The landscape of post-acute care within the Medicare system is complex, involving diverse settings such as Long Term Care Hospitals, Inpatient Rehabilitation Facilities, Skilled Nursing Facilities, and Home Health Agencies. To ensure consistent and quality care across these varied environments, the Centers for Medicare & Medicaid Services (CMS) initiated the Post-Acute Care Payment Reform Demonstration (PAC-PRD). A cornerstone of this initiative is the Continuity Assessment Record and Evaluation (CARE) Item Set, a standardized patient assessment tool designed to bring a uniform Care Tool Scale to evaluating patient needs and outcomes across the post-acute spectrum.
This CARE Item Set emerged from the Deficit Reduction Act of 2005, which mandated CMS to develop demonstrations that utilize standardized patient data. The aim was to analyze the consistency of payment incentives within Medicare across different treatment settings. The Medicare Payment Reform Demonstration (PRD) was launched to compare patient health and functional status, irrespective of where care was received. By using a standardized care tool scale, CMS sought to understand if similar patients were being treated in different settings and to assess resource utilization within each setting. This was crucial for informing appropriate payment reform recommendations based on patient needs, treatment outcomes, and costs of care.
Expanding on this, the Medicare, Medicaid, and the SCHIP Extension Act of 2007 further broadened the Medicare PRD, allowing more providers to participate. This expansion also authorized CMS to examine the adequacy of acute hospital payments for medically complex populations. The CARE Item Set, therefore, became a vital instrument in this comprehensive evaluation, serving as a standardized care tool scale to measure patient status from acute discharge through post-acute care.
The CARE Item Set is implemented at acute hospital discharge and at post-acute care admission and discharge. It’s meticulously designed to standardize the assessment of a patient’s medical, functional, cognitive, and social support status across all post-acute settings. The ultimate goal is to create uniformity in the items used in existing assessment tools, minimizing administrative burdens on healthcare providers while enhancing the ability to compare and scale quality of care.
Built upon extensive prior research and clinical insights, the CARE Item Set incorporates measures that reflect variations in patient care needs. These include factors influencing treatment and staffing patterns, such as predictors of physician, nursing, and therapy intensity. The development process considered recommendations for a uniform patient assessment for post-acute care and aimed to update existing federal assessment tools like the IRF-Patient Assessment Instrument (IRF-PAI), the Minimum Data Set (MDS), and the Outcome and Assessment Information Set (OASIS).
The CARE Item Set effectively functions as a care tool scale by measuring outcomes in physical and medical treatments while accounting for variables that can influence these outcomes. These variables include cognitive impairments and social and environmental factors. Notably, many of the items within the CARE Item Set were already being collected in hospitals, Skilled Nursing Facilities, and Home Health Agencies, although the format might have varied.
To provide a comprehensive yet focused assessment, the CARE Item Set is structured with two types of items:
- Core items: These are fundamental questions asked for every patient within a specific care setting, regardless of their condition. They establish a baseline care tool scale for all patients.
- Supplemental items: These are condition-specific questions, designed to provide a more detailed and granular measurement of severity or need for patients with particular conditions. They allow for a more nuanced application of the care tool scale.
For instance, in assessing skin integrity, a core item would be whether a patient has one or more unhealed pressure ulcers at stage 2 or greater. If the answer is yes, supplemental items would then delve into the specifics of these ulcers. This layered approach ensures both broad applicability and detailed condition-specific insights, enhancing the precision and utility of the care tool scale.
The development of the CARE Item Set spanned 14 months and prioritized items directly related to patient severity, payment considerations, and monitoring the quality of care. Items used solely for care planning in tools like MDS and OASIS were excluded to maintain focus. The CARE Item Set is intended as a framework for a standardized set of items, potentially accessible through an item bank. Most items are typically found in patient medical records, although the format and collection methods may vary across settings. The selection and evaluation of items were rigorous, aiming for maximum reliability, validity, and broad applicability, while also minimizing incentives for providers to deviate from best care practices.
B-CARE, a streamlined version of the CARE Item Set, is under consideration for use within the Bundled Payments for Care Improvement (BPCI) Initiative. B-CARE aims to provide consistent data across different BPCI models and care settings. This consistent application of a care tool scale would enable monitoring of how care redesign impacts beneficiaries’ health status and care outcomes. It can also help in understanding how patient mix influences results across various BPCI models and settings.
In conclusion, the CARE Item Set represents a significant advancement in standardizing patient assessment in post-acute care. By providing a robust and consistent care tool scale, it facilitates better measurement of patient needs, outcomes, and quality of care across diverse settings. This standardization is crucial for informed payment reforms and for driving continuous improvements in the post-acute care landscape, ultimately benefiting Medicare beneficiaries.
Useful Links:
Overview of the Medicare Post-Acute Care Payment Reform Initiative
Section 5008. Post-Acute Care Payment Reform Demonstrations Program. Deficit Reduction Act of 2005
Post-Acute Care Payment Reform Demonstration: Final Report
Report to Congress: Post Acute Care Payment Reform Demonstration (PAC-PRD) (PDF)
Post-Acute Care Payment Reform Demonstration Report to Congress Supplement-Interim Report (PDF)
Post-Acute Care Payment Reform Demonstration: Final Report. (PDF) Volume 2 of 4 (PDF)
