1440 Main Street  ■   Suite 310  ■   Waltham, MA 02452-1623 Phone 781-434-1717 E-mail bgage@rti.org Fax 781-434-1701 Post ...
Deficit Reduction Act of 2005 <ul><li>Congressional mandate to establish a PAC Payment Reform Demonstration by January 200...
CMS Post Acute Demonstration <ul><li>Three components: </li></ul><ul><ul><li>Development of a Patient Assessment Instrumen...
Patient Assessment Instrument Development  <ul><li>Sponsored by CMS, Office of Clinical Standards and Quality </li></ul><u...
Project Overview <ul><li>Year 1: Gain input from the providers/research community </li></ul><ul><ul><li>Open Door Forums <...
Post Acute Payment Reform Demonstration <ul><li>Sponsored by CMS, Office of Research Development and Information </li></ul...
Current Tools for Measuring Patients Across the Continuum in Medicare <ul><ul><li>Acute Hospitals    no standard tool  </...
Common Domains in Current Assessment Tools <ul><li>Administrative Information </li></ul><ul><li>Social Support Information...
Differences in Tools <ul><li>Individual Items to measure each concept </li></ul><ul><li>Scales used to measure each item <...
Functional Item Comparisons  Assessment day varies 8 OASIS Past 5 days 8 12 MDS 3.0 Past 3 days 7 18 IRFPAI Assessment Per...
Functional Scales Unknown 1= Total Asst. 0= Activity NA 5= totally bathed by other 8= Activity NA 2=Maximal Asst. 25% 4= u...
Continuity Assessment Record and Evaluation (CARE) Tool Development <ul><li>4 Clinical Workgroups  </li></ul><ul><ul><li>M...
Clinical Workgroup Charge: <ul><li>Identify critical areas/domains for measuring case-mix acuity, resource use, or outcome...
Framework for CARE Patient Assessment Tool <ul><li>CORE Items:  </li></ul><ul><ul><li>Pre-Admission </li></ul></ul><ul><ul...
Issues in Selecting Items <ul><li>Identify Standard –  </li></ul><ul><ul><li>Measures that applied across severity groups ...
Data Collection Process <ul><li>Each acute provider will be asked to: </li></ul><ul><ul><li>Identify a coordinator who wil...
PAC PRD Timeline <ul><li>Market Selection:  Fall 2007 </li></ul><ul><li>Provider Enrollment:  </li></ul><ul><ul><li>Market...
Market/Site Selection <ul><li>Fall 2007 </li></ul><ul><li>Market selection criteria </li></ul><ul><ul><ul><li>Geographic v...
Web-Based Data Submission <ul><li>Inter-operable data standards being applied to allow providers to incorporate specs into...
Your Input is invited <ul><li>Questions or requests to Participate in Demonstration –email to: </li></ul><ul><li>[email_ad...
CARE Tool Attachment <ul><li>Attached is the Continuity Assessment Record and Evaluation (CARE) Tool that was published in...
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Post Acute Care: Patient Assessment Instrument and Payment Reform Demonstration

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Presented at the National Academy for State Health Policy's 20th Annual State Health Policy Conference in Denver, Colorado. Authors: Judith Tobin and Barbara Gage.

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Post Acute Care: Patient Assessment Instrument and Payment Reform Demonstration

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

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