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Optimizing Your Medication Documentation in OASIS-E

    Assisting patients with safe medication management is one of the fundamental services that home health agencies can provide. 

    The OASIS-E system has introduced a more holistic approach to safe and effective medication management by incorporating mechanisms that can help identify medication issues and barriers to safe self-administration and promote the development of more personalized plans of care. As a result, it creates opportunities for conversations with patients about these issues and provides chances for education to improve safe use and self-administration. Additionally, OASIS-E prioritizes education on high-risk drugs by introducing best practices for identifying high-risk drugs and determining whether physician or practitioner intervention is necessary. 

    By addressing these issues and education needs, agencies can reduce the likelihood of patients requiring acute-care hospitalization (ACH) or emergency department (ED) use due to adverse drug events (ADEs). Based on research, ADEs lead to about 1.3 million emergency department visits and 350,000 hospitalizations yearly, with an average of 8,000 deaths. Preventable ambulatory ADEs make up over 40% of these cases.

    ACH and unplanned ED use are critical for home health agencies not only because it indicates poor patient care, but also because it comprises the claims-based measure part of the performance scoring for home health value-based purchasing.

    Assessing Patients’ Competence in Safe Medication Management

    During the start-of-care visit, clinicians assess the patient’s ability to manage their medication safely. They do this by asking the patient to show them where they store their medications, explain how and why they take each one, and demonstrate the necessary skills, such as opening bottles and selecting pills. This assessment helps identify barriers to safe medication management, including ambulation (M1860, GG0170), vision (B1000), hearing (B0200), compliance (M1033), health literacy (B1300), and safe ability to self-manage meds (M2020, M2030). By understanding these barriers, clinicians can develop interventions to address them and help set the patient up for success, improved safety, and better outcomes.

    Performing the Drug Regimen Review (DRR)

    During the DRR, clinicians can identify medication issues that require immediate follow-up with the provider (M2001, M2003) to avoid ACH or ED visits. Here are some things to keep in mind:

    • Identify any drugs in the six classes listed in N0415, as well as any other high-risk drugs (M2010) that the patient is taking. 
    • Determine if there is an indication noted for those medications in N0415
    • Identify other high-risk meds like chemotherapy and certain IV medications using the OASIS item O0110 Special Treatments, Procedures, and Programs.
    • Ensure that the patient and caregiver are taught about any special precautions, especially for high-risk meds, and how and when to report any problems. Teaching high-risk meds during the SOC/ROC time points is critical to ensure patient safety and prevent ADEs.

          The Impact of Social Determinants of Health (SDoH) on Medication Access

          OASIS-E highlights the need for healthcare to focus on health equity and SDOH. The new transportation question (A1250) directly addresses whether patients face difficulty getting to medical appointments and accessing medications. It’s a gateway to discussing other barriers to proper medication management. By identifying SDoH and addressing them, clinicians can help patients take their medications safely and prevent hospital readmissions and ED visits.

          The Importance of Transferring Health Information

          OASIS-E added new items (A2120, A2121, A2123, A2122, A2124) related to sharing health information. Sharing an up-to-date medication list at discharge or transfer can improve care quality and coordination, and prevent medication-related issues. It is critical to communicate medication information to the patient and their family during transitions between healthcare settings. These new items will hold agencies accountable and help them maintain updated medication lists to improve coordination for safe medication management.

          Getting the Needed Support for Effective Medication Management

          Through these developments in the OASIS-E, the role of clinicians in patient care has become bigger and more significant. Consequently, it is vital that clinicians have adequate knowledge and education to seamlessly incorporate these new factors into patient care.

          To guarantee this, it is important to have a robust QA program that supports clinician re-education beyond making sure that their assessments and documentation are accurate and substantive. Furthermore, a key component of the QA process should involve cross-referencing all medications mentioned in the OASIS with the patient’s medication profile. If any discrepancies are found, the medication profile should be promptly updated to reflect the correct information. This is crucial because the medication profile plays a central role in developing the patient’s Plan of Care. By helping clinicians effectively assess and document factors that impact medication management, QA programs can promote safe and effective medication management.