And we're live. This is a lawless and an ill-starred kingdom. It has no time for justice or the law, but everything is bought and sold for money. One wasteful, plots and schemes in such a way that great and small all openly defend his villainy and his immoral case. Without a care for truth, without a thought, for consequences that their vote brings with it. These folk don't understand the cancer is harm that the degeneracy of their young people does their republic. They have set a price on virtue and on shame. When one's amongst them, it's not impossible to practice goodness. They ruin homes, bring states to destitution, then cause their downfall. Troy, you'll see in time. And by their own example, they corrupt great numbers with them. Look at how they're followed by hordes of spongers growing fat as hogs through constant indolence and overeating. You think that any of these of this herd is able to serve his country? Where are a suit of armor? Wouldn't even silks too heavy for their shoulders? Do sentry duty when they've learned to snore till afternoon? Withstand the enemy's blows when endless drunkenness has sapped their health? They think they're different and they call for war. God grant me always men like this to fight with, eternal sun and you abundant earth and you expansive sea and all you gods, both high and low, be now my witnesses. The thing that I was asking for is just. I wanted satisfaction for an insult and a great wrong, yet I got not but laughter, which merely made for more ear feeling than mighty gods. I now commit to you my hurt and my resentment. If this plea comes from a spotless heart, avenge this insult, this gross misdeed, let Paris in my clutches so that my sword may feed upon the blood of this baseman who in his turn is sated on my disgrace and thrives on it today. A white-winged swimmer of the sea, sir, hewn from the beaches found in plenty. Upon the summit of Mount Ida, craft that delivered smooth-faced Paris, son of King Priam, by salt sea lanes, to the eurotous gleaming Fordways. What sister-in-law did you bring here for our great monarch's noble daughters? For Polyxena in her virtue and for Cassandra, the prophetic one that's pursued here like a slave girl fleeing her masters? Surely this isn't Venus's present. From the beginning, strife and discord branded your marriage, son of Priam. O mighty Venus, stop me wanting things that are not mine. Grant me only one kind companion, one true bedmate. Those who want more still let them ask it. There have been many led to error by their eyes craving. Those, however, who can entirely curb their longing, they'll go on living long and safely. Soon it will come. Soon the time when bandit will find bandit. Your Highness, I have loyally advised you that Helen should be given to the Greeks so as to douse the torch of certain war as fast as possible. And yet my counsel carried no weight, in consequence of which I warn you in advance that there will be a great campaign that wars a certain thing, as surely as I stand before you now. You heard the way the envoys bid farewell to you and all of us. The border chieftains have written saying that the Grecian fleet is nearing all us. There can be no doubt. They're coming here, or else why send their envoys, or speak so sharply of the wrong they've suffered. Don't wait before we lose all of our coastline. Make sure our ports and border fortresses are suitably provided in advance with man and rations. Tell the vassal princes to be in readiness. Ensure the soldiers are set for battle. Send out spies. Keep watch on land and sea so that the cunning Greeks don't catch us napping. This is my advice.  Best to be frightened now, Your Highness. Fear makes one more provident and well-prepared. Later, there'll be no time to think, just fight, or run away. There'll be no other choice. I mean to take good care of everything so that we're not reduced to sudden flight. May God forbid. But who's this woman here? Her hair disheveled in her face so pallid. Her limbs are trembling. She can scarcely breathe.  Now she's silent, now tries to speak. This is my luckless daughter, Cassandra. I can see Apollo's spirit has seized her as it's want to. At such times, a person cannot choose but has to listen. Oh, why do you torment me to no purpose, cruel Apollo? You gave prophetic powers but not the gift of being understood. So all my auguries fly in the wind. No one will give them credence anymore than empty fairy tales or fleeting dreams. Who will help me with my heart bound up in chains? Who sought my memory from vanishing? Who needs this alien spirit in my mouth? I fight in vain. It is imposed on me. I can't control myself. I'm not myself. Dear Lord, where am I? I can't see the light. A sudden dark has fallen on my eyes. I see two shining suns. I see two troids. I see a graceful hind sailing the sea. She means misfortune and she heralds ill. Shepherds, defend the shoreline. Don't allow this fateful visitor to ever land. It is a wretched land and wretched shore where she'll arrive. And wretched is the glade she'll enter laying down her slender form. Her, all her footsteps everywhere she sleeps must run with blood, fire, ruin, devastation she carries with her. Oh, my lovely homeland, what end is waiting for you? You, my brother, shield of our homeland, guardian of our house.  And if our father wishes to make a burial of your body, you'll have to pay the murderer with gold. You priceless soul, with you the homeland died.  And you as well, cruel trafficker in corpses, you'll fall as well the cause of your demise, an arrow fired by an unmanly hand. And what horse is this, towering so tall over the battlefield? Take my advice, don't lead it to the stable. It kicks and bites. You ought to burn it, rather. If you don't want to die in flames yourselves. Centuries, watch out. A suspect night is coming. A mighty blaze will burn, a fire so great. Things will be seen as if the sun were shining. But on the next day, nothing will be seen.


Titans preparing for Monday night football with the Buffalo Bills. So John, a little extra time coming off game one, time for more practice, more meetings. What's the team really been working on since your season opening game with the Giants? Well, I think improvement, Mike. I mean, there were certainly some things that we did well in that game. But also, you know, we've said before, it comes down to five or six plays that when you don't execute them properly, you know, the outcome usually doesn't bode in your favor. So really identifying those guys, working through practice, in meetings, stressing the points. When those present themselves again, we can execute them properly. What was your impression of the Titans rookies in the season opener? Well, I thought we got production out of several of those guys really in all three phases, offensively, defensively, and in the kicking game. There were certainly some positive plays that all of them made, but also some teachable moments like any young player that we can coach up and hopefully improve on. Let's talk about Buffalo, your opponent this coming Monday night. What impressed you about their opening win over the Rams on September the 8th? Yeah, really impressive in all three phases of the game, offensively, defensively, and in the kicking game.  He's got a lot of playmakers in digs, knocks, McKenzie, Davis made some plays for him down the field. I thought the line did a good job protecting for him.  You know, with Von Miller, Dayquan Jones showed up on the inside, Phillips on the inside, Ed Oliver, they got two great safeties in Poirier and Micah Hyde. Both of those linebackers were running fast and getting to the ball, Edmunds and Milano. So, you know, really complementary, offensively, defensively, and special teams. And they played well. Does it help you prepare that you've seen the Buffalo Bills the last four seasons in a row? Yeah, it feels like they're in our division. But, you know, from an X's and O's standpoint, you know, coaches always kind of tweak a little something here or do a little something different there. Buffalo players standpoint and, you know, personnel standpoint, you at least kind of have an idea of the skill sets of the guys that you're going to go against this player. He kind of, I remember when he did this or, you know, he did that and I thought I could take advantage of it. So, knowing the, you know, the skill sets of the player certainly is beneficial when you've got, you know, some consistency playing against an opponent every single year. John, what do the Titans have to do well Monday night to win at Buffalo? Well, I think improve on the things that, you know, we talked about earlier in the show and get better at those. I mean, it's a raucous environment up there. We know that we're going to have to handle all of the distractions with playing in Buffalo that comes with that. You know, but offensively, we've got to establish a run game. You know, we've got to protect Ryan. Guys got to get open quick because we know that rush is coming. And defensively, we know the problems that Josh poses as a runner and as a thrower. So, we've got to be disciplined in our rush lanes because he can escape at any moment and take off running. There's a lot of playmakers downfield. We've got to be sticking our coverage. And we've got to be really sure attackers. Now, we've got to ask you. We saw Manny Hooker make some big plays in last Sunday's game. What led you to extend his contract last week?  It started on special teams. He was a personal protector on the punt team. He carved out more of a role defensively. He was a sub-starter for us defensively. He showed up. He made plays. He works hard. He's smart. He's intelligent. Those are the types of players that you want to commit to when they come in and they do it the right way. They grow in our program and happy for his family and excited for us that he's going to be around here for several years.


Okay, today I'm coming to you with a quick tip about dream recall. If you don't know, this is where you improve the ability to remember your dreams so that you can therefore remember more dreams and have more lucid dreams. So this tip is gonna be basically centered around your ability to focus on different images. So normally, say on an average day, okay, you're gonna wake up and you'll probably start to think about what you might have dreamt about and maybe you'll remember a few details and then it will sort of go fuzzy from there, right? If you're like me when I started, this will be you. So you'll find it easy to remember a few details, but then when you try and really remember the meat of the dream and all the intricate storylines and everything that happened, it will sort of go a bit fuzzy. So this video is gonna be explaining how to fix that problem. So when you first wake up, okay, this has to start as soon as you wake up, what you're gonna want to do is write down everything you can naturally remember, okay? So all of the things that you remember naturally that just sort of come to your mind as soon as you wake up. And then when you start to get a bit hazy and fuzzy, just stop, just lay there in the bed, okay? And don't try and remember anything, but instead, I want you to cycle through as many random images as you possibly can, okay?  And what this means is, when you think of a particular image, for example, a cow, you will usually have semantics attached to that image, which means things that are related to the original image, but things that you didn't think about to start with. So if I say cow, you might then say milk or farm or dairy or something like that, okay? And it really is an easy way of remembering more about your dreams, because let's say you only remember one detail, for example, you're walking down the street in a city, okay? And then everything goes fuzzy from there. What you can then do is just cycle through a load of random images, okay?  And one of them, maybe one or more of these images will then trigger a semantic, which will then remind you of something that happened in the dream. And that just that tiny reminder can be enough most times to give you back the entire memory of that dream scene, okay? I've had this before when I've, you know, cycled through images when I've woken up. One of the images was a phone, for example, and just the image of a phone triggered me, you know, triggered my memory of the dream that I just had where I was on the phone to the president, okay? It's kind of random.  You wanna think about as many random images as you can. It might even help to have like a, you know, like an encyclopedia or something, a dictionary even, but by your bed. And then when you wake up and you're trying to remember your dreams, just flick through to a random page and just look at a view of the words and try and get a vivid image of that word in your head. And then what will usually happen is, as I say, it will just trigger random related images or things or ideas, okay? And this will be really, you know, helpful to you to remember dreams that you can't normally remember. So yeah, I hope this has helped. If it does help, obviously leave a comment. Don't forget to subscribe and I'll see you in the next video. What's up guys, thanks for watching. If you enjoy these videos and you like what I do on this channel, you can actually support me using the Patreon link down in the description or I'll put one that will come here as well. And that's patreon.com forward slash how to lose it. That's the way you can sort of support me with giving small monthly amounts and it really does make a huge difference to me. That allows me to keep doing these videos. Also, if you're about to get a free and lucid resource guide PDF, make sure you click the link that should be in the corner here. Absolutely.


We humbly ask that you shield and protect our recruitment teams from harm and danger, both seen and unseen. Keep them safe, O Lord, from the snares of the enemy and the hidden girls that may lie ahead. We ask you to send the right candidates for this job. People who are your perfect choice to fill the backhand positions in our midst. We pray, O Lord, for Ergo Kenyans who will protect and defend the sovereignty of our nation. We ask this in your most beautiful names and your attributes that are most high. Amen. In the name of the Father, and of the Son, and of the Holy Spirit, Heavenly Father, Ruk Veverapuri upon thy servant who supplicates before you this morning, In humble prayer that your presence may be with them, as they commence the recruitment process for the new members of Kenyan Defence Forces, who will continue the mission of the defence of our country. You are once and seen. From the people at Raj, choose capable, God-fearing men, men who are trustworthy and incorruptible, and put them in charge as hands of thousands, hundreds, fifties, and tens. All those who will be involved in this recruitment process are called by the same spirit. Of this day, we dedicate them to you, knowing that they may face battles which among them must not be against their flesh and blood, but principalities, powers and rulers of darkness of this world. Lord, we ask that you cancel every evil plan that may be decided to harm thy servant. We pray that you express every skin, throat, and pran that the evil one may set in motion. We pray that they may be nerfed and rendered powerless in the name of Jesus. Surround thy servant, our Chief of Defence Forces, Vice Chief of Defence Forces present here with us, the service commanders and all who work under them with your fatherly care and protection. May your rights and counsel be with them so that they may be able to guide the process to its logical conclusion. We pray that you grant all the ground recruiting personnel wisdom and discernment to recognize and avoid the traps of the evil one, grant them safety as they travel, protect, protection and peace wherever they will be tired. May your blessings and guidance be upon them now and always, as we know and trust and believe you hear our prayers in the name of the Father, and of the Son, and of the Holy Spirit. Amen. Kindly, for the press conference on the launch of the Nationwide Recruitment. My name is Bogita Ogueri. I am the Director of Public Communications for the Ministry of Defence. And before we start off, I would like to introduce the leadership. Starting with our main speaker today, Lieutenant General John Omani, who is our Vice Chief of Defence Forces. We also have Major General David Tarlus, Deputy Army Commander, just next to him. We have Major General David Tarlus. Major General David Tarlus is our Assistant Chief of Defence Forces, Personnel and Logistics. And I defined, we have Major General Dr George Nanna, who is our Director of Medical Sciences. And we also have here Brigadier Matthew Denhamnai, who is the Chief Recruiting Officer for this exercise. From the order of proceedings that we have today, our Vice Chief of Defence Forces, Lieutenant General John Omani, will be making this address and officially launch the 2023 KDF Nationwide Recruitment. And I think we are going to, this will be followed by a brief media, where is it you have, and it will give you time so that you can ask any clarification that you may need. And we will give you that opportunity so that there are some issues and crossfire.


Hello, everyone. I'm Doris McMillan. Welcome to the Outcome and Assessment Information Set, OASIS Satellite Broadcast. The purpose of today's broadcast is to provide our viewers with a general understanding of the requirements concerning the Home Health Comprehensive Assessment and OASIS Collection Regulation and the OASIS Reporting Regulation. Now, in our program today, you will hear a series of pre-recorded presentations by HICFA experts, representatives from the National Association for Home Care and the University of Colorado's Health Sciences Center on the impact of integrating OASIS data set into the Home Health Agency recordkeeping system, the need to collect and encode OASIS data, and the state's role in training and receiving the data. You will also hear and see a presentation on the help that will be provided by HICFA through the Home Assessment Validation and Entry Software, or HAVEN. Before we begin the broadcast and introduce our first panel, Sally Richardson, Director, Center for Medicaid and State Operations, Healthcare Financing Administration, and Val Halamideris, President of the National Association of Home Care, would like to make a few opening remarks about today's program. Good morning. I'm Sally Richardson, Director of the Center for Medicaid and State Operations at the Healthcare Financing Administration, and I'm delighted to have this opportunity to welcome each of you to this satellite training for Home Health Agency providers and staff who will be working with the collection and automated submission of the outcome and assessment information system, the system we know as OASIS. The OASIS is a key component of Medicare's partnership with the home health care industry to foster and monitor improved home health care outcomes for our beneficiaries. The satellite training is the result of a lot of effort by a lot of different people. The staff here at HICFA has collaborated with representatives of your association at the national level for home care on this training session, and I'd like to begin by thanking those involved for contributing their expertise and experience. During the training session, you will learn more about the HICFA, what HICFA is looking for, as your facilities and staffs work to meet the requirements for OASIS collection and submission. Many of you come here with years of experience in the home health field, and we're anxious to work with you on this new initiative. We want to make sure that we provide you with the best information you need to make your jobs of meeting the requirements as easy as possible. All of us know that data is becoming more and more important in shaping healthcare policy decisions that ultimately improve the life of patients across all of the care settings. That's why your work in ensuring the accurate submission of the OASIS dataset is a critical step in our joint efforts to improve not just the operation of the Medicare and Medicaid programs, but more importantly, the outcomes of care for our beneficiaries. It's also important to note that the Balanced Budget Act of 1997 relies on OASIS data for the implementation of a per-episode prospective payment system for Medicare services in home health agencies. The next two hours are intended to provide you with the beginning knowledge necessary to help you understand OASIS and prepare you to begin planning for OASIS in your agency. It's an important milestone in our shared commitment to programs and initiatives that promote the well-being of patients receiving care from home health agencies. We're confident that we can count on your contributions to making OASIS and its outcome-based quality improvement reports to improve the care of beneficiaries. We look forward to a productive training session and to continuing to work with you in the implementation of this major national initiative. Thank you. Hello. I am Val J. Halamanderis, President of the National Association for Home Care. It has been my privilege to serve the home care and hospice communities through NACC for the past 16 years. In an environment of ever-increasing health care costs, there is no possibility to be as efficient as possible and to demonstrate the value of services that we provide to Medicare beneficiaries. In order to fulfill that obligation nearly 15 years ago, NACC gave its support to HICFA in its efforts to better understand what constitutes quality services provided by home care agencies. Whether through our support of case-mix demonstrations or the implementation of the outcome assessment information set by a family called OASIS, NACC is committed to collecting data which will help agencies, payers and policymakers understand which services bring the most effective results for patients at home. Now, how can OASIS benefit your agency in several ways? First of all, OASIS has proven to be a valid and reliable tool for the objective assessment of the services provided to home health patients. OASIS will help develop a common language concerning care in the home. Second, OASIS helps meet the legislative and regulatory mandates to focus on outcomes of care. Third, it becomes a useful tool for state surveyors to monitor individual patient outcomes. Fourth, it is a useful performance indicator for accrediting organizations and payers. Fifth, significantly, it allows for collecting information on a national level in order to establish norms in variations among providers. Sixth, it enables providers to measure outcomes based on standardized assessments and to link these outcomes to cost and utilization. Seven, OASIS will enable agencies to be creative and identify employed the most effective means of care. Number eight, the National Association for Home Care, the state associations in the entire home care community have supported and moved toward perspective payment with the hope of sustaining the viability for Medicare home care benefits for generations to come. OASIS is expected to be an important part of this effort as the basis for case-mix demonstrations under PPS. Finally, and most importantly, OASIS continues our commitment to quality. It is about documenting care, measuring care, and determining what works best for patients who have received care in the home. Now for over a century, home care has provided the highest quality of healthcare to the ill and to the disabled. Today, OASIS offers us a new tool which will help us to provide the best care to a growing number of elderly and disabled Americans who need help in order to live at home with dignity. Now I invite all of you to become part of this partnership and to join us in support of OASIS and its implementation. It will help us demonstrate the intrinsic value of home care services. Thank you very much. Thank you, Sally Richardson and Val Halimederis. Now as I stated earlier, today you will see a series of pre-recorded presentations by our panel of experts. The first four presentations that you will see will discuss the purpose and benefit of OASIS, the history of OASIS, the comprehensive assessment requirement and the Balanced Budget Act and home health perspective payment. Following these sessions, we will then open the telephone lines for questions. We invite you to call in your questions on a toll free line. That number is 1-800-953-2233. Now if you prefer to fax in your questions, the number is area code<PHONE_NUMBER>. The phone and session will last approximately 10 to 15 minutes followed by a short 5 minute break. After the break, we'll return to our second series of presentations which will include discussions on the plan for the states, the home assessment validation entry software referred to as HAVEN, views from a provider's perspective and how home health agencies should prepare for OASIS. Following these presentations, we will once again open the telephone lines for questions. The entire broadcast today is expected to last approximately two hours. Well now that I've given you an idea of what you can expect over the next couple of hours, let's introduce our panelists. On the right is the Professor, Division of Geriatrics and Director of the Center for Health Services and Policy Research, University of Colorado. Mary Vienna, Director, Clinical Standards Group in the Office of Clinical Standards and Quality. And Robert Wardell, Director, Division of Community Post-Acute Care, Center for Health Plans and Providers of HICVA. Now that we've met our panel, let's take a look at each of their presentations. This is a great time for all of us who believe that better information about a beneficiary's care needs, strengths, weaknesses and changes in condition can result in overall improvement of care. The automated OASIS system will provide for a rich database and for outcome of care information that we can all learn from. Home health agencies, government agencies and most of all beneficiaries and their families will benefit from this effort. During the next few minutes I will review for you an overview of the OASIS system. This will be a framework for what will be discussed later. Secondly, the expected benefits of the system for the individual patient, for the care provider, for the government and for the frail, elderly population and the whole. Finally, I will mention some of the things that you can and cannot expect to learn during this session. Remember, this is just the start of training opportunities that we will provide on the OASIS and the automated OASIS system. For starters, a little background. The OASIS dataset has been developed by Dr. Peter Shaughnessy and his staff of professionals from the University of Colorado over the last several years. This dataset was developed as a key ingredient of the outcome and quality improvement process for home health agencies. Much of the work by the University of Colorado has been done under contract with HICFA. Dr. Shaughnessy will discuss the OASIS and its purpose later on in this session. HICFA issued a proposed regulation that would require all home health agencies incorporate OASIS dataset in assessment instruments used for determining the care needs of beneficiaries. This requirement was part of a proposal for new conditions of participation for home health agencies. Later, Mary Viana will be discussing the proposed requirements for OASIS. Also, as background, it's important to remember that the Recent Balance Budget Act of 1997 or BBA requires that HICFA implement a prospective payment system for home health agencies. Bob Wardwell will discuss plans for a prospective payment system. As part of the overall plan for making better use of information, HICFA is building an automated data system that will include assessment information from various Medicare and Medicaid providers. We started with nursing homes. Now we're working on adding to this system to collect OASIS data from home health agencies. Before I go over a brief description of how the system works, I want to review what will be the key responsibilities of each home health agencies for the system. First of all, the home health agency must incorporate the OASIS data set required by HICFA into its own assessment instrument. Secondly, the HHA must assess care needs for all patients in the Medicare or Medicaid certified unit using instruments that includes the OASIS. Next, the HHA must encode and transmit the OASIS to the state. Finally, the HHA should use the performance feedback reports for quality improvements. So each HHA should keep these points in mind as we continue with today's session. The automated data system that HICFA is developing provides for OASIS data to go from the home health agency to the state and from the state to HICFA. The HHA will encode and send OASIS data for patients to the states. Agencies will receive edits and other reports from the states. These reports will identify records that fail edits. In the future, HHAs will receive outcome reports from HICFA in the states that will show the HHA's performance for numerous care areas. One thing I want to make sure of to mention is the free data entry software that HICFA is creating for HHAs to use in submitting OASIS data to states. It will be called HAVEN and it's free. There will be more discussion about HAVEN later. I would expect that an HHA would be asking how will we benefit from the OASIS data and reporting system? One of the prime purposes of the OASIS collection and automation system is to provide an HHA with information on its performance improvement efforts. Feedback reports will describe how an HHA compares on performance measures. This information, as Dr. Shaughnessy will discuss, can be used by the HHA to improve the care and services it provides to patients. There are many other benefits and uses for comprehensive OASIS data at the HHA state and national levels. We have just discussed the use of this information as a support to provider improvement activities. Secondly, data will be available to enhance on-site inspections as well as to monitor agency performance on-going basis. Survey agencies will be able to compare an HHA over time to itself as well as to state and national averages rather than solely depending on short on-site visits. Eventually, quality performance information will be available for beneficiaries and their families to use when making important health care choices. Before we implement reports for the beneficiary, we will need to work with consumers and their families to assess the type and format of information that will be most beneficial. And as I mentioned earlier, the development and implementation of a case mix PPS system for Medicare will be based on OASIS data. OASIS information will inform Medicare fiscal intermediaries and HICFA regarding payment accuracy and medical necessity decisions. Information from OASIS will assist peer review organizations or PROs in identifying and or targeting quality improvement initiatives. With the automation of OASIS data, we expect that PROs will increase their efforts in developing improvement programs for home health agencies. Information can also be used in the development and dissemination of clinical best practices. Lastly, this data can be used to help establish coverage, payment and health care policy. We are becoming an information driven society. OASIS data will be useful for decision makers at all levels. Over the next hour or so you can expect to hear discussions from several presenters about general guidelines for OASIS, plans for OASIS automation, introduction to prospective payment for HHAs, hardware and software requirements, future types of training that HICFA will provide to HHAs and states, an introduction to outcome based quality improvement or OBQI and how we will communicate with you in the future such as through regulations. Remember, this is a short introduction to the OASIS data set and the OASIS automation system. So not all of your questions will be answered today. But we do encourage you to continue to educate yourself about OASIS over the next few months. There will be a requirement that HHAs use and submit the OASIS data set. So the earlier you learn about expectations and begin to prepare, the more ready you will be to meet the requirements. Unfortunately, due to illness, Helene Fredeking is not with us today. We do wish her a speedy recovery. Now Helene started out on the right foot by providing us with an overview of the purposes and benefits Next we'll see a presentation by Peter Shaughnessy as he responds to a series of questions regarding the development of OASIS. OASIS is a set of data items that can be used to describe health and health related characteristics of home health patients and clients. It should be used as part of a comprehensive assessment but it is not a comprehensive assessment itself. OASIS items cover several categories such as physiologic, functional and cognitive health. In order to measure changes in health status, which in fact are outcomes, it is necessary to collect OASIS data items at start of care and approximately every 60 days thereafter until and including time of discharge. Our Center for Health Services and Policy Research at the University of Colorado developed OASIS over a 12 year period with funding from HICFA, the Robert Wood Johnson Foundation and other governmental organizations. OASIS resulted from our efforts to develop practical and useful outcome measures. Developing outcome measures included input from multiple clinical panels conducting comprehensive programmatic and literature reviews and applying a variety of scientific measurement criteria. OASIS was developed through extensive clinical and empirical review thereafter and tested over a period of several years. It is most noteworthy that the outcome measures preceded and determined the development of OASIS data items. For our purposes in discussing OASIS, a patient outcome is a change in health status between two time points as illustrated in this slide. Examples include number one, improvement and ability to ambulate between start of care and discharge. In this case the health status indicator is ambulation. The change is improvement and the two time points are start of care and discharge. And number two, stabilization in dyspnea or shortness of breath between start of care and discharge. In this case the health status indicator is dyspnea or shortness of breath. The change is stabilization and the two time points are start of care and discharge once again. In examining outcomes the typical time points are start of care and discharge in home health care. In this definition of an outcome health status is very broadly defined. It includes physiologic, functional, cognitive, behavioral and mental health. And this is why OASIS includes a variety of different data items in these domains. Basically in order to measure outcomes across a multiplicity of domains of health status. OASIS is important primarily because it allows us to measure, evaluate and enhance patient outcomes. Outcomes are immensely important in health care. When you think about it, they are the reason why we provide health care and in this case home health care to impact the wellbeing of patients. When everyone is collecting OASIS data, it is possible to measure common outcomes across multiple agencies. In this instance, ultimately we are able to produce outcome reports so that I can compare my agency with a benchmark sample in terms of outcomes and ultimately compare my agency's performance one year in terms of outcomes with the preceding year. This takes us to outcome based quality improvement or OBQI. OBQI can be depicted as indicated on this graph. The left side represents outcome analysis and the right side represents outcome enhancement. On the left OASIS data are collected by an agency processed and transmitted so that outcomes can be computed and outcome reports produced. I then move to the right side where I choose certain target outcomes for the remediation or reinforcement of care behaviors that produce the outcomes. I next conduct an investigation to determine where I am weak and where I am strong in terms of the care behaviors that produce the target outcomes. I then use this information to develop and implement a written plan of action indicating how care behaviors will be changed who will be in charge a timetable and a method for monitoring the change. The effectiveness of the change can be monitored using the next outcome report to assess the impact on aggregate patient outcomes. HECFA funded our research center in 1994 to implement a national OBQI demonstration program in order to assess the feasibility of OBQI and determine whether or not it works. Shortly after that, the New York State Department of Health funded another demonstration program in that state for the same purposes. After the first year of outcome reporting each agency was asked to select at least two target outcomes. One of them was a common target outcome across all agencies, namely hospitalization. They were asked to enhance these outcomes to the extent that they could using the OBQI methodology just described. The net impact of OBQI in a national demonstration was to reduce hospitalization rates by 3 percentage points as you can see on this slide from approximately 31 percent to 28 percent. Roughly a 10 percent rate of decline over just a one year period. Similar impacts were found for other outcomes and at this point although the New York State findings are not available, we expect them to be somewhat similar to those in the national demonstration. These results will be published in the near future but the main conclusion that can be drawn now is that OBQI can impact outcomes pervasively and extensively if it is properly implemented. There are two ways in which you might react. First home care agencies might simply do no more than necessary to meet the Medicare requirements for OASIS data collection and reporting. I would call this the minimalist reaction. Secondly, you would be well advised, however, to recognize that OASIS and OBQI were developed primarily for the benefit of agencies and their patients. Not primarily for the benefit of government or regulation or payment although they can certainly be used for these purposes. With this in mind it would be wise to be very conscientious about carefully and diligently implementing OASIS understanding OBQI from the outset. This would reflect an awareness of an investment in your own future. I would call this the investor reaction. Adopting the investor response means several things. First, it means that administrators, CEOs, top management should be involved in implementing and maintaining not only OASIS but OBQI. Secondly, agency personnel should avail themselves of the various training opportunities and training materials that either are or shortly will be available to them. Third, it is important not to focus only on OASIS. I'll repeat that. Do not focus only on OASIS. OBQI is far more important than OASIS and OASIS is a means to that end. Fourth, OASIS and OBQI should be pervasive in the thinking throughout the agency. Not only in terms of management but in terms of staff, especially clinical staff. Fifth, internal training should be emphasized. This means not only internal training for your current staff but to put programs together as well that will be useful as refresher activities for current staff and also as training opportunities for new staff as they are hired. OASIS and OBQI are winners. In fact, they are big time winners. But only you and your agency staff can choose to make them so. Peter, what is the most significant challenge in implementing outcome-based quality improvement? Without doubt, the most significant challenge is remembering what OASIS is really all about. Basically, it's very easy to get tangled if you will in the data trees for the outcome forest. It's so critical to remember that OASIS deals with outcomes and where we're going with all of this is not just through data collection, not just through the minutia of all the problems of implementation and there are challenges. It results in a way to assess what happens to my patients and to improve those outcomes over the course of time. Thank you, Peter. Mary Vienna will now discuss the Comprehensive Assessment Condition of Participation. In the March 10, 1997, notice of proposed rulemaking, Hickford proposed to require that the Home Health Agency complete a comprehensive assessment in each patient for the use of the OASIS. The OASIS is intended to be the assessment instrument specified in section 1891D of the Social Security Act, which requires the secretary to designate an assessment instrument that the HHA uses in order to evaluate the extent to which the quality and scope of services provided by the Home Health Agency attains the highest capacity of the patient as reflected in the plan of care. In this section, I'll discuss the Comprehensive Assessment Condition of Participation, elements of the requirements, the use of the OASIS as a part of the Comprehensive Assessment, and considerations for the Home Health Agency in meeting these requirements. A comprehensive assessment of the patient is a critical process in the provision of care so that patients are identified so that they may be addressed by the agency. In addition, a comprehensive assessment will identify patients' progress towards expected outcomes or goals of the care plan. Changes in the health care system have also increased the importance of timely assessment and delivery of Home Health Services. In recognition of the importance of the assessment process in patient-centered care, we've established a condition of participation that addresses this standard clinical practice. The primary requirement under the proposed condition would be that each patient receive from the Home Health Agency a patient-specific comprehensive assessment that accurately reflects the patient's health status. The assessment needs to demonstrate the patient's progress towards desired outcomes and meet the patient's medical, nursing, rehabilitative, social, and discharge planning needs. The assessment need to incorporate the exact use of the oasis and, for Medicare patients, identify eligibility for the Home Health Benefit which would include the patient's homebound status. The desired outcome or goal of a comprehensive assessment is the identification of the patient's care needs. Therefore, in addressing this requirement we'd expect the agency to examine the content and the process of its own patient assessment in terms of its comprehensiveness and suitability in identifying patient care and discharge planning needs, progress towards patient outcomes and eligibility for the Home Health Benefit for Medicare beneficiaries. The agency should modify the assessment to address identified gaps, if any, and incorporate the oasis data set into the assessment. There are five standards contained in the comprehensive assessment condition and in these standards we detail the following requirements. Standard A addresses the initial assessment visit. The initial visit is performed by a nurse in order to determine the immediate care and support needs of the patient. This visit is conducted within 48 hours of referral or within 48 hours of a patient's return home from an inpatient stay or on the physician-ordered start of care date. If speech language pathology or physical therapy service is the only service ordered by the physician, the speech therapist or physical therapist may conduct the initial assessment within the timeframe stated. This process reflects the previous requirement for an initial evaluation visit with the addition of a timeliness requirement. We believe that it is critical to patient health and safety that a patient not be left unattended in the home when home health services are needed and it's reasonable to expect the agency to deliver services when the physician orders them. Standard B addresses the comprehensive assessment. The nurse must complete the comprehensive assessment in a timely manner consistent with the patient's immediate needs but no later than five calendar days after the start of care. If speech language pathology or physical therapy services is the only service ordered by the physician, the speech therapist or physical therapist may complete the comprehensive assessment within the required timeframe. This requirement does not preclude an agency from completing the comprehensive assessment during the initial visit and many agencies currently operate in such a manner. This timeframe provides operational flexibility to the agency while maintaining patient safety in ensuring that all patient needs will be identified within a standard time period. We believe that these two requirements reflect the practices of most agencies and therefore we encourage an agency to evaluate their policies and operational practices regarding timeliness expectations and consider administrative processes to track admissions and timeliness of services if not currently doing so. Standard C addresses the Drug Regimen Review. The Drug Regimen Review requirement is not new and was moved from the plan of care requirements to the assessment requirement which reflects the true nature and purpose of this activity. Under this requirement the comprehensive assessment must include a review of all medications the patient is currently using in order to identify any potential adverse effects and drug reactions including ineffective drug therapy, significant side effects and drug interactions, duplicate drug therapy and non-compliance with drug therapy. Please note that we modified the requirement by eliminating the need to identify adverse actions and contraindicated medications and substituting the more concise requirements for review of drug interactions, duplicate therapy and non-compliance with drug therapy. This modification narrows the scope of the Drug Regimen Review, provides accountability and focuses the assessment towards information predictive of a significant patient outcome. Given the narrower scope of the Drug Regimen Review we don't expect that agencies will have to expand this activity. We do encourage agencies to review their current Drug Regimen portion of the patient assessment in light of the increased specificity of the requirements. Standard D addresses update of the comprehensive assessment. The comprehensive assessment including the OASIS must be updated and revised as frequently as the patient's condition requires, beginning with the start of care date within 48 hours of the patient's return home from a hospital admission of 24 hours or more for any reason except diagnostic testing and at discharge. For purposes of this requirement we consider discharge to mean discharge to the community, transfer to another facility or the death of the patient. In meeting this requirement we would encourage agencies to consider establishing a tracking system to ensure that updates are completed when required. The final standard, standard E, addresses the incorporation of the OASIS data items. The OASIS data set must be incorporated into the agency's own assessment exactly as written in the OASIS. The OASIS data set is not intended to constitute a complete comprehensive assessment instrument. Rather, the data set comprises items that are a necessary part of a complete comprehensive assessment and are essential to uniformly and consistently measuring patient outcomes. The OASIS items are already used in one form or another by virtually all agencies that conduct thorough assessments and simply adding the OASIS data set to the rest of the agency's paperwork is burdensome and duplicates efforts. Therefore, we expect agencies to replace similar assessment items with OASIS items in their assessment forms. Placing the OASIS data items in chronological order in the comprehensive assessment increases the speed and accuracy of data entry. In determining how to meet the OASIS collection requirements, an agency should consider the effort and resources needed to modify their own forms versus the cost and usefulness of purchasing a commercially available product which includes the OASIS items. If the agency chooses to make the necessary modifications itself, it should evaluate its current assessment forms and processes, using the need to change as an opportunity to improve efficiencies in the assessment process. Several agencies in the OASIS demonstration dramatically decreased assessment times by streamlining and integrating forms and processes. We also encourage agencies to pilot their forms and processes in order to test them before distributing them agencywide. In conclusion, the requirement that agencies collect OASIS data represents a change in practice and an opportunity for agencies to examine their processes for additional efficiencies and improvements. We believe that these requirements will result in improved patient outcomes, more efficient agency practice and recognition of the value of home health services. Mary, are there any patients for whom OASIS should not be collected? Yes, there are. OASIS does not need to be collected on patients who are under the age of 18, patients who are exclusively receiving pre- and post-partum services, and patients who are not receiving health services or personal care services. Those kinds of patients would be those that are receiving housekeeping, lawn mowing, those sort of things. Okay, thank you, Mary. Now, before our next presentation, I'd like to remind our viewers that following this session, we will have a 15-minute phone-in session. The number for calling in your questions is 1-800-953-2233. The fax number is<PHONE_NUMBER>. And now let's return to our next presentation. I'd like to take just a few moments of your time to explain the importance of OASIS in the development and implementation of prospective payment for home health under Medicare. As many of you are aware, the Balanced Budget Act of 1997 outlined the broad requirements for prospective payment system under which Medicare home health payments would be made. While Congress left many of the parameters that system open to our rulemaking, it makes clear that payments under prospective payment must be adjusted for case mix, which will account for variations in the level of service intensity which differ between patients. Early in the conceptual development of PPS, even before the enactment of BBA, it was clear that case mix adjustment would be necessary to provide equitable PPS payments. Any case mix adjustment must be based on timely and accurate measurement of the characteristics of patients receiving care. Rather than developing a new means of collecting data, it was decided the most efficient method to use, if possible, was a data source already available and on the drawing boards in HICPA to measure patient outcomes. The OASIS data set. If successful, this would enable one data collection to be used both to assure quality and to adjust payment levels. This isn't only efficient, but appealing. It's an exorbitantly linked payment and quality in a way which would synergistically enhance the validity of both. The first step in deciding if and how OASIS will be used to adjust prospective payment rates is well underway. In HICPA-sponsored research being conducted by APT associates, a group of home health agencies is voluntarily since last fall and providing detailed information on the resources each has employed to treat patients. These data are being compiled and analyzed to identify those OASIS items which most reliably predict home health resource utilization. It should be noted that the OASIS data set being tested is not identical to the version with which you are most familiar, the OASIS-B, but rather is a data set called OASIS Plus. HICPA solicited and received numerous comments from the home health industry on additional or slightly modified OASIS items which experts believe might more accurately predict resource utilization. Should some of these Plus items prove significantly more useful than OASIS-B alone, they'll be added to OASIS data collection and reporting prior to the implementation of PPS. Because the case mix adjustment index will determine the amount of payment a home health agency receives, I'm sure you can understand why it will be important when PPS is implemented. But it's less obvious why it's important that OASIS-B implemented as quickly and accurately as possible before the effective data of PPS. As we develop the rates we'll pay under PPS, it's critical that we know as completely and as accurately as possible what the current distribution of case mix is for home health agencies. Because Congress has established a budget limit for total spending under PPS, we must be able to predict what our total expenditures will be at various PPS rates, adjusted by case mix on a national basis. Now we could assume that the numbers and types of cases represented in our research is the same as that of the entire country. But since this research did not employ a large sample, the results of using only these data would not be as exact as we'd prefer. It's a bit like trying to price a grab bag full of items based on one handful without knowing exactly how many of each item is in the entire bag. With full implementation of OASIS, including timely and accurate reporting to HICFA, we'll be able to price the PPS payments with a higher level of accuracy. Borrowing from my grab bag analogy, we will have opened the bag, sorted, identified and counted every item. It's important to note that the same legislation which ordered the development of Home Health Perspective Payment provided a contingency clause in the event that it was not feasible to develop a viable system by October 1, 1999. It requires us to reduce the cost limits under the interim system by 15%, which is the same budget savings target which is otherwise required under PPS payment. Thus there's every reason for us all to work as diligently as possible to reduce the development of the PPS system. Aside from the importance of OASIS implementation from a rate setting perspective, it's critical that agencies develop expertise in completing the OASIS based on actual experience. Well, virtually everyone I've met who's used OASIS has ultimately found that both user friendly and very useful like most things it gets better and easier with experience. On the first day of Home Health PPS, the response to key items on the OASIS will determine the amount of payment an agency will receive. It's important to everyone that this information be accurate so you're not overpaid or underpaid and that it be timely so billing is not delayed. We envision a system in which billing will not be able to go forward until the relevant OASIS items have been abstracted and incorporated into the agency's billing. While we envision this abstraction process to be automated like any computerized process the data will only be as good as what humans put in. The more practiced one becomes with OASIS the more quick and accurate payment will become. While my emphasis has been on the pivotal role OASIS is destined to play in perspective payment I would be remiss if I didn't also emphasize the use of OASIS to assure quality under PPS. As in any prospective payment system the incentives shift from overutilization to underutilization. The same OASIS data which governs payment will simultaneously be used to monitor patterns of patient outcome. Thus we believe an unwarranted reduction or change in care patterns which results in negative outcomes can be identified and appropriate interventions initiated. To assure that there are not differences between the OASIS data which are submitted to the quality system and those used to generate billing and the OASIS data which compares the data on a patient specific basis. In conclusion I want to reiterate how critical it is to everyone involved in home health that the implementation of OASIS be successful and be accomplished as soon as possible. OASIS is the first step and what I believe we'll look back on as a new and better era in Medicare home health. One in which outcomes take precedence over process. One in which payment is more driven by needs and outcomes than by what services generate how much revenue. I believe there's close to universal agreement that cost reimbursement is a thing of the past for all providers and that a prospective payment system which accurately measures and reflects patient needs and outcomes will be better for agencies better for the Medicare trust funds. But most importantly for all of you who are playing a role in this effort will have an opportunity to make this change better for the people we're all involved in serving. Medicare beneficiaries. Well Bob it's certainly quite an ambitious endeavor to implement the OASIS collection and the reporting system in a relatively short time why is it so important that it be done so quickly? Well because OASIS drives case mix and case mix ultimately drives payment to develop the payment system we need the information as soon as we can get it as much as we can get and on a national basis. It would be nice to have that national basis right now as soon as we can get it we can use it. Alright thanks Bob. Well it is now time for you to ask the panel about anything that has been discussed they have all of the answers please restrict your questions though to the presentations that were given prior to this telephone session. The number that you can call for questions is 1-800-953-2233 or you can fax your questions to us at<PHONE_NUMBER> and while we are waiting for the first call Bob let me ask you will the case mix adjustment for home health PPS use all of the items on the OASIS data set? There are quite a few elements in the OASIS data set so it is unlikely we will use all of them. I would like to think that we are going to be able to limit it to perhaps 20 to 30 of the key items. And how will my OASIS data actually be used to make a difference in how much my agency is paid under PPS? The research that is being conducted right now by APTIS associates is determining how much of utilization can be predicted by the OASIS data elements. Once we have that information we will be able to predict how much influence case mix index will have on each individual agency's payment. And I think it would have some place at least in the nature of 20 to 30 percent. Let's take a telephone call. We have Yvonne calling from Georgetown. Thank you for calling Yvonne. Please go ahead. Thank you. We have not been able to hear the last two speakers because the satellite seems to be a miss but thank you for taking our call. What plans this is for HICFA representative? What plans does HICFA have to create an outcome data set for the other Medicare providers within the acute care hospital equity as seen from the home care agency perspective? At this point we don't have any plans on developing a standardized data set for those two provider types. OASIS is important for measuring and evaluating quality as well as for case mix adjustment in a prospective payment system. And currently we don't have plans to develop other kinds of minimum data sets or standardized data sets. Thank you. Thank you, Yvonne. Pete, let me ask you a question. What is the most significant challenge in implementing outcome based quality improvement or OBQI? Well, aside from the earlier challenge that I mentioned which is to really keep track of the big picture I think one of the most significant impediments if you will is making certain that the staff at a given agency at my agency understand the rationale for using OASIS and the fact that OASIS was fundamentally developed to help home health agencies assess their own outcomes with a view toward improving their performance. Okay, thanks. Let's take another phone call. We have Patty calling us from North Carolina. Please go ahead, Patty. Thanks for calling. Hello? Hello, Patty. This is not Patty, but... Who is this? This is Karen. Well, Karen, do you have a question? Yes, I do. Okay, you guys stop laughing back there. I hear you. Go ahead with your question. I have a question about the... Oh, Karen, be sure to turn down the audio on your set so we don't get the feedback. I think that's distracting you. Okay. Go ahead. For the payer sources when a patient is only receiving personal services, does an OASIS have to be completed? Are you asking if the patient is only receiving aid services? Personal services, baby. Right. That would be considered personal care services and therefore we would expect OASIS to be collected on that patient. Okay, thank you. Thanks, Karen. Pete, how does OASIS differ from the minimum data set in the nursing home field? Well, the MDS, the minimum data set in the nursing home field, first of all, is much larger. It contains at least twice as many items. It was developed in part as a comprehensive assessment instrument. Really developed for chronic care patients who are institutionalized. And the OASIS, on the other hand, was really developed with a view toward measuring outcomes and evaluating outcomes. The total framework for OASIS is one of allowing agencies to innovate in terms of monitoring and then enhancing outcomes for patients. How long is it going to take for an agency to see the benefits of OASIS and OBQI? Well, the time frames differ. First of all, sometime during the first year, most agencies will probably experience, after going through the data collection, early data collection stages and so on, will probably experience a more precise way to go about assessment that will enhance assessment. It will also enhance care planning and enhance care coordination. As Helene Fredeking mentioned in her video, thereafter, sometime toward the end of the first year or maybe toward the end of the second year, reports will be available to actually allow agencies to examine their own case mix and to examine their outcomes relative to other agencies as well as relative to their own prior performances. Let's try another telephone call. We have Hanson calling from Jacksonville. Please go ahead, Hanson. I hope I've read the question correctly. At what point in existing patient care do you anticipate HEPA will mandate the start of OASIS data collection or will these patients not participate? To what extent? Would you repeat the question? Oh, HECFA. Do you repeat the question? I'm just delivering this from the group. At what point in existing and then there's an abbreviation, PTS that I read as patient care, do you anticipate HCFA or HEPA will mandate the start of OASIS data collection or will these PTS not participate? I read it as patient. Does it make sense? No, he's talking about PPS. I'm not really sure. Let me see if I can paraphrase your question and perhaps one of the HECFA representatives can answer it, but I think you're asking the time point at which HECFA is going to mandate that OASIS data collection begin. I think that's true. And if patients are already on service, do we have to collect data for them? I believe that's correct. Thanks for clarifying that. Yes, we plan on at the issuance of a final rule having an effective date at which we would expect agencies to begin collection of OASIS data on their patients. And so we would expect OASIS data to be collected on patients that are currently on census and they reach the time points that are required in the rule. Okay. Thank you very much, Hanson, for your call on behalf of the group. Let's take another call. We have Carrie, who's calling us from Florida. Please go ahead, Carrie. Okay. I'm calling for a group as well and I have four different questions, please. Okay. The proposed implementation of data entry for OASIS is October 1st. Is this true? The requirement for collection and reporting won't become effective until the final rule is published. We expect the final rule to be published shortly, but we need to be clear that any questions that we answer at this time point have to be vague in regards to specific dates. I know folks are really anxious to learn about when this is going to happen, but it really won't be effective until the final rule is published. Okay. Will Haven be available to all the agencies prior to the effective date for those limitations? I would encourage you to ask that question at another panel when they talk more about Haven. At this point, none of us in this panel are really familiar enough to know the exact date when Haven will be available. Okay. My next question is could you please define the episode of care? Well, if you're talking about the episode of care under the prospective payment system, it is envisioned that the prospective payment system would be paying for an episode of care. At this point, we haven't determined what that episode of care will be. The demonstration, as you may be aware, is using 120-day episode of care. We don't feel that necessarily 120-day episode of care will be used in the prospective payment system that goes live. It may well be a shorter period of time. Okay. Is that it? I have two more questions, please. How often will the home health agencies be receiving the reports from HECFA? Again, you're asking questions that are going, the subject matter, which is going to be addressed at a later time. Okay. So we can't really answer that. Just hold on to those. Just one more. This one was for Robert. Someone asked for a clarification, please. Will home health agencies be required to incorporate OASIS items in the electronically submitted billing data? Yes, but it should happen pretty painlessly through the software system. What we actually envision is that the agency will be completing the OASIS forms as they complete them on all patients. For Medicare patients, data elements that are required to come up with a case mix indicator will go into a software routine which will actually put on each claim a grouper indicator which will tell the payment system at the intermediate area at what level to pay the claim. Okay. Thank you very much. I really appreciate your time. Thank you. Molly, hold on to those questions that you have because when we come back again, you'll get a chance to ask them to the appropriate panel. Some of the questions, some of them, come to us from New Jersey. Peter, I think this one is directed to you and it says, what are the plans for a specialized agency which cares for the developmentally disabled only to be compared with outcomes of similar agencies? I believe that's what that says. Well, in terms of specialized agencies that really focus on certain types of patients, over the course of time, again, the process of risk adjusting or compensating for differences in agencies' case mix in order to compare their outcomes with others, will entail several different steps. One of them would be stratification or grouping simply to find similar agencies, especially in this type of application. And then there is also a set of multivariate statistical procedures which we don't have to get into here from a technical perspective that will be used in that regard that when an agency's outcomes are being evaluated relative to a benchmark sample, that differences between that agency's case mix or types of patients and the benchmark sample are taken into consideration. Mary, we have a fax for you. It says it is now within the scope of practice for speech language pathologist or physical therapist to assess drug regimen. If there is no nurse serving the patient, how is this assessment safely done? Well, our requirements currently allow for therapists to do an evaluation of the drug regimen and if in the physician's opinion nursing services are not necessary, then it is reasonable to assume that the physical therapist or the speech language pathologist can do that service. Okay, here is another one for you. For MSW only, who does the initial assessment and the completion of the comprehensive assessment? That's a really good question. At this point, I don't have an answer. Okay. Well, we have another question. What did you mean by patient specific assessment? This comes to us from Alexandria, Louisiana. By patient specific assessment, we mean that the information collected reflects the patient's real status. The comprehensive assessment itself might be standardized. You might have a form of information that you collect on each patient, but by patient specific, we mean that that data reflects the actual condition of that individual patient. Okay, we have another one. Are we required to collect data on managed care, Medicare patients as well as traditional Medicare patients? Absolutely. The home health conditions of participation apply to all patients who are provided care by that agency and all Medicare patients, regardless of the payer type, need to have Oasis information collected. Okay, Mary, you're the woman of the hour here. Does Oasis need to be done on hospice patients? Oasis collection is not a requirement for hospices, and therefore we would not expect that Oasis information would be collected on those patients. Okay, let's take another telephone call. We have Molly on the line from Tallahassee. Please go ahead, Molly. Hello. I would like to know if all home health agencies are required to submit Oasis data are just those that are Medicare certified, and if it is just Medicare certified, does Oasis need to be completed for all patients, even those that are not Medicare patients of that agency? The hospital, I mean the home health conditions of participation, excuse me, apply to all home health agencies that are certified. So therefore to answer your question, we would expect Oasis to be collected by Medicare certified home health agencies. The conditions of participation apply to all patients served by the agency, and therefore we would expect Oasis to be collected on all patients, except for those who are under the age of 18 who are receiving pre and postpartum services, and those patients who are not receiving postpartum services or personal care services. Can I ask one question to clarify? You did say Medicare certified only, so that does mean if you're Medicaid, but not Medicare, then you would not be required to collect Oasis. Well actually, in order to be Medicaid certified, you need to meet the Medicare conditions of participation. So we would expect Oasis data to be collected on Medicaid certified home health agencies. Now I'm aware that a number of Medicaid agencies are involved in some of the waivers in home and community-based demonstrations, and therefore the applicability of the conditions of participation to those agencies would depend on the state law. Okay, so those home health agencies that are Medicaid only would still have to collect Oasis data because of the conditions of participation. That's my expectation, although I have to be clear that it would not necessarily apply to those agencies that are involved in home and community-based waivers. Thank you. Thank you, Molly. Let's take another call. We have Susan calling us from Denver. Please go ahead, Susan. Oh, hello. Hi. I have actually have several questions. Until Medicare gives us the exact deadline that we need to start, should we start with the October 1 deadline that was published previously? No. No home health agency is required to collect Oasis information until the final rule and the effective date that is published with the final rule. Some agencies might begin work and we encourage agencies to begin work integrating Oasis into their comprehensive assessment, piloting the tools and practicing collecting the information, but it won't be required until the regulation is published. All right. Should we use the Oasis data set B1 or B? I would encourage you to ask that question in a later panel. All right. Thank you all. Could I clarify one more question, please? Oh, okay, Susan. Okay, thank you. To Mary, when you were talking about the five days, calendar days for completion, did you imply that you have five days to assess the patient and complete the Oasis or you should do the full assessment the first day and you have five days to physically write out the completion? What we really mean is your first point. The initial visit is a visit that is done on the patient when they're first admitted to the home health agency. The agency may choose to complete the Oasis during that visit and, as a matter of fact, it might be prudent to do so. However, what we are currently expecting is that the agency will have five days to complete the Oasis. In other words, go back and visit the patient and collect all the information within that five-day period. All right. Okay, thank you very much. Thank you, Susan. And as we mentioned, we will have another opportunity for you to ask your questions. Well, we've been on the air now for about an hour, so why don't we take a short five-minute break? And when we come back, we'll hear presentations on the implementation plan for the states, the home assessment validation entry views from a provider's perspective and how home health agencies should prepare for Oasis. So we'll see you back in five minutes. You know, I'm 65 years old, and I've learned the two most important things in life, your family and your health. So once a year I fix them dinner on their birthdays. That's their special day. And once a year I get a mammogram. That's my special day. You can't be too safe. I should know a survivor and I'm going to stay that way. Memograms. It's not something you do just once, but for a lifetime. I'm Andre Brower. Did you know that in 1918 a flu epidemic made millions sick and killed over 700,000 Americans? The survivors of that terrible epidemic remember that year and they know what they need to do every fall see your doctor and get the flu shot and not the flu. It only takes a minute and is covered by Medicare. About all means take your flu shot. Welcome back everyone. Let's introduce the members of our next panel. Mary Weaklin, nurse consultant nursing homes branch Center for Medicaid State Operations. Bob Goldrich director division of national systems data and systems group in the Center for Medicaid and State Operations. And Kathy Crisler assistant director of the Center for Health Services and Policy Research University of Colorado Health Sciences Center. Well there are many questions related to implementing OASIS in the states and how the system will work for home health agencies collecting and electronically submitting OASIS data. Our next presentation will attempt to answer those questions. HICFA is developing a network within all states to promote the automation of the OASIS data set and this is how the system will work. The home health agency conducts the assessment and enters the OASIS data into a computer using a special software system. On a monthly basis the agency will electronically send the OASIS data to the state agency using a direct telephone connection from the home health agency to the state. At the state the data will be sent to the standard state system which was installed in each state last year to accommodate nursing home data. This fall HICFA will install additional software to accommodate the transmission of OASIS data to the state. The state will pay a key role in the process to promote consistency in implementing OASIS. Each state survey agency is funded by HICFA to provide educational and technical resources to support and promote training programs for the agencies. HICFA is funding the position of educational coordinator to provide training to agencies administering the OASIS. They will also provide training to the agencies on integrating the OASIS data items into the agency's comprehensive assessment system. They will field questions from agencies in their states on the clinical elements of OASIS. They will assist the agencies with training on the automation related issues on the data set and they will be explaining the use of the outcome reports generated by the OASIS data when those reports are ready. HICFA is also funding the position of automation coordinator in each state whose expertise is in the technical issues concerning the computer related automation functions. The automation coordinator's role is to provide for the statewide administration of the OASIS project by providing for operational and technical support for the agencies, vendors and the state agency staff. The state will provide start-up training and ongoing support for statewide home health agencies for entering OASIS data into the agency's computer system in a certain format we call encoding. Creating an export file this is the file that the agency will transmit to the state. Using a communication software to dial into the state database to electronically submit the export file to the state database for transmission logging error tracking and resolution reporting functions such as validation and error reports. The state will also do system backup and have responsibility for data management which includes cleaning and aggregating data prior to retrieval by the HICFA central repository. This fall HICFA plans to conduct standardized training programs for state personnel with these responsibilities so that they can assist the home health agency staff and software vendors in implementing the OASIS data set as well as the reporting requirements for the OASIS data. This standardized train and trainer program will provide the state staff in training the home health agencies at the local level. We are fortunate to have been partnered with the National Association for Home Care who will lend additional support to providing training to the home health agencies. In addition, HICFA regional offices have already designated regional office personnel who will be able to provide similar expertise to agencies and vendors. We expect to hold at least an opportunity for these state staff to update them on any changes that we anticipate in OASIS. We also expect to continue our monthly teleconferences with the states to hold a forum on issues in OASIS. I can tell you what is projected by way of regulation currently in progress titled reporting outcome and assessment information set OASIS data as part of the conditions of participation for home health agencies. The reporting regulation is targeted to be published at the same time as the collection regulation which specifies the requirement for collecting OASIS information. The reporting regulation focuses on three issues reporting OASIS information privacy of the patient and state survey functions. HICFA believes that these three requirements are equally significant as we set health and safety standards for agencies to require patient specific information to evaluate care and outcomes and also to fulfill the provisions for prospective payment mandated by the balanced budget Act of 1997. We expect OASIS data must accurately reflect the patient's status at the time of the assessment. In the collection regulation the time frames are set to allow sufficient time to allow the home health agencies to collect OASIS data about the patient at certain time points. Once the information has been collected home health agencies have seven days after the completion of all required OASIS items to enter this information into their computers and coding. Once the OASIS data is encoded each home health agency will use special software and we'll tell you more about this or you can use other vendor software to edit patient assessments according to the HICFA's edit specifications and lock the record. Home health agencies will use their software to review and edit the OASIS data in preparation for transmission to the state survey agency or other entity approved to receive this transmission. We believe that home health agencies who really want to provide good care will assess patients and will submit OASIS data in a timely fashion for data entry so that you can maintain a current and viable plan of care for each patient. We are proposing that home health agencies transmit OASIS data at least monthly. For example, data collected and coded and locked in February will need to be transmitted during the month of March. We have chosen a monthly time frame for several reasons. We want to reduce burden on the home health agencies associated with frequent transmissions. We want to maintain uniform assessment reporting time frames for all data sets and we want to maintain a clear reporting time frame which eliminates the variation of days in a month. It's also important to note that the home health agencies may send assessments to the state or HICFA contractor more frequently than monthly if they choose. The protection of privacy of patient specific information is a key element in this reporting process. No one may release OASIS assessment information that is patient identifiable to the public, not the agency, not the state agency or HICFA. At the home health agency and the state agency, access to OASIS data, whether the data is hard copy or electronic must be secured and controlled in compliance with our requirements for safeguarding the confidentiality of clinical records. We are requiring that the home health agencies keep all information contained in the patient's record confidential and maintain safeguards against the unauthorized use of a patient's clinical record information regardless of the form of storage method. The state survey agency will also provide training and manage the OASIS database as we discussed earlier. Final reports on the Medicare home health case mix project are expected in late January 1999. At that time HICFA will determine which items to add or remove from the data set that allow for the case mix adjustment. Whenever there's going to be a change, HICFA will revise all data sets, the software, training materials, users manuals, and post changes to the HICFA website. We will announce plans for training on the web when those changes them. We will also post the additional software needed for the case mix adjuster. HICFA has created a website as a source of information for OASIS and other home health requirements. The web address is seen on your screen. The HICFA website is a user friendly source of documents and information on OASIS and other HICFA related home health issues. It was designed to hold materials that can be downloaded in standard formats. Once downloaded you can print these files into usable documents. If there's a format that's unfamiliar directions will be given to instruct you in obtaining a downloadable tool at an internet site at no cost like Adobe Acrobat Reader. Therefore the home health agency or software vendor will need to have internet access to their agency or at a public or a private source such as the public library to get them to use this new source of information. The HICFA website was chosen and will be supported by HICFA to provide direct access by agencies, state agencies, software vendors, professional organization and consumers. We strongly encourage vendors and agencies to regularly review the website for the information related to the home health of OASIS and other home health related issues. We will continue to promote processes for assuring accuracy in the software. The required OASIS data set is currently available on the website. Home health agencies will be able to download and print the required OASIS data set for each data collection time point. For example, start of care, resumption of care following an inpatient facility stay, discharge, transfer to an inpatient facility and death of home. Also on the website are HICFA-defined data specifications, electronic record layouts, edit specifications and data dictionaries that give guidance to software vendors in creating the software necessary to meet the electronic reporting requirements required in implementing OASIS as a national system. Agencies may use other vendor software as long as it allows data to be transmitted in a format that conforms to HICFA's standardized electronic record formats, edit specifications, data dictionaries and that passes standardized edits defined by HICFA. HICFA will also provide software on its website that can be downloaded at no charge to home health agencies and be used to report OASIS data. This software, referred to as HAVEN, will be described by Bob Goldrich later in this program. As Helene Frederickane reported to you earlier, the OASIS data set has undergone several changes until it became the data set we will implement. The required OASIS varies slightly from the one published in the Federal Register on March 10, 1997 in the proposed role. The March 10th version is also available on the website. Several items have been added to clarify the identity of the patient such as the first name, middle name, social security number and reason for assessment. However, there are no other changes in the core data items that were published in the proposed role. If you're currently using an electronic version of OASIS, you'll need to contact your software vendor for an updated version for national implementation. We plan to post documents to our website such as a user's manual for the OASIS data set, the HAVEN manual, a home health agency data submission manual. In the future, if an alternate version of the OASIS is required such as when additional items to allow for case mix adjustment are selected, home health agencies will be directed to the HIPAA website for the apical version of the OASIS data set and other issues related to the data set. Again, we strongly encourage vendors and home health agencies to regularly review the website for information related to the computerization of OASIS and other HIPAA-related home health issues. We will post new information as soon as we have it available. Mary, during your presentation, you talked about coordinators. Where can a home health agency find out the names of the coordinators in their state? We'll be posting on the website next week. I'm going to caution you not to call them right away because we haven't given them our first training yet. That will occur at the end of August. You might want to wait a while before you call them. One more thing I'd like to add is the HIPAA website and the email system for HIPAA will be down for a few days starting tonight. They're going to try and make some improvements for our customers to view our websites. You can access the OASIS webpage on Monday, August 24th in the morning. Thanks, Doris. Next, we're going to talk about haven or home health assessment validation and entry software. What will HIPAA be doing to help HHAs collect and electronically send the automated assessment data to the states? Let's see how Bob Goldrich thinks HIPAA will address this issue. Let's talk about the software that HIPAA will provide to enable agencies to enter, validate, store, and transmit the assessment data. This software product is called HAVEN which stands for Home Health Assessment Validation and Entry. HIPAA used this same approach for the implementation of the minimum data set for long-term care providing a tool called RAVEN to nursing homes that elected to use it and it proved to be a very important option. Let me tell you more about what HAVEN is, what it is not, and what computer resources agencies will need in order to use it. First of all, what HAVEN is. It is software available at no cost to the agency. Secondly, it is software that resides on the agency's computer. I'll tell you more about that in a few minutes. HAVEN is a tool for entering, maintaining, and submitting assessment information. A tool that ensures data integrity via rigorous edit checks and a product that includes online help. But let me also tell you what HAVEN is not. It is not the only option. Agencies can use vendor products or develop their own software. HAVEN is not intended to compete with commercial products. It is just one alternative, but it's one that HIPAA felt compelled to provide to ensure that automation capabilities would be available to everyone. Another thing that HAVEN is not is a comprehensive tool for providing information processing requirements. For example, HIPAA will not include add-on modules to support care planning, billing, or accounting. Some other features of HAVEN, it is a windows-based product. It has drop-down menus and other features common to most PC software available today. Here's an example of the opening screen you would say. HAVEN also includes and enforces all the HIPAA standard edits and all the HIPAA requirements. And it imports and exports data in OASIS standard format. In other words, you could use HAVEN to process an assessment file created by a vendor product and it would apply all the edits and give you a validation report on the data. And you can use HAVEN to send assessment data to the HICFA standard OASIS processing system in each state. It will be available on the internet or we can send you a CD-ROM version. Both options will be available to you, but we encourage using the internet to acquire the software. It will make it easier for you to acquire new versions of HAVEN, as well as additional information about it. And internet access will also be very useful for accessing information about the entire assessment process, such as that available via the HICFA website. Now what type of computer will home health agencies need to run HAVEN? HICFA doesn't endorse or recommend any specific brand to personal computer, but we do need to see what capabilities your computer must have in order to run HAVEN. I'll tell you the minimal requirements, but I'd really like you to keep this in mind. Minimal does not mean desirable. In other words, the HICFA product will run on the configuration I am about to show you, but it will run slowly, and you may have problems with it if you have other software products on the same machine, as is very likely. Now here are the minimum system requirements for HAVEN. A 486 PC, Windows 3.1 or a later version, 8 megabytes of RAM, 100 megabytes of available hard drive space, a CD-ROM drive, a modem with a speed of 28.8 kilobytes per second, internet access, and web browser software. Now if your children are using a PC at home, or if you check out the latest products at your local computer store, you will see that most software being sold now has requirements well beyond those I've just shown you. Inflation processors are much more prevalent than 486s. Inflation processing capabilities are expanding so dramatically that we encourage you to think ahead of optimal rather than minimal processing capabilities. So here's a recommended configuration. A Pentium processor, Windows 95 or Windows NT, 32 megabytes of RAM, a 2 gigabyte hard drive, a CD-ROM drive, a modem with a speed of 56 megabytes per second, and again, internet access and web browser software. There are other requirements, such as a mouse and a printer. I have not identified all of them in this presentation, just the major ones. Now here's one final feature of Haven. HICFA will continue to support the Haven product. As new elements are added to the OASIS dataset, such as case mix items, they will be incorporated in the Haven product, and will be provided, including all the standard data edits and all the HICFA reporting requirements. Information about Haven is and will continue to be available via the HICFA website.