When a patient returns to Home Health services after an inpatient stay, the OASIS Resumption of Care (ROC) is crucial for ensuring accurate continuity of care and maintaining compliance. Beyond simply updating patient status, the ROC reflects your agency’s quality performance and directly impacts reimbursement.
Here are key pointers to help clinicians create accurate and thorough ROC OASIS:
1. Review the Hospital Stay Thoroughly
Before resuming care, review all hospital or facility discharge documents, including discharge summaries, medication lists, and new diagnoses. Clarify why the patient was hospitalized and how their condition has changed. This ensures updates to diagnoses, functional status, and medications are accurate and clinically supported.
2. Compare Pre- and Post-Hospital Function
Focus on GG items and M1800 functional items to capture any changes from the last OASIS. Compare the patient’s prior ability at Start of Care with their current performance at ROC. Under- or overestimating these changes can skew HHVBP outcomes and misrepresent patient progress.
3. Conduct a Full Medication Reconciliation
The ROC requires a complete medication review, not just an update. Confirm new orders, discontinued medications, and dosage changes directly with discharge paperwork or the prescribing provider. Inaccurate reconciliation is a common compliance pitfall.
4. Update Diagnoses and Plan of Care
Reassess the primary diagnosis and comorbidities—the hospitalization may have shifted clinical priorities. Review whether therapy frequency, nursing needs, or home health disciplines should be adjusted accordingly. Coding and POC alignment are essential for accurate reimbursement.
5. Validate All Assessment Timelines
Timing is everything. The ROC must be completed within 2 calendar days of the patient’s return home. If delayed due to circumstances (e.g., patient unavailability), document the reason clearly in the clinical record to stay compliant.
6. Don’t Skip the Discharge OASIS Review
Before finalizing the ROC, revisit the previous Discharge or Transfer OASIS. This helps identify trends, such as functional decline or new risk factors, ensuring your documentation reflects a complete clinical picture.
7. Capture Risk and Clinical Complexity
Include details on new or worsened symptoms, wound status, cognitive changes, or new assistive devices. These can influence quality measures and care planning under HHVBP and PDGM.
8. Leverage QA Expertise to Catch Common ROC Errors
Your QA team is a helpful partner in ensuring your ROC documentation is complete and compliant by identifying inconsistencies especially in common error-prone areas including:
a. GG items and M1800 scoring alignment between disciplines or pre- and post-hospital status.
b. Diagnosis sequencing and coding for new or resolved conditions.
c. Medication changes from the inpatient stay
d. Alignment with the Transfer OASIS and compliance with the 2-day completion window.
Position your QA program as a collaborative partner rather than a correctional process. Encourage clinicians to recognize that working closely with QA specialists enhances their assessment accuracy and strengthens clinical documentation over time.
The OASIS Resumption of Care plays a vital role in capturing a patient’s post-hospital status and guiding the next phase of care. It is designed to record accurate information that supports an updated plan of care, ensures quality outcomes and compliance, and promotes appropriate reimbursement—making it a critical component of home health documentation.
