The landscape of healthcare is constantly evolving, with a significant focus on enhancing the quality and efficiency of patient care, particularly within post-acute care settings. To address these needs, the Centers for Medicare & Medicaid Services (CMS) introduced a pivotal initiative: the Post-Acute Care Payment Reform Demonstration (PAC-PRD). Central to this demonstration and the drive for improved patient outcomes is the Continuity Assessment Record and Evaluation (CARE) Item Set, a standardized assessment tool designed to provide a comprehensive view of patient health across different care settings. This article delves into the CARE Item Set, exploring its development, purpose, and significance as a crucial care tool, especially within Inpatient Rehabilitation Facilities (IRFs).
The Genesis of the CARE Item Set: Addressing Payment Reform and Data Standardization
The CARE Item Set emerged from the Deficit Reduction Act of 2005, which mandated CMS to develop the Medicare Payment Reform Demonstration. This initiative aimed to standardize patient information collection across various healthcare settings, including acute care hospitals, Long Term Care Hospitals (LTCHs), IRFs, Skilled Nursing Facilities (SNFs), and Home Health Agencies (HHAs). The core objective was to analyze payment incentives and ensure consistency in care delivery for Medicare beneficiaries treated in these diverse environments.
This demonstration highlighted the critical need for standardized data on patient health and functional status, irrespective of the care setting. By collecting uniform data, CMS could effectively compare resource utilization and patient outcomes across different post-acute care settings. This comparative analysis was essential for understanding variations in treatment approaches, outcomes, and associated costs, ultimately paving the way for informed payment reform recommendations.
The Medicare, Medicaid, and the SCHIP Extension Act of 2007 further expanded the PRD, enabling broader provider participation and authorizing CMS to evaluate the adequacy of acute hospital payments for complex medical populations. The CARE Item Set became a cornerstone of this expanded demonstration, providing the necessary data to drive these analyses and reforms.
The CARE Item Set: A Standardized Patient Assessment Tool
Developed as part of the PAC-PRD, the CARE Item Set is a standardized patient assessment tool implemented at acute hospital discharge and during admission and discharge in post-acute care facilities. This tool serves as a primary source of data within the demonstration, focusing on measuring the health and functional status of Medicare beneficiaries transitioning from acute care to post-acute care settings. Crucially, it also tracks changes in patient condition severity and other outcomes throughout their post-acute care journey.
The overarching 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 LTCHs, IRFs, SNFs, and HHAs. By standardizing assessment items, the aim was to minimize administrative burden on providers while ensuring data uniformity. The CARE Item Set is built upon extensive prior research and incorporates insights from clinicians across various care settings. It targets 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 development of the CARE Item Set incorporated recommendations from CMS and the 2006 Recommendations for a Uniform Patient Assessment for Post-Acute Care. It aimed to update and harmonize existing federal assessment tools, such as the IRF-Patient Assessment Instrument (IRF-PAI), the Minimum Data Set (MDS), and the Outcome and Assessment Information Set (OASIS). The CARE Item Set is specifically designed to measure outcomes in physical and medical treatments while 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 the format might have varied.
Core and Supplemental Items: A Granular Approach to Patient Assessment
The CARE Item Set employs a two-tiered approach to patient assessment, utilizing both core and supplemental items.
- Core Items: These are fundamental questions asked for every patient within a specific care setting, irrespective of their condition. They provide a baseline understanding of the patient’s overall status.
- Supplemental Items: These are condition-specific questions asked only of patients presenting with a particular condition. Supplemental items offer a more detailed and granular measurement of the severity or degree of need for patients with specific health issues.
This combination of core and supplemental items allows for a comprehensive yet targeted assessment. For instance, while a core item might identify the presence of unhealed pressure ulcers at stage 2 or greater, supplemental items would delve deeper into the characteristics and severity of these ulcers, but only for patients who actually have them. This standardized language across care sites facilitates improved measurement of patient acuity, treatment needs, and outcomes, while also enhancing information transfer between different healthcare settings.
B-CARE: Streamlining Assessment for Bundled Payments
Building upon the foundation of the CARE Item Set, B-CARE emerged as a streamlined version specifically considered for use within the Bundled Payments for Care Improvement (BPCI) Initiative. B-CARE is designed to provide consistent patient information across various BPCI models and care settings. This consistent data collection is crucial for monitoring the impact of care redesign efforts on beneficiaries’ health status and care outcomes. Furthermore, B-CARE data can be instrumental in understanding how patient mix influences results across different BPCI models and care settings.
Conclusion: The CARE Item Set as a Cornerstone of Post-Acute Care Improvement
The CARE Item Set stands as a significant advancement in the pursuit of higher quality and more efficient post-acute care. As a standardized and comprehensive care tool, particularly valuable within IRFs and other post-acute settings, it provides the data necessary to understand patient needs, evaluate treatment effectiveness, and drive payment reforms that incentivize quality and value. By standardizing patient assessment across the healthcare continuum, the CARE Item Set facilitates better communication, data-driven decision-making, and ultimately, improved outcomes for Medicare beneficiaries receiving post-acute care.
