The landscape of healthcare is constantly evolving, with a significant focus on improving patient outcomes and ensuring efficient resource allocation. Within this evolution, standardized assessment tools have emerged as critical components for evaluating and enhancing the quality of care, particularly in post-acute care settings. These “Care Tool Items,” exemplified by the Continuity Assessment Record and Evaluation (CARE) Item Set, play a vital role in providing a consistent framework for understanding patient needs and measuring the effectiveness of treatments across different healthcare environments.
The development of standardized care tool items was significantly propelled by the Deficit Reduction Act (DRA) of 2005, which mandated the Centers for Medicare & Medicaid Services (CMS) to explore Medicare Payment Reform Demonstrations. This initiative aimed to utilize standardized patient information to analyze the consistency of payment incentives across various care settings, including acute care hospitals and post-acute care facilities such as Long Term Care Hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs), and Home Health Agencies (HHAs). The core purpose was to gain a clearer understanding of how similar patients are treated in different settings and to assess the resources and outcomes associated with their care.
This demonstration highlighted the critical need for standardized data collection. It underscored that to effectively reform payment models and ensure equitable care, a uniform method for assessing patient health and functional status, irrespective of the care site, was essential. The expansion of the Medicare PRD under the Medicare, Medicaid, and the SCHIP Extension Act of 2007 further emphasized the importance of this standardized approach, allowing for a broader examination of acute hospital payments for complex medical populations.
At the heart of this movement towards standardization lies the Continuity Assessment Record and Evaluation (CARE) Item Set. Developed as a cornerstone of the Medicare Post-Acute Care Payment Reform Demonstration (PAC-PRD), the CARE Item Set represents a standardized patient assessment tool 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 foundational source of information for the demonstration, providing crucial insights into the health and functional status of Medicare beneficiaries and tracking changes in their condition and outcomes throughout the post-acute care journey.
The CARE Item Set’s primary objective is to standardize the evaluation of patients’ medical, functional, cognitive, and social support status across the continuum of care, spanning from acute care hospitals to post-acute care settings like LTCHs, IRFs, SNFs, and HHAs. This standardization aimed to create a common language and set of metrics across existing assessment tools, minimizing administrative burdens on healthcare providers while maximizing the comparability of patient data. The CARE Item Set is built upon extensive prior research and incorporates valuable lessons gleaned from clinicians working across various care settings. It focuses on capturing a spectrum of measures that reflect variations in patient care needs, including factors that influence treatment and staffing patterns, such as predictors of physician, nursing, and therapy intensity.
The development of the CARE Item Set was informed by CMS findings and the 2006 Recommendations for a Uniform Patient Assessment for Post-Acute Care. It sought to update and harmonize 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 measurement initiatives in geriatric care. The CARE Item Set is specifically engineered to measure outcomes in both physical and medical treatments, while also accounting for factors that can influence these outcomes, such as cognitive impairments and social and environmental determinants. Notably, many of the items within the CARE Item Set were already being collected in hospitals, SNFs, and HHAs, although potentially in different formats.
The CARE Item Set is structured around two main categories of items: core items and supplemental items. Core items are universally applied to every patient within a given setting, irrespective of their specific condition. Supplemental items, on the other hand, are condition-specific and are only administered to patients who present with particular conditions. These supplemental items are designed to provide a more detailed and granular measurement of severity for those patients who have specific health issues. For instance, a core item might be whether a patient has one or more unhealed pressure ulcers at stage 2 or greater. If the answer is yes, supplemental items would then delve into the specifics of those ulcers, such as their stage, number, and location.
The standardization offered by care tool items like the CARE Item Set brings significant advantages to the healthcare system. By establishing a common language and set of measures, it facilitates improved communication and information transfer between different care settings. This enhanced data consistency and comparability ultimately supports more accurate measurement of patient acuity, treatment needs, and outcomes. Furthermore, it lays the groundwork for more refined payment models that are better aligned with patient needs and the costs of care, driving towards a more efficient and patient-centered healthcare system. The ongoing refinement and implementation of care tool items are crucial steps towards achieving higher quality and more equitable post-acute care for all Medicare beneficiaries.
