The landscape of healthcare is constantly evolving, with a growing emphasis on efficient, high-quality care delivery, particularly in the post-acute care (PAC) sector. Central to these advancements is the concept of Care Tool Assessment, which plays a vital role in standardizing patient evaluations, improving care coordination, and informing payment reforms. This article delves into the significance of care tool assessments, drawing insights from the development and implementation of the Continuity Assessment Record and Evaluation (CARE) Item Set, a pivotal initiative by the Centers for Medicare & Medicaid Services (CMS). Understanding these principles is crucial for healthcare providers, policymakers, and anyone interested in the future of patient care and healthcare economics.
The journey towards standardized care assessment gained significant momentum with the Deficit Reduction Act (DRA) of 2005. This legislation directed CMS to initiate the Medicare Payment Reform Demonstration (PRD). The core objective was to utilize standardized patient information to scrutinize the uniformity of payment incentives across various healthcare settings. This demonstration encompassed acute care hospitals and four key post-acute care settings: Long Term Care Hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs), and Home Health Agencies (HHAs).
This pioneering demonstration provided a crucial standardized lens through which patient health and functional status could be viewed, irrespective of the care setting. It facilitated the examination of resources and outcomes linked to treatments in each setting type. This approach empowered CMS to gain a deeper understanding of the extent to which patients with similar conditions were being treated in disparate settings. Furthermore, analyzing resource utilization within each setting was essential to discern variations in patient treatment, outcomes, and the costs of care. This comprehensive understanding was foundational for formulating well-informed payment reform recommendations.
The scope of the Medicare PRD was subsequently broadened under the Medicare, Medicaid, and the SCHIP Extension Act of 2007 (MMSEA). This expansion allowed for the participation of more providers and authorized CMS to evaluate the adequacy of acute hospital payments, especially for medically complex patient populations. The findings derived from the Medicare PRD are available in the Downloads section, offering valuable insights into the early stages of care tool assessment implementation and its impact on healthcare delivery and payment structures.
The Continuity Assessment Record and Evaluation (CARE) Item Set emerged as a cornerstone of the Medicare Post-Acute Care Payment Reform Demonstration (PAC-PRD). This standardized patient assessment tool was specifically designed for use at acute hospital discharge and at both admission and discharge points within post-acute care settings. Data gathered through the CARE Item Set served as a primary information source for the demonstration, providing critical metrics on the health and functional status of Medicare beneficiaries at the point of acute discharge. It also tracked changes in severity and various outcomes for patients undergoing Medicare post-acute care.
The fundamental design of the CARE Item Set is to bring uniformity to the assessment of patients’ medical, functional, cognitive, and social support status across the continuum of care. This includes not only acute settings but also the diverse landscape of post-acute care, encompassing long-term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies (HHAs). The overarching goal was to standardize the items utilized in existing assessment tools while ensuring minimal administrative burden on healthcare providers. The CARE Item Set is built upon a foundation of prior research and incorporates valuable lessons gleaned from clinicians working across the entire spectrum of patient care settings. It targets a comprehensive range of measures that effectively document variations in a patient’s level of care needs. These measures include factors that are predictive of treatment and staffing patterns, such as the intensity of physician, nursing, and therapy services required.
The development of the CARE Item Set thoughtfully integrated findings from CMS and the 2006 Recommendations for a Uniform Patient Assessment for Post-Acute Care, spearheaded by Kramer and Holthaus (2006). This integration was a deliberate effort to modernize existing federal assessment tools. These included: (1) the IRF-Patient Assessment Instrument (IRF-PAI) (Gage, Bernard, Constantine, et al., 2005); (2) the Minimum Data Set (MDS); (3) the Outcome and Assessment Information Set (OASIS); and (4) other relevant measurement initiatives in geriatric care. The CARE Item Set’s design is centered on measuring outcomes in both physical and medical treatments while meticulously controlling for factors that can influence these outcomes, such as cognitive impairments and social and environmental determinants. Significantly, many of the items within the CARE Item Set were already being collected in hospitals, SNFs, and HHAs, although the specific format of these items might have varied across settings.
For further detailed information, the Useful Links and Downloads sections provide additional resources and reports on the CARE Item Set.
The CARE Item Set is structured around two primary types of items:
- Core items: These are fundamental questions posed to every patient within a specific care setting, irrespective of their condition.
- Supplemental items: These are condition-specific questions asked only of patients presenting with particular conditions. Supplemental items are designed to provide a more detailed and nuanced measurement of severity or the extent of need for patients who have a specific condition.
These supplemental items are crucial for achieving a more granular understanding of patient needs based on their specific conditions. By establishing a standardized language for clinicians across different care sites, significant strides can be made in accurately measuring acuity, treatment needs, and patient outcomes. This standardization also markedly improves the transfer of vital patient information between various healthcare settings, leading to better coordinated and more effective patient care.
Consider, for instance, the domain of skin integrity. A core question asked of all patients is whether they have one or more unhealed pressure ulcers at stage 2 or greater. For patients who answer affirmatively, supplemental items are then utilized to gather detailed information describing these ulcers. These supplemental items are only applicable to patients who are identified as having one or more stage 2 or higher pressure ulcers, demonstrating the targeted and condition-specific nature of these assessment components.
The CARE Item Set underwent a rigorous development process spanning 14 months. Its creation was driven by the need to standardize assessment items based on robust scientific literature and practical experiences with mandated assessment items within Medicare payment systems. This included items from instruments such as IRF-PAI, MDS, and OASIS. The selection of items was carefully limited to those directly related to patient severity, payment considerations, or the monitoring of care quality. Consequently, the CARE Item Set functions as a framework for a standardized collection of items that can be readily accessed through an item bank. Items from existing MDS and OASIS tools that were exclusively used for care planning were intentionally excluded from the CARE Item Set. The majority of items included in the CARE Item Set are typically documented in patients’ medical records. However, it was acknowledged that the format and formality of medical records, the location of data within these records, and the designated individuals or clinicians responsible for data collection could vary across different healthcare settings. Items were meticulously evaluated and selected to optimize reliability, validity, and the breadth of their application, aiming to minimize both floor and ceiling effects. Furthermore, item selection prioritized the minimization of incentives that might inadvertently encourage provider behavior that is not aligned with best practices in patient care.
Detailed reports and further information concerning the development and reliability analysis of the CARE Item Set are available in the Useful Links and Downloads sections. These resources offer deeper insights into the methodological rigor and empirical evidence supporting the CARE Item Set’s validity and utility in post-acute care assessment.
Building upon the CARE Item Set, B-CARE emerged as a streamlined version, specifically considered for use within the Bundled Payments for Care Improvement (BPCI) Initiative. B-CARE is designed to provide consistent patient information across various BPCI models and care settings. This consistency is crucial for monitoring the impact of care redesign initiatives on beneficiaries’ health status and care outcomes. Moreover, B-CARE data can be instrumental in understanding how patient mix influences the results observed across different BPCI models and care settings. This refined tool underscores the ongoing evolution of care tool assessments in response to the changing needs of healthcare delivery and payment models.
More comprehensive information about the BPCI initiative can be accessed through the provided links in the Useful Links section, offering further context on the application of streamlined care assessment tools in innovative payment models.
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)
