The Centers for Medicare and Medicaid Services (CMS) recently issued their report to Congress on the Post Acute Care Payment Reform Demonstration (PAC-PRD). One purpose of the demonstration project was to test the standard data collection tool, the Continuity Assessment Record and Evaluation (CARE), which is proposed for use in acute care hospitals and post-acute care settings including Long-Term Care Hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs), and Home Health Agencies (HHAs). The demonstration involved 140 general acute hospitals and post-acute providers in 11 markets.
The CARE tool was designed to collect data at discharge from acute care hospitals and at admission and discharge from each PAC setting with standard assessment windows (timeframes) of the first two days following admission and the last two days of a stay prior to discharge.
The CARE item set is comprised of items that are consistent with the domains currently collected in most patient assessment tools or intake assessments and the three CMS mandated tools. Not all CARE items are collected on all Medicare patients. CARE incorporates screener questions to allow less clinically complex patients to be assessed quickly. The assessment takes 30 minutes to an hour to complete depending upon the complexity of the patient.
The CARE dataset includes:
• Administrative Items: Patient demographic information and basic insurance information.
• Pre-Morbidity Patient Information: Baseline data on patient’s preadmission status and status before the current spell of illness. These are important factors for risk-adjusting outcomes, including the probability of discharge to the community and expected changes in functional abilities.
• Current Medical Information: Factors explaining medical or level of care needs. Patients with greater medical complications may need more intensive settings and higher frequency physician and nursing care. The factors in this section are commonly used in current case mix systems, such as diagnosis, comorbidities, procedures, and skin integrity. These items are typically included in a patient’s current medical record.
• Interview Items: Cognitive Status, Mood and Pain: Patient-centered interview items reflect the voice of the patient. Cognitive, mood and pain items provide important risk adjusters. Observational measures were also included in order to obtain information on these domains where it was not possible to interview the patient.
• Impairments: Screening and supplemental items identifying impairments which may impact a patient’s functional abilities or otherwise impact a patient’s care needs.
• Functional Status: The person’s ability to perform specified motor tasks, activities of daily living and instrumental activities of daily living. Functional status items serve as both predictors of resource needs and outcomes.
• Discharge Information: Patient discharge destination, discharge support needs, and other non-medical, social support factors that might affect placement decisions and which may improve care transitions
One of the most important contributions of this project is the consistent measures of patient severity across the different PAC settings, allowing for inter-setting comparisons. It includes items that standardize ways of measuring severity for patients who have medical or functional conditions identified by the screener items. The value of using the same measures of a concept across settings is that it allows one to determine equivalent costs independent of setting and to measure changes in outcomes for equivalent cases.
CMS states that the use of the CARE tool was successful, and that they will continue to work with the CARE tool beyond this project. The post-acute care settings were all able to use the same tool to collect data “in a consistent, reliable, and comprehensive manner for their Medicare populations”. All providers in the post-acute care setting will want to continue to follow developments based on this demonstration.
