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1440 Main Street ■ Suite 310 ■ Waltham, MA 02452-1623Phone 781-434-1717 E-mail bgage@rti.orgFax 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:

PAT-COMMENTS@RTI.ORG

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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.