Home Health Blogger

Train Nurses on the New OASIS C2 'Advance Careplanning' Requirement

Posted by Peggy Mathews on May 9, 2017

OASIS C documentation of a patient's Advance Care Planning is one of 3 new HOME HEALTH PROCESS MEASURES that are required under home health Value-based Purchasing and included in the training for MyHomecareBiz.  HHAs in the 9 states have already started reporting on this measure as of October 7, 2016 through a Web Portal. Under Value-based Purchasing home health agencies are required to...

1. Document those patients who have an advance care plan or surrogate decision maker documented in the medical record


2. Document in the medical record that an advanced care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.

The difference between Advance Careplanning and Advance Directive…

Advance Care Plans are fundamentally different than advanced directives (also referred to as living wills.)  The basis for an Advance Care Plan is ONGOING COMMUNICATION with health providers, family members, and potential surrogate decision makers; they are not focused exclusively on end of life or life threatening conditions.  Advance Care Plans ensure patient centered care by providing an opportunity for health care providers and patients to identify how a patient would like to be cared for when a medical crisis makes it difficult or  impossible to make their own healthcare decisions.

Advance Careplanning includes the process for selecting an Advance Directive...


The two (2) types of Advance Directives are...

1. A living will spells out what types of medical treatment a person wants at the end of life if he’s unable to speak for himself. It tells medical professionals a person’s wishes regarding specific decisions, such as whether to accept mechanical ventilation.

2. A health care power of attorney appoints someone to make health care decisions — and not just decisions regarding life-prolonging treatments — on one’s behalf. The appointed health care agent (also called an attorney-in-fact or proxy) becomes the patient’s spokesman and advocate on a range of medical treatments the patient sets out in the document. Of course, the health care agent makes decisions only when the patient can’t communicate on his own. This type of document is sometimes referred to as a health care proxy, appointment of a health care agent or durable power of attorney for health care. It is different from a regular durable power of attorney, which typically covers only financial matters.

An opportunity for important patient education

According to Medicare, the intent of the measure is to provide education and guidance to the beneficiaries, not to pressure them regarding Advance Careplanning.  Medicare reports that they will provide "robust technical assistance for HHAs" related to this new measure, including necessary tools and information for ensuring autonomous decision making on the part of the patient. JCAHO, CHAP and ACHC all have requirements that the HHA provide education on Advance Careplanning/Advance Directive for the HHA to be accredited.

Some interesting facts about patients and Advance Careplanning…

•    Most people say they would prefer to die at home, yet only about one-third of adults have an advance directive expressing their wishes for end
•    Only 28 percent of home health care patients have an advance directive on record (Jones 2011).
•    88 percent of hospice care patients have an advance directive on record (Jones 2011).

Download the Patient Teaching Sheet for Advance Directives

Download the Home Health Aide Competency Checklist

For more information on Medicare's Home Health Care Quality Indicators click here.