The landscape of healthcare is constantly evolving, with a significant focus on improving the quality of care while managing costs effectively. In the United States, the Centers for Medicare & Medicaid Services (CMS) plays a pivotal role in shaping healthcare policy and payment models. One crucial initiative in this realm is the development and implementation of standardized assessment tools, such as the Continuity Assessment Record and Evaluation (CARE) Item Set, often referred to as a Cms Care Tool, aimed at refining post-acute care (PAC) and promoting payment reform.
The Genesis of the CARE Item Set: Addressing Payment Reform
The journey towards standardized patient assessment in post-acute care began with the Deficit Reduction Act (DRA) of 2005. This legislation mandated CMS to initiate a Medicare Payment Reform Demonstration (PRD). The core objective was to utilize standardized patient information to analyze the consistency 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)
- Home Health Agencies (HHAs)
This initiative was groundbreaking as it aimed to provide a uniform view of patient health and functional status, irrespective of the care setting. By examining resources and outcomes across these settings, CMS sought to gain deeper insights into how similar patient populations were being treated differently. Furthermore, understanding resource utilization within each setting was crucial for identifying variations in treatment approaches, patient outcomes, and the associated costs. This comprehensive analysis was essential for formulating evidence-based recommendations for payment reform.
The Medicare PRD was further expanded through the Medicare, Medicaid, and the SCHIP Extension Act of 2007 (MMSEA). This expansion broadened participation in the demonstration and empowered CMS to evaluate the adequacy of acute hospital payments, particularly for medically complex patient populations. The findings from the Medicare PRD have been made available by CMS to inform stakeholders and guide future policy decisions.
Introducing the CARE Item Set: A Standardized 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 was meticulously developed for use at two critical junctures: acute hospital discharge and post-acute care admission and discharge. Data collected through the CARE Item Set served as a cornerstone of information for the demonstration. This CMS care tool is designed to measure the health and functional status of Medicare beneficiaries as they transition from acute care, and to track changes in their condition and outcomes throughout their post-acute care journey.
The overarching goal of the CARE Item Set is to establish a standardized approach to assessing 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 standardization of items used in existing assessment tools while striving to minimize the administrative burden on healthcare providers.
The CARE Item Set is built upon a foundation of prior research and incorporates valuable insights gleaned from clinicians who manage patients across various care settings. It targets a comprehensive range of measures that capture variations in patients’ care needs. These measures encompass factors influencing treatment and staffing patterns, such as predictors of physician, nursing, and therapy intensity.
The development of this CMS care tool was also informed by CMS findings and the 2006 Recommendations for a Uniform Patient Assessment for Post-Acute Care. This effort 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)
- Other measurement initiatives related to geriatric care.
The CARE Item Set is specifically designed to evaluate outcomes in physical and medical treatments while accounting for factors that can influence these outcomes, such as cognitive impairments, social determinants of health, 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 specific format or wording of the items may have varied.
Core and Supplemental Items: A Granular Approach
The CARE Item Set employs a two-tiered approach with two distinct types of items:
- Core Items: These are fundamental questions asked of every patient within a given care setting, regardless of their specific condition. They provide a baseline assessment across all patients.
- Supplemental Items: These items are condition-specific and are only administered to patients who present with a particular condition. Supplemental items are designed to provide a more detailed and granular measurement of the severity or degree of need for patients with specific conditions.
For instance, in the domain of skin integrity, a core item might be whether a patient has one or more unhealed pressure ulcers at stage 2 or greater. Supplemental items, on the other hand, would delve into the specifics of those ulcers, such as their number, stage, and location – but only for patients who are identified as having pressure ulcers.
By standardizing the language used by clinicians across different care settings, the CARE Item Set, as a crucial CMS care tool, facilitates advancements in measuring patient acuity, treatment needs, and outcomes. It also significantly enhances the transfer of critical patient information between care settings, leading to improved care coordination and continuity.
Development and Refinement: Ensuring Reliability and Validity
The CARE Item Set underwent a rigorous development process spanning 14 months. The creation of this CMS care tool prioritized the use of standardized assessment items grounded in scientific literature and practical experience with existing mandated assessment items within Medicare payment systems. These included instruments like the IRF-PAI, MDS, and OASIS. The item selection process focused exclusively on items relevant to patient severity, payment considerations, and the monitoring of care quality.
The CARE Item Set is conceived as a framework for a standard set of items that can be readily accessed through an item bank. Items from existing tools like MDS and OASIS that were solely intended for care planning were intentionally excluded from the CARE Item Set. A significant portion of the items in the CARE Item Set are typically documented in patients’ medical records, although variations may exist in the format, formality, location of data within the record, and the designated individuals or clinicians responsible for data collection. Each item was carefully evaluated and selected to maximize reliability, validity, and breadth of application, minimize floor and ceiling effects, and mitigate incentives that could potentially encourage provider behaviors inconsistent with best practices in patient care.
Comprehensive reports and detailed information regarding the development and reliability analysis of the CARE Item Set are accessible through the provided links and downloads.
B-CARE: A Streamlined Version for Bundled Payments
Building upon the foundation of the CARE Item Set, B-CARE emerges as a streamlined version of the Continuity Assessment and Record Evaluation (CARE) Item Set. B-CARE is under consideration for implementation 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 consistent information is vital for monitoring the impact of care redesign initiatives on beneficiaries’ health status and care outcomes. Furthermore, B-CARE data can be leveraged to understand how patient mix influences the results observed across different BPCI models and settings.
For those seeking deeper insights into the Bundled Payment for Care Improvement (BPCI) initiative, comprehensive information is readily available through the provided resources.
Conclusion: The CARE Item Set as a Cornerstone of Post-Acute Care Improvement
The Continuity Assessment Record and Evaluation (CARE) Item Set stands as a testament to CMS’s commitment to enhancing the quality and efficiency of post-acute care. As a vital CMS care tool, it provides a standardized framework for assessing patient needs, tracking outcomes, and informing payment reform initiatives. By promoting data-driven decision-making and fostering better communication across care settings, the CARE Item Set plays a crucial role in shaping a more patient-centered and value-based healthcare system.
