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1440 Main Street ■ Suite 310 ■ Waltham, MA 02452-1623Phone 781-434-1717 E-mail [email protected] 781-434-1701
Post Acute Care: Patient Assessment Instrument and Payment
Reform Demonstration
Presented to National Academy for State Health PolicyOctober 16, 2007
Presented by
Judith Tobin, BS, MBACenters for Medicare & Medicaid Services
andBarbara Gage, PhD RTI International
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Deficit Reduction Act of 2005
Congressional mandate to establish a PAC Payment Reform Demonstration by January 2008 to examine cost and outcomes across different post acute sitesSingle comprehensive assessment at acute
hospital dischargeStandardized assessment in all PAC settings to
measure health and functional status and other treatment factors
Collection of information on resources/patient
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CMS Post Acute Demonstration
Three components:Development of a Patient Assessment InstrumentDevelopment of a web-based, electronic reporting
system Implementation of a Payment Reform
Demonstration
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Patient Assessment Instrument Development
Sponsored by CMS, Office of Clinical Standards and Quality
Project Officer: Judith Tobin, CMS
Principal Investigator/RTI Team: Barbara Gage, Shula Bernard, Roberta Constantine, Melissa Morley, Mel Ingber
Co- Principal Investigators: Allen Heinemann, Trudy Mallinson, Anne Deutsch, David Cella, Richard Gershon
Consultants: Margaret Stineman, Deborah Saliba, Patrick Murray, and Chris Murtaugh
Input by pilot test participants, including workgroup participation by RML and on-going input by participating acute hospitals, LTCHs, IRFs, SNFs, and HHAs
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Project Overview
Year 1: Gain input from the providers/research communityOpen Door ForumsTool development based on existing assessment toolsTechnical Expert Panels (March/April)2 Pilot Tests: 1 market (April/May)Small Group meetings (Summer/Fall 2007)Draft report to CMS (Fall 2007)
Assist developers of web-based data submission system at CMS for direct submission to CMS or thru vendors
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Post Acute Payment Reform Demonstration
Sponsored by CMS, Office of Research Development and Information
Project Officer, Shannon Flood
10 Market Study, 150 providers (Acute, LTCH, IRF, SNF, HHA)
Collecting two types of data: Acute hospitals: CARE assessment data to measure patient
case mix (7/24/07 Federal Register) PAC providers: CARE assessment (case mix severity and
outcomes) & Cost and Resource Utilization (CRU) to measure resource use (8/24/07 Federal Register)
January 2008 - First demonstration site underway
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Current Tools for Measuring Patients Across the Continuum in Medicare
Acute Hospitals no standard tool Long-Term Care Hospitals no standard tool Inpatient Rehabilitation Facilities IRFPAI Skilled Nursing Facilities MDS Home Health Agencies OASIS
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Common Domains in Current Assessment Tools
Administrative Information
Social Support Information
Medical Diagnosis/Conditions
Functional Limitations Physical Cognitive
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Differences in Tools
Individual Items to measure each concept
Scales used to measure each item
Look-back or assessment periods
Unidimensionality of individual items
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Functional Item Comparisons
Tools
No. of Functional
ItemsScale Levels Assessment Periods
IRFPAI 18 7 Past 3 days
MDS 3.0 12 8 Past 5 days
OASIS 8 varies Assessment day
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Functional Scales
IRF-PAI MDS OASIS
7= Complete independence 0= Independent 0= bathe independent tub/shower
6=Modified (device) 1= Supervision 1= with devices, independent
5=Supervision 2= Limited Asst. (guided maneuvering)
2= with person (reminders, access, reach difficult areas
4=Minimal Assistance 25% 3= Extensive Asst (3+ times/week)
3= participates but req. other person
3= Moderate Assistance 50%
4= Total Dependence 4= unable, bathes in bed/chair
2=Maximal Asst. 25% 8= Activity NA 5= totally bathed by other
1= Total Asst.
0= Activity NA
Unknown
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Continuity Assessment Record and Evaluation (CARE) Tool Development
4 Clinical Workgroups Medical acuity/continuity of careFunctional impairmentCognitive impairmentSocial/Environmental support
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Clinical Workgroup Charge:
Identify critical areas/domains for measuring case-mix acuity, resource use, or outcomes
Review existing legacy tools (MDS, IRFPAI, OASIS), other leading measurement tools (PROMIS, COCOA-B, VA) and existing tools in LTCHs and acute hospitals
Propose core data set that can be used to standardize information at hospital discharge and across all PAC settings
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Framework for CARE Patient Assessment Tool
CORE Items:
Pre-Admission Medical Function: Self Care and
Basic Mobility Cognitive Discharge
Supplemental Items
For those who answer yes on a screening item –
Pressure ulcer/wound items
Function items Caregiver items
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Issues in Selecting Items
Identify Standard – Measures that applied across severity groups but capture the
range of severity Scales that do not lead to ceiling or floor effects when
measuring severity Assessment windows that would allow severity comparisons
at time of discharge and across settings
Self-report/performance-based items
Current Medicare payment methods
Minimal burden on providers
Varying technology options across providers
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Data Collection Process
Each acute provider will be asked to: Identify a coordinator who will attend a local 1 day training and train your
staff on tools’ use Help identify 1-2 units for participation Use CARE tool to assess Medicare patients in study unit admitted during 9
month period Submit the data using the web-based, privacy protected CMS system
Each PAC provider will also submit: a second assessment on each Medicare patient in the participating
units/areas. Resource data 3 times during the 9 month data collection period. Resource
data will be collected for 2 week periods. Each unit staff member will record their time with individual patients during each study day in the 2 week period. Pilot tests showed 15 minutes per day burden.
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PAC PRD Timeline
Market Selection: Fall 2007
Provider Enrollment: Market 1: November, 2007Market 2-10: December, 2007-March 2008
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Market/Site Selection
Fall 2007
Market selection criteria Geographic variation PAC “richness” variation
Provider selection criteria Rural/urban Size (large, medium, small) Hospital-based units and Free-standing Chain/system-based and independents
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Web-Based Data Submission
Inter-operable data standards being applied to allow providers to incorporate specs into their own application or submit in a standard HL-7 format
Developed with IRT/CAT structure so that core screening question responses will provide “opt-out” options – respondent does not have to scroll thru inappropriate supplemental questions
Drop-down menus and radio buttons to allow quick clicks for data entry
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Your Input is invited
Questions or requests to Participate in Demonstration –email to:
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CARE Tool Attachment
Attached is the Continuity Assessment Record and Evaluation (CARE) Tool that was published in the Federal Register July 27, 2007
This master version of the CARE tool contains both core items (for any Medicare case) and supplemental items (for cases where a screening item triggers additional information needs such as for patients with skin conditions, respiratory conditions, functional impairments, etc). Both are imbedded on the master tool to show the range of potential items included in the tool. Only the core items will be asked of all Medicare patients.
Based on existing assessment tools used in hospitals, LTCHs, IRFs, SNFs, and HHAs.