The healthcare landscape is constantly evolving, and with it, the need for efficient and standardized systems to ensure quality patient care. In the realm of post-acute care, the Centers for Medicare & Medicaid Services (CMS) has spearheaded initiatives to reform payment structures and enhance patient assessment. At the heart of these efforts lies the Continuity Assessment Record and Evaluation (CARE) Item Set, a pivotal Care Tool Rehab strategy designed to standardize patient information across diverse healthcare settings. This article delves into the CARE Item Set, exploring its development, purpose, and impact on post-acute care quality and payment reform.
The journey towards the CARE Item Set began with the Deficit Reduction Act (DRA) of 2005, which mandated CMS to develop the Medicare Payment Reform Demonstration (PRD). This initiative aimed to scrutinize the consistency of payment incentives within Medicare for patients treated across various settings, including acute care hospitals and four post-acute care environments: Long Term Care Hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs), and Home Health Agencies (HHAs). The core objective was to establish a standardized method for evaluating patient health and functional status, irrespective of the care setting. This approach would enable CMS to gain a clearer understanding of patient distribution across different settings and optimize resource allocation, paving the way for informed payment reform recommendations.
The Medicare PRD expanded under the Medicare, Medicaid, and the SCHIP Extension Act of 2007 (MMSEA), broadening participation and empowering CMS to assess the adequacy of acute hospital payments for complex medical cases. Findings from the Medicare PRD are publicly accessible, offering valuable insights into the demonstration’s outcomes and impact.
The CARE Item Set: A Standardized Assessment Tool
A cornerstone of the Medicare Post-Acute Care Payment Reform Demonstration (PAC-PRD) was the development of a standardized patient assessment tool: the Continuity Assessment Record and Evaluation (CARE) Item Set. This instrument is designed for use at acute hospital discharge and during post-acute care admission and discharge. Data gathered through the CARE Item Set served as a critical information source for the demonstration, enabling the measurement of health and functional status of Medicare beneficiaries at acute discharge, and tracking changes in severity and outcomes for post-acute care patients.
The primary goal of the CARE Item Set is to standardize the assessment of patients’ medical, functional, cognitive, and social support status across the continuum of care. This includes long-term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies (HHAs). The development process prioritized the incorporation of standardized items already utilized in existing assessment tools, while minimizing administrative burden on healthcare providers. Drawing upon prior research and clinical expertise, the CARE Item Set encompasses a range of measures that capture 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’s design is informed by CMS findings and the 2006 Recommendations for a Uniform Patient Assessment for Post-Acute Care, aiming to update existing federal assessment tools such as 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. It is structured to evaluate outcomes in physical and medical treatments while accounting for factors that influence these outcomes, such as cognitive impairments, and social and environmental determinants. Notably, many of the items within the CARE Item Set are already collected in hospitals, SNFs, and HHAs, albeit potentially in different formats.
Further details about the CARE Item Set are available in the Useful Links and Downloads sections, offering comprehensive resources for those seeking deeper understanding.
Core and Supplemental Items: A Granular Approach
The CARE Item Set is composed of two distinct item types:
- Core items: These are fundamental questions asked of every patient within a given setting, irrespective of their specific condition.
- Supplemental items: These are condition-specific questions, designed to measure the severity or degree of need for patients presenting with particular conditions.
Supplemental items offer a more detailed and nuanced measurement of severity for patients with specific conditions. By standardizing the clinical language used across different care settings, the CARE Item Set facilitates advancements in measuring patient acuity, treatment needs, and outcomes. This standardization also significantly improves information transfer between various healthcare settings, enhancing continuity of care.
For instance, in assessing skin integrity, a core question addresses whether a patient has one or more unhealed pressure ulcers at stage 2 or greater. Supplemental items then delve into the specifics of these ulcers, applying only to patients who meet the criteria of the core question. This layered approach ensures comprehensive yet targeted assessment.
Development and Refinement of the CARE Item Set
The CARE Item Set underwent a rigorous 14-month development process. Its creation was grounded in scientific literature, experiences with mandated assessment items in Medicare payment systems (including IRF-PAI, MDS, and OASIS instruments), and a focus on items relevant to patient severity, payment considerations, and monitoring quality of care. The CARE Item Set serves as a framework for a standardized item set, accessible through an item bank. Items primarily used for care planning in existing MDS and OASIS tools were intentionally excluded. The majority of items in the CARE Item Set are routinely documented in patients’ medical records, although the format, location, and designated personnel for data collection may vary. Item selection prioritized reliability, validity, broad applicability, and the minimization of incentives that could potentially skew provider behavior away from best care practices.
Reports and additional information concerning the CARE Item Set’s development and reliability analysis are accessible via the Useful Links and Downloads sections, providing transparency and in-depth insights into its validation.
B-CARE: Streamlining Assessment for Bundled Payments
Building upon the CARE Item Set, B-CARE emerges as a streamlined version, currently under consideration for use within the Bundled Payments for Care Improvement (BPCI) Initiative. B-CARE aims to deliver consistent information across BPCI models and care settings, enabling the monitoring of care redesign effects on beneficiaries’ health status and care outcomes. Furthermore, B-CARE data can be instrumental in understanding the impact of patient mix on results across diverse BPCI models and settings.
More comprehensive information about the BPCI initiative is available through the provided Useful Links, offering context and further understanding of B-CARE’s potential application.
Conclusion: The CARE Item Set as a Vital Care Tool Rehab Component
In conclusion, the Continuity Assessment Record and Evaluation (CARE) Item Set represents a significant stride in the care tool rehab efforts within post-acute care. By standardizing patient assessment across various healthcare settings, the CARE Item Set provides a robust foundation for payment reform, quality improvement, and enhanced patient care. Its development, grounded in rigorous research and clinical expertise, underscores its value as a critical instrument for healthcare providers, policymakers, and researchers striving to optimize the post-acute care landscape. The CARE Item Set is more than just an assessment tool; it is a catalyst for a more integrated, efficient, and patient-centered post-acute care system.
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)
