used to do it, not much, but a little bit longer. On average it takes a nurse six months to learn how to do this assessment well. We only use those nurses who can do it well, as well as physical therapists in the process.

Okay. So I am going to be your patient today, and we'll give you a little bit of setting. Now, we're from Broward County. That's the boring group north of here. Okay. We're not quite as exciting. We spend most of our time learning how to vote, okay, and the process.

Karen Carnes is our Director of Clinical Services, and she's going to be the nurse today.

I am a 65-year old. I get to stay a woman, thank heavens, and I have just come home from a hospitalization.

Now, to set the scene, you need to realize we do this in the home. All right. We've wandered down streets. We've taken wrong turns. If we're lucky, Price is Right is not on when we come in, or their favorite soap opera, and if we're really lucky, we don't have about a five and a half pound dog gnawing at our feet during the process, and you're wandering through a trailer, an apartment on the 15^th floor or anything else in the process.

MS. CARNES: I just wanted to clarify a few things. Not only can -- can you use other methods besides interviewing for this assessment, but you really must use other methods besides interviewing to do an effective and efficient comprehensive assessment, and if the clinician is only using interviewing, we have found that that's where a lot of the problems have come from.

Now, I know many of you have heard complaints about OASIS, and so have we, and actually I'd like to take this first part of our demonstration to show you perhaps where some of those complaints are coming from. We have identified some problematic areas in OASIS. Some of the areas are problematic for the patient. Some of the areas are problematic for the clinician, and so we'll take this first portion to demonstrate some of those areas that -- that are a little tough, some tough questions, and this part will be an interview.

Now, this is Ms. McCann. She did tell you that she's 65 years old. She's been diagnosed with diabetes only within the last year or so. She was admitted to the -- an inpatient facility 12 days ago, and she's recently been discharged to home care to adjust her medications, to stabilize her diabetes and to regain her strength, >cause it really took the strength out of her. She's a little bit weak now.

She lives in her own home. Her daughter lives with her. She tried to get her married off, but it just didn't work out. It's a middle class home here in Miami, which means there are no stairs. Okay. It's one -- one-story, and it's a nice, clean, basic middle class home.

Now, the first area I want to demonstrate is an area that's difficult for patients, and you'll probably see why.

On your assessment form if you would turn to Page 2 and look at Item No. 29, and we'll start there, and that's M0 Item 175. Okay. That's how they're referred to, M0. All of the OASIS items start with an M zero, so, you know, all of our training materials have little cow references all over them.

Ms. McCann, I understand you were in an inpatient medical facility recently; is that right?

MS. McCANN: Does that mean a hospital?

MS. CARNES: Well, could you tell me the name of the facility you were in?

MS. McCANN: I was in Jackson Memorial.

MS. CARNES: You were in Jackson Memorial. Okay.

MS. McCANN: On a really nice floor.

MS. CARNES: Okay. And that was probably a regular medical unit. You weren't in a rehab unit.

MS. McCANN: Nobody said anything to me about rehab.

MS. CARNES: Yeah. Okay.

MS. McCANN: Do I need rehab?

MS. CARNES: No. Well --

MS. McCANN: Do you think I should get rehab?

MS. CARNES: We'll find out if you need it.

MS. McCANN: Is that covered by Medicare? They didn't tell me.

MS. CARNES: Well, we'll find that out. I'll call the hospital and find out where you were.

MS. McCANN: Okay.

MS. CARNES: Because that's important.

MS. McCANN: I don't want to pay extra, though. Okay?

MS. CARNES: No, you won't be --

MS. McCANN: Okay.

MS. CARNES: -- paying extra.

MS. McCANN: Okay.

MS. CARNES: Now, do you remember exactly what day you came home?

MS. McCANN: Oh, I haven't been feeling well, Karen, I -- I don't remember what day I came home. Maybe -- maybe Sunday?

MS. CARNES: Maybe Sunday. Okay. I'll call and check on that, as well. Okay.

MS. McCANN: They ought to know.

MS. CARNES: They should know. Indeed they should know. And what were you treated for when you were in the hospital?

MS. McCANN: They said I have this diabetes.

MS. CARNES: Okay. Anything else? Just the diabetes?

MS. McCANN: I was just feeling badly with the diabetes. I didn't even know I had it.

MS. CARNES: Okay. I heard somewhere that you might have had pneumonia. I'll call your doctor's office to find out.

MS. McCANN: Is that what makes you breathe, and it hurts?

MS. CARNES: Yes, and it -- it probably did hurt. Okay. And, Ms. McCann, just before you went into the hospital, think back just before you went into the hospital, did you have any problem with holding your water?

MS. McCANN: Holding my water?

MS. CARNES: Urinary incontinence?

MS. McCANN: You mean could I go to the bathroom

MS. CARNES: Could you make it all the way to the bathroom?

MS. McCANN: I could get there.

MS. CARNES: Okay. Without losing your urine along the way.

MS. McCANN: Yes, yes.

MS. CARNES: Okay.

MS. McCANN: Yes, I don't need any --

MS. CARNES: Okay. No problem there.

MS. McCANN: -- of those pads, no, uh-uh.

MS. CARNES: Okay. Did you have any problem with pain that was uncontrollable? Think back. This is before you went into the hospital.

MS. McCANN: When the weather's bad, my knee hurts.

MS. CARNES: Okay. And was it hurting all the time and was not able to be relieved just before you went --

MS. McCANN: I take two Aleve.

MS. CARNES: Okay. Okay. Did you have any problems with your thought processes? Did you have -- now, this is right before you went into the hospital. Did you have --

MS. McCANN: Hey, honey, I did not feel good before I went --

MS. CARNES: Okay.

MS. McCANN: -- that's why I went to the hospital.

MS. CARNES: I understand. Did you have problems making decisions, what you needed to do next, who you needed to call?

MS. McCANN: I use my daughter when I have trouble with that.

MS. CARNES: Okay. Okay.

That's a section that perhaps you can see might cause the patient some difficulty. They're asked to recall some details from awhile ago, recently, and it was during a period of stress.

Many of our patients are not good historians, and so I think you might be able to see where it might be even stressful for the patient not to be able to give you these answers >cause they want to do good, they want to give you the right answers.

A quick little demonstration to further demonstrate this point in another section of the OASIS. If you look on Page 14, begins on Item No. 97, and it goes on for a number of pages here. We'll just do a couple of them real quick.

You'll notice on No. 97, M0700, ambulation, there's a column there called current, and there's a column there called prior, and prior requires that I obtain information about the patient, about their functional status 14 days ago, not functional status about two weeks ago, but functional status 14 days ago. So I'm going to try to get that information from Ms. McCann.

By the way, I told you we're doing these sort of in pieces here and there. I've already done some other assessment on her. Let's make that assumption. Okay.

Ms. McCann, I can see that you need a little help getting around, walking around now, and that's fine. You're probably feeling a little better and getting around a little better, but I'd like for you to think back to 14 days ago, 14 days, and could you tell me how well you were walking 14 days ago?

MS. McCANN: I was in the hospital 14 days ago.

MS. CARNES: Well, no, you were in the hospital 12 days ago, so this was two days before you went into the hospital.

MS. McCANN: Well, I was feeling incredibly poorly, so at that point I would have just been on the couch.

MS. CARNES: Okay. Did you ever get up to go to the bathroom?

MS. McCANN: Yeah, >cause you gotta.

MS. CARNES: You gotta.

MS. McCANN: Yeah.

MS. CARNES: How did you get from the couch to the bathroom?

MS. McCANN: Well, I have to walk.

MS. CARNES: Yes. How well did -- were you able to walk by yourself, or did you have to have your daughter help you?

MS. McCANN: You aren't going to tell my daughter, are you?

MS. CARNES: I won't tell her. How did you get to the bathroom?

MS. McCANN: I hold on to the couch and then the dining room chairs.

MS. CARNES: Okay. And that's about what you're doing now. Was it worse at that point?

MS. McCANN: Well, I felt sick so it was worse.

MS. CARNES: It was worse. Okay.

MS. McCANN: I couldn't hardly breathe.

MS. CARNES: How about getting on and off the toilet? Now, when you're sitting in the living room, you got the arms of the chair to get up, but when you go into the toilet, I notice you didn't have any of those handrails there. Were you able to get on and off the toilet?

MS. McCANN: Two weeks ago?

MS. CARNES: Two weeks ago. Now think, that was two days before you went into the hospital.

MS. McCANN: You know, honey, I felt so badly then that I just -- I don't remember what I did.

MS. CARNES: Okay.

You can see the difficulty she might have. Now, I also need to ask her how well she did her laundry, how well she did her shopping, how well she prepared meals, how well she was able to feed herself, all of the ADLs and IADLs. I need to know how she did 14 days ago.

Now, if I was seeing her and this was a follow-up assessment and I'd been following her all along, I might have that information, but at the start of care I haven't seen her before so I have to rely on her.

Now, I'll also interview her daughter, but the daughter's not home right now, okay, so it's just me and Ms. McCann, and I'm obtaining the information from her as best I can. She's really the one I want to get the information from. Okay.

Here's an area, the next area, that's a little bit uncomfortable for the nurse and oftentimes is uncomfortable for the patient.

If you look on Page 13, begins with Item No. 86, that's M0570, and I'll just sort of -- I'll try to go as much in order as possible, but on this particular page you'll notice that there are a lot of non-M0 items here. I'm going to skip over those. Those are items that we have inserted ourselves to complete the assessment, but I'll just focus on the M0 items.

Now, Ms. McCann, you probably are aware that how you feel and how you think about things can be important to your healing process.

MS. McCANN: I saw a show about that.

MS. CARNES: Okay. So you're educated about that even.

MS. McCANN: Yes.

MS. CARNES: Okay. So I'm going to ask you some questions about your feelings and about how well you're able to handle things day to day.

MS. McCANN: Nobody else sees this, do they?

MS. CARNES: No, it's -- well, I explained to you when I came in on the piece of paper how we use this information, and --

MS. McCANN: Okay.

MS. CARNES: -- it's just between you, me and the government. Okay?

Now, so far you answered all my questions really well.

MS. McCANN: Thank you.

MS. CARNES: And it's really been enjoyable talking to you. Do you ever get confused and have difficulty understanding what's going on around you?

MS. McCANN: Doesn't everybody?

MS. CARNES: And does that happen very often to you?

MS. McCANN: I haven't really thought about being confused, no more than normal, probably, at this age.

MS. CARNES: Okay. Well, think about when you do get confused, when -- when is that? Is that when things are sort of crazy around you? Is it perhaps in the middle of the night?

MS. McCANN: I can't -- I can't remember the last time I was really confused.

MS. CARNES: Okay. So really --

MS. McCANN: Maybe driving I was confused.

MS. CARNES: Okay. So it doesn't happen very often, and you're not out there driving too much, are you?

MS. McCANN: I drive a lot.

MS. CARNES: I've seen you.

MS. McCANN: Yes.

MS. CARNES: Okay. Do you sleep well? Are you sleeping well at night? Do you sleep all the way through the night?

MS. McCANN: No, but me and -- none of my neighbors sleep all the way through the night. We're up about 4:00.

MS. CARNES: Okay. Is -- and what gets you up?

MS. McCANN: I don't know, the birds, the rooster, something. I --

MS. CARNES: You're not worrying about things, are you? Is that what's waking you up?

MS. McCANN: Well, I worry. Sure, I worry.

MS. CARNES: You do?

MS. McCANN: Sure. Where I got a daughter I got to unload. I don't know how much longer I'm going to be around. I worry.

MS. CARNES: Okay. What kinds of things do you find yourself worrying about?

MS. McCANN: Oh, I got to pay the bills, you know, if I'm going to get better. I can't go to a nursing home or something. I got to be here. I --

MS. CARNES: Do you think this is normal, everyday kind of worrying, or do you think you're worrying too much?

MS. McCANN: I don't think I'm worrying more than normal people.

MS. CARNES: Okay. Doesn't make you upset or overly distressed in any way?

MS. McCANN: Well, sometimes. Sometimes it makes me distressed, but --

MS. CARNES: What kinds of things are making you distressed?

MS. McCANN: Well, like whether or not I can -- I can buy that insulin. I don't know if I can afford it or not.

MS. CARNES: Okay. So it sounds like common, everyday things, and you -- you>re probably worrying just about as much as the rest of us then.

MS. McCANN: Yeah, probably.

MS. CARNES: Okay. Do you ever find yourself feeling sad to the point perhaps of being tearful?

MS. McCANN: I don't cry over things.

MS. CARNES: You don't.

MS. McCANN: I learned a long time ago you just don't do that.

MS. CARNES: And how about feeling sad?

MS. McCANN: Oh, I feel sad sometimes. I mean I'm sick, I don't know if I'm going to get well or not. I mean that's just normal.

MS. CARNES: Do you think about that a lot?

MS. McCANN: No, I don't. No, I don't.

MS. CARNES: Okay. Do you ever have --

MS. McCANN: Listen, my soap's starting in about 15 minutes --

MS. CARNES: And we'll be finished pretty soon.

MS. McCANN: Okay.

MS. CARNES: We will be finished pretty soon. Do you ever have thoughts about death?

MS. McCANN: About death?

MS. CARNES: Yes.

MS. McCANN: No, >cause I couldn't afford to die right now. I don't.

MS. CARNES: Do you have thoughts about suicide?

MS. McCANN: Good heavens, girl. You're asking -- I don't -- I don't think about those kind of things.

MS. CARNES: Well, I'm -- I'm glad to hear that. I'm glad to hear that >cause you're an awful nice lady to have around.

Do you ever have difficulty making your mind up about things?

MS. McCANN: Uh-uh, no. No way.

MS. CARNES: No. Okay.

MS. McCANN: Well, maybe if I should turn left fast or not, but other than that I do just fine.

MS. CARNES: Okay. What kinds of things do you like to do to keep busy?

MS. McCANN: I -- I go to bingo about five or six times a week.

MS. CARNES: Not -- not lately, right?

MS. McCANN: Well, I used to before I was sick.

MS. CARNES: Okay. Okay. Since -- since you were sick, what are you doing to keep busy?

MS. McCANN: I watch TV.

MS. CARNES: Okay. Has your illness prevented you from doing things that you like to do?

MS. McCANN: Yeah, I can't get to bingo.

MS. CARNES: Okay. But you'd like to get to bingo.

MS. McCANN: Right, I'm --

MS. CARNES: So you're still interested in that.

MS. McCANN: I'm losing money staying at home.

MS. CARNES: Okay. Have you had any change in your eating habits? Are you eating more, eating less?

MS. McCANN: I don't understand this whole diet thing and why you got -- I don't understand why you got to start reading boxes.

MS. CARNES: Okay. Well, we'll -- I'll make sure that you have that understanding before your home care service is finished.

Have you lost weight or gained weight or have any problems with your appetite?

MS. McCANN: I've lost. It was wonderful.

MS. CARNES: Over what period of time and how much weight did you lose?

MS. McCANN: I lost about 10 pounds, but I'm doing that Slim Fast diet.

MS. CARNES: Ah, good for your diabetes. Okay. Do you ever find yourself very tense and in distress?

MS. McCANN: Why, this whole thing's making me feel a little tense.

MS. CARNES: Yes, I can understand that.

MS. McCANN: And -- no, no, no, not except when I drive --

MS. CARNES: Okay.

MS. McCANN: -- then I feel tense.

MS. CARNES: And you make me tense, too.

MS. McCANN: Yes.

MS. CARNES: Okay. And what happens when you lose your temper?

MS. McCANN: I honk the horn and yell at people.

MS. CARNES: What -- okay. Do you yell? What about when you're at home? Do you yell?

MS. McCANN: I yell at my daughter sometimes, but she needs to be yelled at.

MS. CARNES: Uh-huh, okay. What -- what other things do you do when you lose your temper?

MS. McCANN: Nothing.

MS. CARNES: Nothing. Okay.

MS. McCANN: Clean. I clean.

MS. CARNES: Okay.

Now, you'll notice that in M0610, that's No. 94, I personally find it very difficult to interview for these items, verbal disruption, physical aggression, disruptive infantile behavior. That's pretty difficult to interview for, and it's not likely that I'm going to -- or it's possible, I suppose, that I would observe some of that, but I would have to interview the daughter to complete this particular item.

Anyway, this type of interview -- clinicians are uncomfortable doing it. They'd just as soon write a referral to the social worker to come and find out all this stuff, so, you know, it's a part of the OASIS, and I can't say it's a bad part, but I will inform you that it is a part that makes clinicians uncomfortable, and many patients are very uncomfortable discussing these items.

And, finally, there's a few items that are very difficult for the clinician. If you look on Page 18, Item No. 119, that's M0270, rehabilitative prognosis, and it's either guarded or good or unknown.

Physical therapists and occupational therapists are very good at answering this question. It's in their -- it's in their education. It's in their knowledge base, and it's in their history. Nurses are really lousy at this. Nurses do not have a good knowledge base for making this kind of decision. They often need to consult with the therapist and, unfortunately, don't do that often enough in answering this question.

You need to base your decision on the recent onset of the debility of the patient's prior level of function, and the nurses have not been trained to make this kind of decision. Doesn't mean they can't be, doesn't mean they shouldn't be, but they haven't been, and, therefore, what we see is a lot of inconsistency in this answer. They might answer yes here and be inconsistent in another part of the OASIS and indications that the answer really should be guarded.

The other thing that causes inconsistency on the 485, the plan of care, there's a locator called rehab prognosis that has an entirely different definition than this does, so that's a bit confusing to clinicians, as well.

If you also look at -- on the same page, Item 120, M0280, life expectancy. Nurses just are not prepared to make this judgment. They historically have never had to make this judgment except for hospice nurses, but nurses generally on the street just have not been prepared to make this, and what we're finding is that even some physicians may even be reluctant to have this discussion with us. They may have had it with the patient, but they're reluctant to have this discussion with us, and so nurses are not very well prepared to answer this well, either, and they tend to over-estimate for the patient.

They'll -- they're much more likely to check box number one, life expectancy is -- I'm sorry, box number zero, life expectancy is greater than six months, even if it's not. They're much more likely to do that.

The other problematic question, the last one, is on Page 20, Item No. 129, M0825, therapy need. First of all, the question as stated is not real clear exactly what they're looking for. It talks about meets the threshold for a Medicare high therapy case mix group, which is pretty -- pretty heavy language for a clinician in the field.

What it means is, are you going to have 10 or more therapy visits. So it's a training issue to have the clinicians understand this question. Therapists can answer it quite readily. Nurses have to be able to project what the therapist is going to do. We've been able to train many of our nurses to do that. The other option is to consult with the therapist after the therapist makes an evaluation, and, hopefully, that's what's occurring, but not necessarily.

So those are the areas that we have identified for ourselves that are somewhat problematic. However, we do like the OASIS, and the rest of the OASIS is not so difficult to deal with, and I'd like to give you a demonstration of that, as well.

The rest of the OASIS pretty much can be done not as an interview, so we're going to have to get animated here a little bit.

Ms. McCann, it's important that I see how you're able to move around your house. Okay. That's important in getting you well within your own environment, and I'd also like to see the rest of your house, as well. So could you get up out of your chair --

MS. McCANN: Sure.

MS. CARNES: I'm observing, I'm observing. Okay. Very good.

And could you take me into your kitchen? Okay.

I notice she's having some difficulty walking. She's leaning on furniture, hanging onto the walls, and we get into the kitchen, which, by the way, has a tile floor.

And could you show me what's in your refrigerator?

MS. McCANN: I haven't gone shopping.

MS. CARNES: That's okay. That's good to know that, but could you just show me what's in your refrigerator.

MS. McCANN: Open it right over there. It's -- it's kind of empty.

MS. CARNES: Okay. Could you walk -- show me how you walk over here and --

MS. McCANN: You know, I usually wait for my daughter to come home.

MS. CARNES: Okay. Well, would you like for me to open it then?

MS. McCANN: Yes.

MS. CARNES: Okay.

I'll inspect the refrigerator; does she have any food, is it the appropriate kind of food for a diabetic. Okay.

Now, who does your shopping for you?

MS. McCANN: My daughter.

MS. CARNES: Do you ever go out and do shopping?

MS. McCANN: If they have one of those nice electric carts you sit in. I like that.

MS. CARNES: Okay. When's the last time you were able to do that?

MS. McCANN: I haven't been for months or so, at least.

MS. CARNES: And who prepares your meals for you?

MS. McCANN: My daughter. She leaves things out for me right here on the counter.

MS. CARNES: Okay. Are you able to heat those up in the microwave when she's not --

MS. McCANN: Yes, I can. It's right here. Right here.

MS. CARNES: Okay. Now, I see you have your medications over here. Okay. That's one of your medications, right?

MS. McCANN: I think so.

MS. CARNES: Could you read for me what medication that is and when you're supposed to take it?

MS. McCANN: I try to get my daughter to leave it in egg cartons for me.

MS. CARNES: Okay. So you're not able to see that.

MS. McCANN: No, I was thinking of joining one of those HMOs so I could get new glasses.

MS. CARNES: Okay. Okay. That's fine. Then could you tell me -- look at the egg carton and tell me which medications you take at what time?

MS. McCANN: I always start from the right. I take this one at 9:00. I take this one at 2:00, and I take this one after General Hospital.

MS. CARNES: Okay.

So in the kitchen you could see that I was able to test her mobility, look at her food, test her vision, test that she's able to manage her own medications. I would also ask her if she knows the side effects and the purpose for each medication.

Okay. Could you walk me into your bathroom and let's take a look there.

MS. McCANN: Sure. Sure.

MS. CARNES: You can hold onto me.

MS. McCANN: You know, there's a storm coming up. I can tell. My knee's sore. Uh-huh.

MS. CARNES: Okay. Now, could you show me how you get on and off the toilet?

MS. McCANN: I have to?

MS. CARNES: It's important for me to know.

MS. McCANN: Well, okay. Got to -- you got to move this thing here. Okay. I put my hands here.

MS. CARNES: So you need some support.

MS. McCANN: And then I kind of aim.

MS. CARNES: Okay. Now, I notice you have some difficulty getting back and forth to the toilet. Are you able to get there in time?

MS. McCANN: Most of the time.

MS. CARNES: Most of the time.

MS. McCANN: And I know if there's ever a problem, June Allison has got something I can use.

MS. CARNES: Okay. How often is that a problem for you?

MS. McCANN: I try not to get up at night.

MS. CARNES: Okay. How often during the daytime is it a problem for you to get to the bathroom in time?

MS. McCANN: If I'm not too distracted, I can usually make it. It's the -- the problem is getting in here, aiming and getting down in time.

MS. CARNES: Okay. So it's a mobility problem --

MS. McCANN: Right.

MS. CARNES: -- mostly. Okay. Now, that's urine you usually have problems with.

MS. McCANN: Right.

MS. CARNES: Do you ever have problems getting there in time --

MS. McCANN: No problems with number two.

MS. CARNES: -- for your bowels. No problems. Okay. Okay.

Now, so I'm able to determine her continence, and even though she's telling me her side of the story, I will also be observant for any wet or soiled pieces of clothing that I might see, if there are any odors that might tip me off that she actually has more of a problem than she's letting me know.

Can you show me how you get in and out of the tub?

MS. McCANN: You know, it's great with air conditioning. You don't have to do that very often.

MS. CARNES: Could you show me this one time >cause I'm sure occasionally you would like to get into the tub.

MS. McCANN: I only do that when my daughter's home.

MS. CARNES: Okay. So you need assistance getting in and out of there.

MS. McCANN: This is -- you know, with this knee you got to really swing to get over that.

MS. CARNES: Okay.

MS. McCANN: I don't quite trust it.

MS. CARNES: Okay. So you need help from your daughter.

MS. McCANN: Yes.

MS. CARNES: Now, since you're not able to get into the tub, are you able to stand at the sink, wash your hands and face, brush your hair?

MS. McCANN: Yes.

MS. CARNES: And put on make-up?

MS. McCANN: I can lean. I don't need make-up.

MS. CARNES: No, you're quite a lovely lady.

MS. McCANN: Thank you.

MS. CARNES: How about one last place. Show me into your bedroom. You can hold my arm.

MS. McCANN: All right.

MS. CARNES: Okay. How about let's walk over here to the closet.

By the way, we're now on carpeting. Okay.

Over here to the closet, and perhaps could you get your favorite jacket out of the closet for me?

MS. McCANN: You know, in Florida you just have to wear dusters.

MS. CARNES: Okay. How about your favorite duster.

MS. McCANN: Do you like these new rugs? I put them on top of the other rugs.

MS. CARNES: And we'll probably have a discussion about that. They are lovely.

MS. McCANN: They look good, and they cover up the holes --

MS. CARNES: Okay.

MS. McCANN: -- which is good.

MS. CARNES: Your duster, remember?

MS. McCANN: I ask my daughter to leave it out in the morning, really.

MS. CARNES: Okay. So you have difficulty reaching into the closet, getting your clothes out. Okay.

MS. McCANN: I do. There's not much room.

MS. CARNES: Well, let me give you this duster. Could you put it on for me?

MS. McCANN: I have to button it and everything?

MS. CARNES: Yes, you do have to button it. Okay. Good.

MS. McCANN: I was a great tennis player as a kid, and it's hard for me to get my arm through this side.

MS. CARNES: Okay. I can help you.

So she needs assistance not only retrieving her clothes, which is one element of the functional status, but she also needs help putting them on.

Can you button them?

MS. McCANN: If I take my Aleve first. By the time that they get to the weather on Good Morning America, I can just about do it, but I want those new ones with velcro.

MS. CARNES: Okay. So we can see what kind of assistance she needs with her upper body.

Can you put on this pair of shoes down there?

MS. McCANN: That's why I have carpets. I don't have to have shoes.

MS. CARNES: Even though you don't have to have them, I wonder if you had to wear them outdoors, could you put them on? Could you show me how?

MS. McCANN: I have to go sit down again.

MS. CARNES: Okay. Actually, we can do that. Could you pick those up and then you can show me how you put them on.

MS. McCANN: But you know, I got this carpet >cause I could slide the shoes over.

MS. CARNES: That's good. That's a good technique.

MS. McCANN: It takes me awhile, and I have to go back to get the second one, but --

MS. CARNES: You can just show me one.

MS. McCANN: Okay. I like these big chairs.

MS. CARNES: And show me your shoe.

So in the bedroom I can see that she can go from one type of flooring to another type of flooring without any difficulty. She can dress her upper body, and if she can put her shoe on or not will give me an indication if she can dress her lower body.

Can't quite do it.

MS. McCANN: No.

MS. CARNES: Can't quite do it. Okay.

MS. McCANN: No, I don't have to wear shoes most of the time.

MS. CARNES: Okay.

While we're in the bedroom, I would also ask her to demonstrate to me making a phone call, if she could pick up the phone and use the telephone. I would ask her, since we're talking about clothes, who does her laundry, what part does she play in that, and I would notice if she has any equipment, either in her bedroom or in her living room, such as oxygen.

Now, since you all saw the same assessment that I saw, I'm going to ask you to score a couple of items on the assessment. We'll just do two. Okay.

Go to Page 14, Item No. 97, that's M0700, and take a minute to score that item, and we're just scoring her current, not her prior. Okay.

Did you come out with box number one? Did anybody come out with anything else besides box number one? Okay.

She's obviously not zero >cause she's not able to independently walk, and she's not number -- box number two, walk only with supervision or assistance of another person >cause she stated that her daughter's not home sometimes, and yet she gets to the bathroom. So we're pretty much left with number one, although it does not clearly describe.

It says requires use of a device to walk alone. Well, she didn't have a device, but did you notice she needed one? She should have had a device. She had to lean on the furniture, hold onto the walls or hold onto me. So although it doesn't clearly represent her current exact status right now, that is the closest one. So she's an item number one.

How about go to Page 16 and do Item No. 110. It's M0780, and that one's pretty clear. She'll be Item No. 1 >cause she needs some assistance, and you'll notice that this item, M0780, will be correlated to whatever you answered on Page 4, Item No. 48, which is M0390, vision, >cause that's what her problem was in managing her medications.

Now, this little tour of the home that we just did and having her demonstrate really will allow me to answer just about everything else that's on that -- all the M0 items on our comprehensive assessment. I'll probably have to do some additional interview with her to answer some of our additional items that we had to put in here to make it a comprehensive assessment, but that -- that little tour pretty much wraps up everything else on the assessment beside those problematic interview questions that we did.

Some things that we didn't cover here that are very important are pain. That's always covered on a comprehensive assessment. There are M0 items related to that. The skin and wound items, that's a big item, as well.

There are a few other items on Pages 2 and 3 that we didn't cover in this particular assessment, and then there are the non-M0 items that are required to make the assessment comprehensive.

So, what do I know now that I've finished that assessment? What do I know about Ms. O'Hara? Well, I know what goals are realistic for this patient in this environment for home care. I know what barriers exist that might prevent her from achieving those goals so that I can focus my interventions on those barriers.

I know what services to select, probably, and what intensity they'll require, and most of all, I pretty much have a good idea of when we'll be done. We'll be done when she can do -- when she knows about her diet, when she knows about her medications, when she learns her strengthening exercises, when she gets a few assistive devices and knows how to use those.

Okay. That's our little demonstration. Do I have any questions from anyone?

CHAIRMAN WOOD: Questions.

MR. FAY: Thank you, Mr. Chairman.

I've got two or three questions I'd like to just fold together in one question based upon how the data is pulled together.

Once the assessment is complete, I assume it has to be entered into a computer in order to generate these printouts, so I just wanted to get a feel for how that process works.

And then I also notice that there is a signature block on the assessment form itself, and does CMS require some kind of hard copy signature to be sent in, or does this process allow for an electronic signature?

MS. CARNES: The signature is our signature. That item that requires a signature is specific to Interim. I would suspect other agencies have some -- some other agencies have that as well, but it's not a CMS requirement.

As to how the data gets to where it needs to go, the nurse completes the assessment. Most agencies have established a time frame, an expectation for when that paperwork gets back to the office. It usually is sort of roughly Q/A just to make sure that everything's answered while the nurse is there to give us an opportunity. If it's not answered, the nurse had overlooked it, she can answer it at that time.

So it gets back to the agency within some time period as defined by the agency. It gets routed to the data entry person, and, again, most agencies have some specified time frame when that data entry person has to get it entered into the system.

Barbara, do you want to add?

MS. McCANN: Yeah, it takes, on average, 17 minutes to enter these big assessments once they get a feel for it. After they enter each assessment, an error report comes up as part of HAVEN. If there is a mistake or something blank, you need to call the nurse back in >cause this is the medical record.

Now, here is part of the burden. We have seven days, and if we don't get it entered and corrected in seven days, it's considered lock, and the government monitors how often the records lock without being complete, and then you have to go through a whole process to request to have it opened again to finish it.

Nurses in home care typically only come into the office once a week. Fourteen days would make a lot of sense for us, just to have two weeks, because the nurse has to come back in and you have to correct it like an official medical record. They have to cross it out, put in the answer that they forgot or if they did it wrong and initial it, et cetera.

CHAIRMAN WOOD: Other questions?

MR. TOBY: Two, I guess. First I'm Bill Toby, and I'd like to thank you for a very superb demonstration. I used to work at CMS, I guess, and it's -- this was a rare opportunity for me as a person who used to be responsible writing regulations to see how they really play out in real life. So I want to thank you for that.

It seems to me in the main that you're very satisfied with the OASIS process with the exception of the areas of concern that you said you have, and I presume you'll be leaving that with us.

MS. McCANN: Yes. You know, we've asked our nurses almost daily the last week when we knew we were coming here. Our nurses don't want to give up the OASIS assessment. They don't like all of it, but they honestly don't want to give it up.

MR. TOBY: Yes.

DR. NIELSEN: Why?

MS. McCANN: Why? Because they feel we do a more thorough assessment than we ever have before, and from a supervisory standpoint, you know the assessment is the same. No matter who goes out there, the questions are the same, and so are the answers that they give are within the same realm.

CHAIRMAN WOOD: Barbara, do you think that in terms of preparing for -- the training obviously helps you get an opportunity to make sure that the performance becomes much more consistent. Is that another advantage?

MS. McCANN: Oh, that is a -- that is a big issue. We do all sorts of things. Beyond training like this, we have -- when an office is faced with an outcome report that doesn't look great, one of the things they have to do is they even do shadow, where one nurse goes in right after the other, but one of our biggest training challenges was to teach nurses how to do functional assessments, and that took us a long time to be able to do that. That's not a usual thing that happens.

MS. CARNES: Nurses have a tendency to interview the functional assessment; can you walk, Mary, are you able to get to the bathroom okay, and, of course, Mary's going to say yes, and the nurse is more than happy to write down yes, as opposed to can you show me how. That has been a huge challenge.

CHAIRMAN WOOD: Heidi.

MS. MARGULIS: Thank you, Mr. Chairman.

How do you share this form with other providers and health plans?

MS. McCANN: Health plans outside of the government have no interest on the whole in these forms. We've -- we've tried to share them with case managers, with commercial and especially with Medicare HMOs because it is a solid reflection of what's going on in that house. Pretty much the interest is very low.

With other providers we all pretty much have similar forms. If you put them next to each other, they all pretty much come out the same. It's a head-to-toe assessment.

CHAIRMAN WOOD: Patricia Shafer.

MS. SHAFER: I'm not sure who this is for, but what was the reasoning for asking all the questions about what the person was like 14 days before, because the reliability of past data is really so sketchy for anyone.

MS. BOULANGER: I think part of that, and, Barbara, jump in here, is -- is just to get that what happened before, what happened now for the quality purposes, but that's exactly the kind of thing that -- I mean there's a reason in terms of the development, why they put it together, and I don't have all the answers of exactly what, other than the obvious, you know --

MS. McCANN: Jennifer, can I --

MS. BOULANGER: Barbara.

MS. McCANN: Most -- on the OASIS Technical Committee what you were trying to do was to establish, since most of these people come to home care on an acute exacerbation or an acute episode, two weeks ago if they were able to walk, get to the toilet, et cetera, then you know that it's reasonable to do that.

Now, you'll notice on our form we've added three months, and we did that with the recommendation of PTs because they could two weeks ago be going into their illness and be in pretty bad shape, but if three months ago they couldn't walk, they couldn't get to the toilet, it's incredibly unlikely you're going to make it happen now, and that helped us better respond to the late effects of strokes.

You know, we don't have a Lazarus guideline. We're not at some point going to help people walk who haven't been able to walk for six months, so we've actually added an extra dimension in there.

CHAIRMAN WOOD: Judith Ryan.

MS. RYAN: Two questions. One, how do the informal providers who engage in the home health care along with the RN providers interface with this data?

MS. McCANN: They usually -- they usually have a care planning meeting. You mean the para-professionals --

MS. RYAN: Uh-huh.

MS. McCANN: -- like the aides and the others, and so they know what the expectations are.

The difference that this assessment and the emphasis on outcomes made us do is instead of sending the aide in to always give the bath, now you're sending the aide in to help the family members or the person themselves learn how to bathe more independently. It was like a realization that you're leaving them. You can't just substitute another care.

So there's relief, and then there's helping them learn how to do it otherwise, but everybody has to be in on the goals or you're not going to get there.

CHAIRMAN WOOD: Karen Utterback.

MS. UTTERBACK: Thank you, Mr. Chair. I have two questions.

One, early on you mentioned that it took about six months for the nurse or other professional to get proficient with the assessment. Can you describe what the learning curve was for a new employee to your comprehensive assessment before the OASIS data set?

MS. CARNES: I'm going to have to guess here, but it's a knowledgeable guess. Okay. I would bet you within a month or so because what it -- what it was prior to OASIS was a systems review, and you do that in any setting. You do that in the hospital, and since we only hire nurses who have previous experience, we don't hire new grads, they've already had that experience. So it's just a matter of integrating it into the home setting.

So it was a very short learning curve, and I'm sure it was less than a month.

MS. UTTERBACK: My second question has to do with the comments you made about HIPAA, and that result of that would be that you would stay on paper for awhile, and coming from an agency where we take an automated approach to the documentation and have seen significant reductions in our clerical and other support staff time, I was just curious for you to talk a little bit about your choice there to stay on paper.

MS. McCANN: Well, 300 locations is -- adds up kind of fast. You know, home health billing vendors are not the largest companies in the country, and so right now when we talk to our vendors about being ready for the transaction codes, we may have to go through significant expenditure to get up to the latest upgrades. We're going to have to have probably bigger servers, different operating systems, to be able to handle the additional information.

So I mean quite honestly I don't think this will come as a shock, we're going to emphasize getting ready to be able to continue to bill first before we go to handheld -- we're closer than we ever were, but this is going to make us reevaluate that.

MR. UTTERBACK: I appreciate that comment. Thank you.

CHAIRMAN WOOD: Erik Olsen.

DR. OLSEN: You've added some questions in your personalized. Are there any of the ones that you'd like to take out?

CHAIRMAN WOOD: Karen's going to tell you.

MS. CARNES: The ones that we've added, would we like to take some out?

CHAIRMAN WOOD: No, which of the original instrument would you like to take out?

MS. CARNES: Oh, we have a list for you. Mostly -- it's not a lot. It's maybe like seven or eight, and some of them are related to just being repetitive.

If you ask about my sanitary hazards on my start of care, you know, 28 days later when I'm discharged is it likely that those have changed. No. So why do you have to ask about them again? My living status, is it likely that it's changed? Probably not. I'd rather see a question such as has the living status changed; no. Okay, fine. Skip to the next section, or yes, okay, then you can ask all those individual questions. There are a few in those behavioral, the emergent care.

MS. McCANN: Trying to explain to your own family members if they have utilized emergent care in the previous 60 days or previous six weeks -- first of all, you have to be able to explain emergent care. Now, since you're on healthcare, you may be able to do that pretty well, but that's not that easy, >cause emergent care just isn't emergency room; it's an unscheduled visit to a doctor or a clinic, and then they have to recall that.

I think monitoring the use of emergent care is incredibly important as to whether or not we do our job well in home care, but how well you're able to explain it to a layperson and then have them recall just makes me wonder if indeed that's a valid question to do that.

So when we've added it up, it adds up to only seven or eight questions we probably would like to see not repeated or changed to make it clearer.

Look at that cognitive question. That's a hard one to get through.