In the evolving landscape of healthcare, particularly within the Medicare system, the focus on enhancing patient care quality and optimizing payment structures is paramount. To address these critical aspects in post-acute care (PAC) settings, the Centers for Medicare & Medicaid Services (CMS) introduced a standardized patient assessment tool known as the Continuity Assessment Record and Evaluation (CARE) Item Set. This article delves into the CARE Item Set, exploring its development, purpose, and significance as a vital Care Tool Medicare utilizes to ensure consistent and high-quality patient care across various healthcare environments.
The journey towards the CARE Item Set began with the Deficit Reduction Act (DRA) of 2005, which mandated CMS to establish a Medicare Payment Reform Demonstration (PRD). The core objective was to employ standardized patient information to evaluate the uniformity of payment incentives for Medicare beneficiaries treated in diverse settings. This demonstration encompassed acute care hospitals and four post-acute care settings: Long Term Care Hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs), and Home Health Agencies (HHAs).
This initiative was crucial for obtaining standardized data on patient health and functional status, irrespective of the care site. It facilitated the examination of resources and outcomes linked to treatment in each setting type. This approach enabled CMS to gain a deeper understanding of the extent to which patients with similar conditions were being treated in different environments. Furthermore, insights into resource utilization within each setting were essential to discern variations in patient treatment, outcomes, and care expenses, ultimately informing recommendations for appropriate payment reform. The Medicare PRD was later expanded under the Medicare, Medicaid, and the SCHIP Extension Act of 2007 (MMSEA), broadening participation and authorizing CMS to assess the adequacy of acute hospital payments for medically complex patient populations.
The CARE Item Set emerged as a key component of the Medicare Post-Acute Care Payment Reform Demonstration (PAC-PRD). It was conceived as a standardized patient assessment instrument to be utilized at the point of discharge from acute hospitals and upon admission and discharge from post-acute care facilities. Data gathered through the CARE Item Set became a fundamental information source for the demonstration. This care tool medicare implemented is specifically designed to measure the health and functional status of Medicare beneficiaries at the time of acute discharge and to track changes in severity and other outcomes for patients undergoing post-acute care.
The primary 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, spanning acute and post-acute settings, including LTCHs, IRFs, SNFs, and HHAs. This standardization effort aimed to harmonize the items used in existing assessment tools while minimizing the administrative burden on healthcare providers. The CARE Item Set is built upon previous research and incorporates valuable lessons from clinicians involved in patient care across all settings. It targets a range of measures that document variations in a patient’s level of care needs, encompassing factors influencing 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. This effort sought 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), and other measurement initiatives related to geriatric care. As a care tool medicare utilizes, the CARE Item Set is structured to evaluate outcomes in physical and medical treatments while accounting for factors that can influence these outcomes, such as cognitive impairments and social and environmental determinants. Many of the items within the CARE Item Set were already being collected in hospitals, SNFs, and HHAs, although the specific format of the items may have differed.
The CARE Item Set is composed of two categories of items: core items and supplemental items. Core items are universally applied to every patient within a given setting, regardless of their condition. Supplemental items, conversely, are condition-specific and are only administered to patients presenting with a particular condition. These supplemental items are designed to provide a more detailed measurement of severity for those patients who have a specific condition. By establishing a standardized language for clinicians across different care sites, the CARE Item Set facilitates advancements in measuring patient acuity, treatment needs, and outcomes, and enhances information exchange between various healthcare settings.
For instance, in the domain of skin integrity, the presence of one or more unhealed pressure ulcers at stage 2 or greater is a core question asked of all patients. In contrast, items that describe the characteristics of these ulcers are supplemental, applicable only to patients who indeed have stage 2 or higher pressure ulcers.
The CARE Item Set underwent a rigorous development process spanning 14 months. Its creation was driven by the need to standardize assessment items based on scientific literature and experiences with mandated assessment items in Medicare payment systems, including those in the IRF-PAI, MDS, and OASIS instruments. The selection of items was carefully considered, focusing solely on those relevant to patient severity, payment considerations, or monitoring the quality of care. Thus, the CARE Item Set serves as a framework for a standard set of items accessible through an item bank. Items from existing MDS and OASIS tools solely used for care planning were intentionally excluded from the CARE Item Set. Notably, most items in the CARE Item Set are typically documented in patients’ medical records, although the format, location, and designated personnel for data collection may vary. Items were meticulously evaluated and chosen to maximize reliability, validity, and breadth of application while minimizing potential incentives for provider behavior that might contradict best practices in patient care.
Building upon the CARE Item Set, B-CARE emerged as a streamlined version. 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 BPCI models and care settings, enabling the monitoring of care redesign effects on beneficiaries’ health status and care outcomes. This care tool medicare explores further could also provide valuable insights into the impact of patient mix on results from different BPCI models and settings.
In conclusion, the CARE Item Set represents a significant stride in Medicare’s efforts to refine post-acute care. As a crucial care tool medicare employs, it standardizes patient assessment, enhances data consistency, and supports payment reform initiatives aimed at improving patient outcomes and ensuring efficient resource allocation across the healthcare spectrum.
Useful Links:
Overview of the Medicare Post-Acute Care Payment Reform Initiative
Section 5008. Post-Acute Care Payment Reform Demonstrations Program. Deficit Reduction Act of 2005
Post-Acute Care Payment Reform Demonstration: Final Report
Report to Congress: Post Acute Care Payment Reform Demonstration (PAC-PRD) (PDF)
Post-Acute Care Payment Reform Demonstration Report to Congress Supplement-Interim Report (PDF)
Post-Acute Care Payment Reform Demonstration: Final Report. (PDF) Volume 2 of 4 (PDF)
