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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 AHASeptember 19, 2007

Presented byBarbara Gage, PhD

Melissa Morley, 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 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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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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Benefit to Provider

CMS is moving towards Federally compliant, standardized IT systems which may be built on the results of this demonstration

Standardizes information used in transfers which reduces the burden for inter-facility communication

Better measurement of case mix within each provider

Contributes to community benefit for non-profits and can help qualify nursing staff for Magnet status

Provides input into future Federal policy development including development of efficient processes and better case mix measures

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Provider Burden

CARE assessment: Tool is similar to assessment tools currently used in

hospitals; shorter than SNF and HHA tools Acute completion times: 20 minutes for home discharges; up

to 45 minutes for PAC discharges; average of 30 minutes IRF/HHA avg. completion times: 45 minutes SNF avg. completion times: 1 hour Team responses – different sections may be completed by

different staff – up to provider to identify best respondents Coordinator review before submission

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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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Master CARE Tool

Published in the Federal Register July 27, 2007

Includes both core and supplemental items so you can follow skip patterns

Associated item matrix identifies the core and supplemental items in a comprehensive table

Based on current assessment tools in each of the 5 types of settings

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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