In the landscape of healthcare, particularly within post-acute care settings, the drive for standardized and efficient patient assessment tools is paramount. The journey towards optimized patient care and effective payment models has led to the development and implementation of sophisticated systems designed to capture patient health and functional status comprehensively. One such pivotal development is the Continuity Assessment Record and Evaluation (CARE) Item Set. This tool emerged from the Medicare Post-Acute Care Payment Reform Demonstration (PAC-PRD) as a standardized approach to evaluate patient conditions across various healthcare environments, including inpatient rehabilitation facilities.
The Genesis of Standardized Care Tools: Addressing Payment Reform
The concept of standardized patient assessment tools gained significant traction with the Deficit Reduction Act (DRA) of 2005, which spurred the Centers for Medicare & Medicaid Services (CMS) to initiate the Medicare Payment Reform Demonstration (PRD). This demonstration aimed to scrutinize the consistency of payment incentives across different healthcare settings, such as Acute Care Hospitals, Long Term Care Hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs), and Home Health Agencies (HHAs). The core objective was to use uniform patient data to understand how similar patient populations were being treated in these varied settings.
This initiative highlighted the necessity for standardized information on patient health and functional capabilities, irrespective of the care location. By gathering consistent data, CMS sought to gain insights into resource utilization, treatment outcomes, and the overall costs associated with care in each setting. This understanding was crucial for formulating informed recommendations for payment reform. The Medicare PRD was further broadened by the Medicare, Medicaid, and the SCHIP Extension Act of 2007 (MMSEA), enabling more providers to participate and allowing CMS to evaluate the adequacy of acute hospital payments for complex medical cases.
Introducing the CARE Item Set: A Uniform Assessment Tool
At the heart of the Medicare Post-Acute Care Payment Reform Demonstration (PAC-PRD) lies the Continuity Assessment Record and Evaluation (CARE) Item Set. This standardized patient assessment tool is designed for use at the point of discharge from acute care hospitals and upon admission and discharge from post-acute care facilities. Data collected through the CARE Item Set became a cornerstone of the demonstration, serving as a primary source of information. The CARE Item Set is instrumental in measuring the health and functional status of Medicare beneficiaries at the time of acute discharge and tracking changes in severity and outcomes for patients undergoing post-acute care.
The primary goal of the CARE Item Set is to standardize the assessment of patients’ medical, functional, cognitive, and social support status across the spectrum of care settings. This includes long-term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies (HHAs). The development process focused on harmonizing the items used in existing assessment tools to minimize administrative burden on healthcare providers. The CARE Item Set is built upon previous research and incorporates insights from clinicians experienced in treating patients across different care continuums. 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 creation of the CARE Item Set was informed by CMS findings and the 2006 Recommendations for a Uniform Patient Assessment for Post-Acute Care. It aimed to update and refine 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 engineered to evaluate outcomes in both physical and medical treatments, while accounting for variables that can affect these outcomes, such as cognitive impairments, social factors, and environmental influences. Significantly, many of the items included in the CARE Item Set were already being collected in hospitals, SNFs, and HHAs, although the specific format of these items might have varied.
Core and Supplemental Items: A Detailed Look
The CARE Item Set is structured around two main types of items: core items and supplemental items. Core items are fundamental questions asked of every patient within a given care setting, regardless of their specific condition. Supplemental items, conversely, are designed to be administered only to patients who present with a specific condition. These supplemental items are crucial for providing a more detailed and nuanced measurement of the severity or degree of need for patients with particular conditions.
These supplemental items are vital for offering a more granular measurement of severity for patients with specific conditions. By establishing a standardized language for clinicians across different care sites, the CARE Item Set facilitates advancements in measuring patient acuity, treatment needs, and outcomes. It also plays a crucial role in enhancing information transfer between various healthcare settings, ensuring continuity of care and improved patient management.
Consider, for example, the area of 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, then supplemental items would delve into describing those ulcers in detail. These supplemental questions are only relevant and applied to patients who have already been identified as having a stage 2 or higher pressure ulcer.
Development and Refinement of the CARE Item Set
The CARE Item Set underwent a rigorous development process spanning 14 months. Its creation was rooted in scientific literature, experiences with mandated assessment items within Medicare payment systems—such as those in IRF-PAI, MDS, and OASIS—and a focus on items relevant to patient severity, payment considerations, and quality of care monitoring. The result is a framework for a standard set of items accessible through an item bank. Items primarily used for care planning in existing tools like MDS and OASIS were intentionally excluded from the CARE Item Set to maintain its focus on standardization for payment reform and quality measurement.
A significant aspect of the CARE Item Set is that most of its items are typically documented in patients’ medical records. However, it acknowledges that the format, formality, location of data, and designated personnel for data collection can vary across settings. Items were carefully selected and evaluated to maximize reliability, validity, and the breadth of their application, ensuring they are effective across diverse patient populations and conditions. Furthermore, the selection process aimed to minimize any incentives that might inadvertently encourage provider behaviors that are not aligned with best practices in patient care.
B-CARE: Streamlining Assessment for Bundled Payments
Building on the foundation of the CARE Item Set, B-CARE emerged as a streamlined version. B-CARE is currently under consideration for use within the Bundled Payments for Care Improvement (BPCI) Initiative. The adoption of B-CARE would ensure consistent data collection across various BPCI models and care settings. This consistency is essential for monitoring the impact of care redesign on beneficiaries’ health status and care outcomes. Information derived from B-CARE can also be instrumental in understanding how patient mix influences the results observed across different BPCI models and settings, providing valuable insights for further refining payment and care delivery models.
Conclusion: Enhancing Inpatient Rehabilitation with Standardized Tools
The development and implementation of the CARE Item Set represent a significant stride towards enhancing the quality and efficiency of healthcare, particularly in inpatient rehabilitation and post-acute care settings. By providing a standardized framework for patient assessment, the CARE Item Set facilitates better understanding of patient needs, outcomes, and resource utilization. Tools like the CARE Item Set are crucial for driving improvements in patient care, informing payment reforms, and ultimately ensuring that patients receive the most appropriate and effective care throughout their rehabilitation journey.
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)
