The landscape of healthcare is continuously evolving, with a growing emphasis on optimizing patient care and ensuring seamless transitions between different healthcare settings. In this context, the Care Tool Cms emerges as a pivotal framework designed to standardize patient assessment and enhance the quality of post-acute care. Developed under the guidance of the Centers for Medicare & Medicaid Services (CMS), the Continuity Assessment Record and Evaluation (CARE) Item Set is at the heart of this initiative, aiming to bridge information gaps and improve patient outcomes across the healthcare spectrum.
The Genesis of the CARE Item Set: Addressing Payment Reform
The journey towards the CARE Item Set began with the Deficit Reduction Act (DRA) of 2005, which mandated CMS to pioneer a Medicare Payment Reform Demonstration (PRD). This demonstration was a response to the need for a more consistent and standardized approach to Medicare payments across various healthcare settings. It included acute care hospitals and four post-acute care settings: Long Term Care Hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs), and Home Health Agencies (HHAs).
The core objective of this demonstration was to utilize standardized patient information to evaluate the consistency of payment incentives. By gathering uniform data on patient health and functional status, irrespective of the care setting, CMS sought to understand how similar patients were being treated in different environments. This initiative also aimed to analyze resource utilization within each setting to identify variations in patient treatment, outcomes, and care costs. The ultimate goal was to inform and guide appropriate payment reform recommendations.
The Medicare PRD was further expanded by the Medicare, Medicaid, and the SCHIP Extension Act of 2007 (MMSEA), enabling broader provider participation and allowing CMS to assess the adequacy of acute hospital payments for complex medical populations. The findings from the Medicare PRD have been instrumental in shaping the understanding of post-acute care payment structures and are available for review in the Downloads section.
The CARE Item Set: A Standardized Assessment Tool
A key component of the Medicare Post-Acute Care Payment Reform Demonstration (PAC-PRD) was the development and implementation of a standardized patient assessment tool – the Continuity Assessment Record and Evaluation (CARE) Item Set. This tool is designed for use at acute hospital discharge and at both admission and discharge in post-acute care settings. Data collected through the CARE Item Set has served as a crucial information source for the demonstration, providing insights into the health and functional status of Medicare beneficiaries and tracking changes in severity and outcomes for post-acute care patients.
The primary purpose of the CARE Item Set is to standardize the assessment of patients’ medical, functional, cognitive, and social support status across the continuum of care, encompassing long-term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies (HHAs). The development process focused on integrating items from existing assessment tools while minimizing the administrative burden on healthcare providers. The CARE Item Set is built upon extensive research and incorporates practical insights from clinicians across various care settings. It targets a range of measures that document variations in patient care needs, including factors influencing treatment and staffing patterns, such as predictors of physician, nursing, and therapy intensity.
The CARE Item Set development process took into account recommendations from CMS and the 2006 Recommendations for a Uniform Patient Assessment for Post-Acute Care. It aimed to update existing federal assessment tools, including the IRF-Patient Assessment Instrument (IRF-PAI), the Minimum Data Set (MDS), the Outcome and Assessment Information Set (OASIS), and other geriatric care measurement initiatives. The CARE Item Set is structured to measure outcomes in physical and medical treatments while accounting for factors that can influence these outcomes, such as cognitive impairments and social and environmental factors. Notably, many of the items included in the CARE Item Set were already being collected in hospitals, SNFs, and HHAs, although the format might have varied.
Core and Supplemental Items: A Granular Approach to Patient Assessment
The CARE Item Set employs a two-tiered approach with core and supplemental items:
- Core Items: These are fundamental questions asked for every patient within a specific care setting, regardless of their condition. They provide a baseline assessment across the board.
- Supplemental Items: These are condition-specific questions asked only when a patient presents with a particular condition. They offer a more detailed measurement of severity or the degree of need for patients with specific health issues.
Supplemental items enable a more granular measurement of severity for patients who have specific conditions. By standardizing the clinical language used across different care sites, the CARE Item Set facilitates improvements in measuring acuity, treatment needs, and patient outcomes. It also enhances the transfer of essential patient information between various healthcare settings, promoting continuity of care.
For instance, in the domain of skin integrity, a core question is whether a patient has one or more unhealed pressure ulcers at stage 2 or greater. If the answer is yes, supplemental items are then used to describe the characteristics of these ulcers in detail.
Development and Refinement of the CARE Item Set
The CARE Item Set underwent a rigorous development process spanning 14 months. The creation of the CARE Item Set focused on standardizing assessment items based on scientific literature and experiences with mandated assessment items in Medicare payment systems, such as those in the IRF-PAI, MDS, and OASIS instruments. Only items directly related to patient severity, payment considerations, or monitoring the quality of care were included. The CARE Item Set is designed as a framework for a standard set of items that can be accessed through an item bank. Items from existing MDS and OASIS tools primarily used for care planning were intentionally excluded.
The majority of items in the CARE Item Set are typically documented in patients’ medical records, although the format, formality, data location, and designated data collectors may vary across settings. Items were carefully evaluated and selected to ensure maximum reliability, validity, and breadth of application, minimizing floor and ceiling effects and mitigating incentives that could lead to provider behaviors inconsistent with best practices.
Further reports and detailed information about the CARE Item Set’s development and reliability analysis are available in the Useful Links and Downloads sections.
B-CARE: Streamlining Assessment for Bundled Payments
Building on the foundation of the CARE Item Set, B-CARE is a streamlined version designed for potential use within the Bundled Payments for Care Improvement (BPCI) Initiative. B-CARE aims to provide consistent patient information across different BPCI models and care settings to monitor the impact of care redesign on patient health status and care outcomes. B-CARE data can also be instrumental in understanding how patient mix affects results across various BPCI models and settings.
More detailed information about the BPCI initiative is available via the Useful Links section.
(Note: Since the original article does not contain images, no images are included in this rewritten version.)
