Question: As a therapist who regularly performs start-of-care visits for referrals with PT-only orders, I am responsible for the OASIS form. I often struggle with the medication section, and wonder when I should ask for nursing to be added to the case to assist in this area. Though the agency is supportive and assists with the medication section, I am unsure as to what liability concerns exist. How should I proceed so that the patient receives appropriate care regarding medications?
Answer: When addressing the question of therapist involvement in the medication management of the Home Health episode, many factors must be considered as Medicare, home health agencies, and individual clinicians seek a common approach. Issues that include scope of practice, medico-legal liability, educational levels and clinical control all contribute to current climate in the rehab world. Many therapists share similar concerns and have a general un-ease regarding their specific role and responsibilities when acting as the start-of-care clinician.
The introduction of the Prospective Payment System to home care established the use of the Outcome and Assessment Information Set (OASIS) as a comprehensive evaluation tool for all home health patients.
The OASIS mandated the recording of all current medications as a necessary element of the initial assessment as part of a multi-system approach to clinical programming. In addition, the emphasis on specific clinical service delivery that was the goal of OASIS-based care served to emphasize the importance of therapy in achieving desired functional outcomes.
The need for nursing to assume the role of clinical and case manager for all home health episodes was eliminated by the PPS utilization of the OASIS to identify specific declines that would be addressed by discipline-specific programming. As a result, OASIS visits were able to be performed by non-nursing personnel (PT/speech) who were then required to complete the medication section.
The concern in your question is shared by many therapists' that clearly lack the educational background as well as the daily working knowledge regarding medications that registered nurses working in home health possess.
A multitude of thoughts come to mind regarding this issue. First, the expansion of professional scopes of practice is common to all licensed medical providers over the past quarter century. Recent and on-going advancements in medical protocols, best practices identification, health care delivery and reimbursement mechanisms, and technological areas have changed the day-to-day complexion of what healthcare is and how it works. Clinicians in nearly all areas of care delivery possess and practice skills that were not present in their particular discipline as recently as 10 years ago. Acute hospital based nurses are now required to be certified in techniques that were only present in ICU staff. For example, PTs are now taking PT/INR measurements in some home health areas.
The recording of medications in the OASIS is where the concern lies for the PT that has proposed today's question. The practice of recording the medications alone does not make the PT responsible for the medico-legal concerns of medication errors or patient responses. The liability lines are clear: 1) prescribing physician, 2) participating pharmacist, 3) Medicare-certified home health provider, and (possibly) 4) licensed nurse/therapist.
Even when a therapist is the clinician of note on a home health episode (that would include the OASIS visit), the agency is responsible for the review and safety of the medication review required by the OASIS. As a result, most agencies have established procedures requiring the review of the medication portion of all OASIS documents, particularly those not performed by nursing personnel.
Further confusion revolves around the question as to when to add skilled nursing to the case for medication issues. When the therapist performing the start-of-care visit finds medication concerns that are confusing to either the clinician or the patient, the addition of nursing to the episode to address these issues is appropriate. The nurse is able to discuss medication issues with all concerned parties; the physician, pharmacist, patient and therapist. In addition, the medication management OBQI scores are more likely to improve when managed by nursing personnel.
Therapists concerned about medico-legal issues should take steps to assure that some supervisory review and control occurs at the management level in the home health agency. Certainly, therapists employed by the home health agency would have liability coverage as part of their employment package.
Those PTs that work in home health under contractual agreements would be well-served to have this item included in their professional contract if they feel the need to define specific lines of liability. Though this author has not taken this step in his professional practice, he certainly supports any actions taken by rehab professionals to delineate working concerns so they can move forward to address clinical concerns.
Arnie Cisneros is a physical therapist with nearly 25 years of home care experience. He is the owner of Home Health Strategic Management in East Lansing, MI, providers of clinical service management and home care consulting expertise. He is a nationally renowned speaker regarding the PPS refinements of 2008 and therapy utilization under the New Rule. Contact him directly at www.homehealthstrategicmanagement.com