burden reduction memo

Title: Medicare and Medicaid Programs OASIS Collection Requirements as part of the CoPs for HHAs and Supporting Regulations in 42 CFR, Sections 484.55, 484.205, 484.245, 484.

OMB Number: 0938-0760

A. Proposed Item Deletion OASIS-C to OASIS-C1

In response to OMB’s request for reduction of burden related to collection of the OASIS data set, CMS and its contractors have identified opportunities to eliminate collection of eight items at various time points, as identified in Table 1.

• M1012, Inpatient Procedures, is currently required at start and resumption of care for all patients discharged from an inpatient facility within 14 days of the start or resumption of care. It asks the clinician to report both the name of the procedure and the ICD-9 procedure code for up to four procedures that a patient had at any time in the preceding inpatient stay. The purpose of collecting the item was to improve risk adjustment of quality measures. It is an item that agencies have previously reported to be time-consuming and burdensome as this information may not be readily available at the time of home health intake. CMS announced in April 2011 that the response to M1012 was not used for payment, quality measure development, or risk adjustment so any response including “unknown” was acceptable to report, but the item cannot be left blank. However, agency interviews conducted as part of OASIS-C1 development in late 2011 indicated that clinicians are not uniformly aware of the CMS announcement. Therefore, the deletion of M1012 from the OASIS will result in a decrease in burden to all OASIS users (in that a response will no longer be required) and will provide an even greater decrease in burden for those users who have continued to collect and report the information on inpatient procedures to complete the item. We propose to completely eliminate the item from the OASIS-C1; this change impacts OASIS assessments conducted at start and resumption of care.

• Items M1310, M1312 and M1314 are currently collected at start and resumption of care and at discharge. They report the length, width and depth of the pressure ulcer with the largest surface dimension. If the patient has more than one pressure ulcer, the clinician must determine the longest length and width of each pressure ulcer and make a determination of which ulcer has the largest dimensions, then measure and report the length, width and depth of that ulcer, rounding to the nearest centimeter. The intention of including these items in OASIS was to provide data for a measure reporting on improvement in the patient’s pressure ulcer status between start/resumption of care and discharge. However, the information is not currently being used for that purpose. We propose to eliminate these three items entirely from the OASIS-C1; this change impacts OASIS assessments conducted at start and resumption of care and at discharge.

• Item M1350 reports whether the patient has a skin lesion or open wound that is receiving intervention from the home health agency, other than a surgical wound, pressure or stasis ulcer. This item is currently used only for risk adjustment of quality measures. We propose to continue collecting this item at start and resumption of care (which is when risk adjustment takes place), but to delete it at discharge.

Table 1. Items in OASIS-C Planned for Deletion in OASIS-C1
OASIS-C Item		Collection Time Points in OASIS-C						Planned Change
Item #	Item Description	SOC	ROC	FU	TRF	DC	DAH
M1012	List each Inpatient Procedure and the associated ICD-9-C M procedure code relevant to the plan of care.	S	R					Delete item at all time points
M1310	Pressure Ulcer Length	S	R			D		Delete item at all time points
M1312	Pressure Ulcer Width	S	R			D		Delete item at all time points
M1314	Pressure Ulcer Depth	S	R			D		Delete item at all time points
M1350	Does this patient have a Skin Lesion or Open Wound, excluding bowel ostomy, other than those described above that is receiving intervention by the home health agency?	S	R	F		D		Delete item at FU and DC
M1410	Respiratory Treatments utilized at home:  (Mark all that apply.)	S	R			D		Delete item at DC
M2110	How Often does the patient receive ADL or IADL assistance from any caregiver(s) (other than home health agency staff)?	S	R			D		Delete item at DC
M2440	For what Reason(s) was the patient Admitted to a Nursing Home?  (Mark all that apply.)				T			Deleted at all time points
Total # deletions at each time point		4	4	1	1	6	0

• Item M1410 reports the types of respiratory treatments (oxygen, ventilator etc) the patient is receiving at home. This item is currently used only for risk adjustment of quality measures. We propose to continue collecting this item at start and resumption of care, but to delete it at discharge.

• Item M2110 reports how frequently the patient receives assistance with activities of daily living from caregivers other than the home health agency. This item is currently used only for risk adjustment of quality measures. We propose to continue collecting this item at start and resumption of care, but to delete it at discharge.

• M2440 is collected at the time of transfer from home health to a skilled nursing facility to identify the reason that a patient was transferred. We propose to eliminate this item entirely from the OASIS-C1 as it is not used for payment, quality measure development, or risk adjustment.

The impact of these changes on the number of items in the OASIS dataset is shown in Table 2:

Table 2. Number of Items in OASIS-C and C-1, by Assessment Reason/Timepoint
Dataset	Total Items	Start of Care (SOC)	Resumption of Care (ROC) after Readmission from Inpatient Stay	Recertification/ Other Followup	Transfer to Inpatient Care	Discharge	Death at Home
OASIS-C	114	95	80	32	19	62	5
OASIS-C1	110	91	76	32	18	56	5

The total number of items in the OASIS dataset decreases from 114 in OASIS-C to 110 in OASIS-C1. The number of items collected at Start of Care decreases from 95 to 91, at Resumption of Care there is a decrease from 80 to 76, at Transfer it decreases from 19 to 18 and at Discharge the number of items collected drops from 61 to 55. The number of items collected at Recertification/Follow-up is anticipated to remain the same despite the deletion of one item (M1350) at that time point. This is because of the anticipated need to begin collecting another item (M1011) at that time point for the purposes of case-mix adjustment used in the payment system.

B. Impact of Changes on Burden

Our estimate of the hours of respondent burden to be reduced by the proposed changes to the OASIS data set was calculated using a methodology generally consistent with the previous round of burden reduction conducted by CMS in 2002.

Because different number of items are collected at different time points (start of care, recertification, inpatient transfer, etc.), the total burden estimate for a year is calculated by multiplying (a) the number of each type of assessment conducted in a year by (b) the number of items in each type of assessment by (c) the average length of time per item. The reduction in burden is the difference between the total estimated burden of the current version of OASIS (OASIS-C) and the projected burden of the proposed OASIS-C1.

Since we lack information on the specific time required to complete each OASIS item, we use a standard average length of time per item. The estimate of average time per item used in the calculation is 0.9 minutes per item. This is slightly higher than the 0.7 minutes per item included in the OMB notice printed on the current version of OASIS, but it is more consistent with the estimated average burden per assessment of 60 minutes which has been used in estimating total burden for OASIS-C. (The estimate of 0.7 minutes per item yields an average per assessment of 43 minutes per assessment.)

Table 3. Calculation of Burden Reduction Impact
Reason for Assmt	Frequency	Freq %	# Items OASISC	# Items OASISC1	# Deletions	Avg Mins per item	Mins saved per Admin	Total Mins saved	Total hours saved
1 - SOC	5647110	0.33	95	91	4	0.9	3.6	20329596	338826
3 - ROC	1071622	0.06	80	76	4	0.9	3.6	3857839	64297
4 - FU	4054919	0.23	32	32	0	0.9	0	0	0
5 - FU (other)	65109	0.00	32	32	0	0.9	0	0	0
6 - TF w/o DC	1641621	0.10	19	18	1	0.9	0.9	1477459	24624
7 - TF w/DC	234749	0.01	19	18	1	0.9	0.9	211274	3521
8 - Death at home	39182	0.00	5	5	0	0.9	0	0	0
9 - DC	4514578	0.26	62	56	6	0.9	5.4	24378721	406312
Totals	17268890	1.00					14.4	50254889	837581

Based on these calculations, we estimate an overall reduction in burden of 837,581 hours per year when OASIS-C1 is implemented in October 2014.In an effort to ease paperwork burden on HHAs and their clinicians, CMS supports the deletion of OASIS items at any time points where the information collected is not currently being used for payment, quality measurement or risk adjustment. We believe the deletions being proposed for OASIS-C1 meet that goal. CMS would have serious concerns, however, about deleting additional OASIS-C items since this would potentially compromise CMS’s ability to fulfill our mandates to: 1) collect the information necessary for development of a reliable case-mix system; and 2) collect information required for the measurement and reporting of home health care quality.

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