OASIS-C, Depression Screening, and M1730: Additional Screening is NecessaryThe Value of Using Standardized Assessments

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While working with behavioral health home care nurses for many years, complaints were frequently heard when additional assessment tools were required above and beyond what was mandated by Medicare. Now that Centers for Medicare and Medicaid Services (CMS) has released the Outcome and Assessment Information Set-C (OASIS-C), we feel vindicated! The OASIS-C includes the two-item Patient Health Questionnaire-2 (PHQ-2) as a screen for depression. If the patient answers yes to these two items, the clinician should administer an additional depression assessment tool such as the PHQ-9 (Kroenke et al., 2001; Pinto-Meza et al., 2005) or the short version of the Geriatric Depression Scale (GDS) (Shiekh & Yesavage, 1986) and then report the results to the physician. Although the OASIS is a comprehensive assessment tool, for specialty areas like behavioral health the Neuro/Emotional/Behavioral items do not allow for quantification of either the degree of disability or the degree of improvement but only provide global glimpses into the presence of dementia and other potentially life-threatening conditions such as depression, anxiety, and psychosis.Dementia steadily worsens but the OASIS-B doesn't pick up gradations of change. Depression, anxiety, and psychotic disorders wax and wane with improvement sometimes occuring slowly and in small steps. It is important for clinicians to be able to track and report these changes. The use of standardized, valid, and reliable assessment tools provides clinicians with the language to communicate improvement, lack of improvement, and an increase in symptomatology to physicians and other professionalsPhysicians need information that clearly indicates the seriousness of depression. The use of a standardized depression assessment tool allows the home care clinician to report whether the patient is responding to prescribed antidepressant medication. If so, to what degree is the patient's response? If the patient is not responding, are there changes that indicate the patient is slipping into a deeper level of depression and is perhaps at risk for suicide? The use of a standardized measure provides concreteness to the home care clinician's observations regarding a patient's degree of depression, improvement, or deterioration.The focus on depression in OASIS-C is the result of an accumulation of research both within and outside of home care that substantiates the high prevalence of depression in the older adult, specifically those that are homebound. In a study reported by Bruce (2002) a structured diagnostic interview was employed with a group of 539 older adults demonstrating that 13.5% had major depression. In a more recent survey, Knight and Houseman (2008) screened 179 homebound older adults and found that 46% were depressed. Not only are these figures high and dangerous in and of themselves, given the potential for suicide in this population, but additionally depression has the added impact of decreasing compliance with medical disorders such as diabetes, cardiac disease, and chronic obstructive pulmonary disease (Koenig & George, 1998; Juurlink et al., 2004; Ranga et al. 2002). In addition, coupled with noncompliance may come increased medical costs paired with increased rehospitalization rates—both are outcomes targeted and measured by CMS (2007) and projected to be used in the "pay for performance" model. For all these reasons, home care providers need to have a better understanding of the identification as well as the treatment and implications of depression in the homebound geriatric population.The Statistics on DepressionDespite the accumulating research demonstrating that depression runs rampant in home care patients with rates ranging from 13.5% to 46% (Bruce, 2002; Banerjee & McDonald, 1996; Knight & Houseman, 2008; Valente, 2005), there has not been a concerted effort to address depression.

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