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Standardizing Assessment Data: Continuity Assessment Record and Evaluation (CARE) Item Set Presented by: Barbara Gage, PhD Engelberg Center for HealthCare.

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Presentation on theme: "Standardizing Assessment Data: Continuity Assessment Record and Evaluation (CARE) Item Set Presented by: Barbara Gage, PhD Engelberg Center for HealthCare."— Presentation transcript:

1 Standardizing Assessment Data: Continuity Assessment Record and Evaluation (CARE) Item Set Presented by: Barbara Gage, PhD Engelberg Center for HealthCare Reform/The Brookings Institution Stella Mandl, BSW, BSN, PHN, RN Center for Clinical Standards & Quality/CMS Presented to: The Long Term Care Discussion Group Wednesday, November 6, 2103

2 Thinking Ahead: Data Element Standardization Stella Mandl, RN Technical Advisor Division of Chronic and Post Acute Care Center for Clinical Standards and Quality Center for Medicare & Medicaid Services

3 When we keep in mind the ultimate goal of and step back to look at the big picture of what’s been done to prepare, it becomes clearer where the work converges; how much of the work is connected and has already been done to achieve Data Assessment Elements Goal 3 Achieving Uniformity to Facilitate Effective Communication for Better Care of Individuals and Communities

4 Assessment Data is: Standardized Reusable Informative Communicates in the same information across settings Ensures data transferability forward and backward allowing for interoperability Standardization: Reduces provider burden Increases reliability and validity Offers meaningful application to providers Facilitates patient centered care, care coordination, improved outcomes, and efficiency Fosters seamless care transitions Evaluates outcomes for patients that traverse settings Allows for measures to follow the patient Assesses quality across settings, and Inform payment modeling CARE: Concepts 4 Guiding Principles and Goals:

5 5 As Is To Be As Is: Multiple Incompatible Data Sources Uniform Data Elements Across Providers Standardized Nationally Vetted Nursing Homes MDS Home Health Agencies OASIS Inpatient Rehab Facilities IRF-PAI Hospitals No Standard Data Set Physicians No Standard Data Set LTCHS LTCH CARE Data Set Outpatient Settings No Standard Data Set To Be: Uniform Assessment Data Elements Enable Use/re-use of Data  Exchange Patient-Centered Health Info  Promote High Quality Care  Support Care Transitions  Reduce Burden  Expand QM Automation  Support Survey & Certification Process  Generate CMS Payment GOAL: Transition

6 Align measures with the National Quality Strategy and Six Measure Domains Implement measures that fill critical gaps within the six domains Develop parsimonious sets of measures - core sets of measures Remove measures that are no longer appropriate (e.g., topped out) Align measures with external stakeholders, including private payers and boards and specialty societies Continuously improve quality measurement over time Align measures across CMS programs whenever and wherever possible CMS Vision for Quality Measurement 6

7 CMS Framework for Measurement Measures should be patient- centered and outcome-oriented whenever possible Measure concepts in each of the six domains that are common across providers and settings can form a core set of measures Patient experience Caregiver experience Preference- and goal- oriented care Efficiency and Cost Reduction Cost Efficiency Appropriateness Care Coordination Patient and family activation Infrastructure and processes for care coordination Impact of care coordination Clinical Quality of Care Care type (preventive, acute, post-acute, chronic) Conditions Subpopulations Population/ Community Health Health Behaviors Access Physical and Social environment Health Status All-cause harm HACs HAIs Unnecessary care Medication safety 7 Safety Person- and Caregiver- Centered Experience and Outcomes Function

8 Assessment Instrument/Data Sets use uniform and standardized items Measures are harmonized at the Data Element level Providers/vendors have public access to standards Data Elements are easily available with national standards to support PAC health information technology (IT) and care communication Transfer of Care Documents are able to incorporate uniform Data Elements used in PAC settings, if desired Measures can evaluate quality across settings and be used for setting comparisons Building the Future State 8

9 Facilities are able to transmit electronic and interoperable Documents and Data Elements Provides convergence in language/terminology Data Elements used are clinically relevant Care is coordinated using meaningful information that is spoken and understood by all Measures can evaluate quality across settings and evaluate intermittent and long term outcomes Incorporates needs beyond healthcare system Keeping in Mind, the Ideal State 9

10 Standardizing Assessment Data: CARE Presented by Barbara Gage, PhD Phone

11 11 State of the Art in Measuring Patients’ Health Status in Medicare Acute Hospitals  no standard assessment tool to admit and monitor patients Long-Term Care Hospitals  newly standardized items for quality reporting Inpatient Rehabilitation Facilities  IRFPAI required Skilled Nursing Facilities  MDS required Home Health Agencies  OASIS required

12 12 DRA of 2005 called for one uniform tool that could be used to measure patient health status at: Acute hospital discharge Admission/discharge/interim times for cases using: Long Term Care Hospitals Inpatient Rehabilitation Facilities Skilled Nursing Facilities Home Health Agencies

13 13 Standard Language important for: Improving coordination of care – one set of terms to define pressure ulcer severity, functional impairment, cognitive impairment across providers Improving data exchangeability – can’t merge inconsistent items; need standard language to transfer information between providers treating the case 13

14 14 Continuity Assessment Record & Evaluation (CARE) Development Sponsored by CMS, Office of Clinical Standards and Quality Principal Investigator/RTI Team: Barbara Gage, Shula Bernard, Roberta Constantine, Melissa Morley, Mel Ingber Co- Principal Investigators: Rehabilitation Institute of Chicago, Northwestern University Consultants: Visiting Nurse Services of NY, University of Pennsylvania, RAND, Case Western University Input by pilot test participants, including participating acute hospitals, LTCHs, IRFs, SNFs, and HHAs 14

15 15 15 Consensus Development Year 1 of CARE development: Gain input from the providers/research community »Review existing assessment tools (MDS, IRFPAI, OASIS, LTCH tools, acute items) »Technical Expert Panels –Clinical communities from 25 associations, including AHA, AMRPA, NALTH, ALTHA, NAHC, VNAA, AHCA, AAHSA, APTA, AOTA, ASHA, ANA,ARN, CMA, Discharge Planners, Joint Commission, to name a few –Research/case-mix communities, including DRG, FRG, HHRG, RUG

16 16 Standardized Assessment Items Should: Build on current measurement science but also add new instrument development methodologies, and Modify existing assessment instruments to develop a standard assessment instrument that will: »Measure health and functional status »Assess service needs »Evaluate treatment outcomes »Guide payment policy »Improve seamless transitions

17 17 17 Common Domains in Existing Assessment Tools nAdministrative Information nSocial Support Information nMedical Diagnosis/Conditions nFunctional Limitations »Physical »Cognitive

18 18 Differences Across Tools Individual items that measure each concept Rating scales used to measure items Look-back or assessment periods Unidimensionality of individual items 18

19 19 Functional Item Comparisons Tools No. of Functional Items Scale LevelsAssessment Periods IRFPAI187Past 3 days MDS Past 5 days OASIS8variesAssessment day

20 20 Differences in Item Details Bathing: »IRFPAI and OASIS – bathing only »MDS – bathing and transferring in/out tub/shower Dressing: »IRFPAI and OASIS – 2 items (Upper/Lower) »MDS – 1 item Toileting: »IRFPAI – level of independence »OASIS – ability to get to/from »MDS – ability to use toilet, transfer, change pads Source: Gage and Green, Chapter 2. The State of the Art: Current CMS PAC Instruments in Uniform Patient Assessment for Post-Acute Care, CMS Report, Contract #IFMC IA03.

21 21 Incomparable Functional Scales IRF-PAIMDSOASIS 7= Complete independence0= Independent0= bathe independent tub/shower 6=Modified (device)1= Supervision1= with devices, independent 5=Supervision2= 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 Dependence4= unable, bathes in bed/chair 2=Maximal Asst. 25%8= Activity NA5= totally bathed by other 1= Total Asst. 0= Activity NA Unknown

22 22 CARE Item Development Formed 4 Workgroups »Medical acuity/continuity of care »Functional impairment »Cognitive impairment »Social/Environmental support

23 23 23 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) Propose core set that can be used at hospital discharge and across all PAC settings

24 24 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 across settings Self-report/performance-based items Current Medicare payment methods Minimal burden on providers Varying technology options across providers

25 25 Medical Items Primary Acute Care Diagnosis PAC Diagnosis Comorbidities/Complicating Conditions Physiologic Factors Treatments Prognosis/Life Expectancy/Frailty

26 26 Social/Environmental Items Physical Living Environment Prior residence Structural barriers Social Support and Assistance Prior lives with Lives with after discharge Type of caregiver Frequency of Assistance

27 27 Function Items Core Function Items »All patients, all settings Supplemental Function Items »Based on patient’s functional status (e.g., bedfast, self-care, basic mobility, IADLs) »Maximize range of patient ability captured (i.e., avoiding floor and ceiling effects) »Provide sufficient variation to capture improvement in function

28 28 Core Function Domains Prior Functional Status Need for Assistance »Eating »Bed Mobility »Oral Hygiene »Toilet Hygiene »Transfer »Dressing - Upper Body »Locomotion Function Modifiers »Weight-bearing »Sitting Unassisted »Swallowing

29 29 Supplemental Function Items Bedfast »Sit to lying, roll left or right, sponge bath Self Care »Lower body dressing, shower/bathe, get in/out of car, curb/1 step, short ramp Basic Mobility »4 steps-exterior, long ramp exterior, walk longer distance-interior, wheel longer distance- interior, 12 steps-interior

30 30 Supplemental Function Items IADLs »Laundry, light shopping, make light meal, dishwashing-by hand, dishwashing-machine, telephone-answering, telephone-placing call, medication management-oral meds, medication management-inhalers, medication management injectables

31 31 Cognitive/Self Report Items Mental status »Orientation »Memory »Screening for delirium Mood/Depression Behavioral symptoms Pain Sensory input »Vision »Hearing

32 32 32 Cognitive Items (cont’d) Communication »Comprehension »Expression Fatigue

33 33 Reliability of the Standardized CARE Items Most CARE items based on existing validated items currently used in the Medicare program; but few items had been used in multiple settings or across different levels of care. Two types of reliability tests were conducted to examine whether the items performed consistently across settings and across disciplines »Traditional Inter-rater Reliability (pairs of assessors rate the same patient similarly) »Video Reliability (cross disciplinary rating of standard video patients) 33

34 34 Traditional Inter-rater Reliability Methods Paired staff, matched on credential, assessed the same patient Tested in subsample of participating PACPRD providers (n = 34) Each site collected data on patients 455 pairs of assessments collected 34

35 35 IRR Methods: Item Selection and Analysis Analyses followed methods used to evaluate existing CMS tools (MDS, OASIS, IRFPAI) Reliability scores at least equal to existing tools »Categorical items: Kappa (for 2 levels), Weighted Kappa (for > 2 levels, Fleiss-Cohen weights) –Range: 0 poor, 0.01–0.20 slight, 0.21–0.40 fair, 0.41– 0.60 moderate, 0.61–0.80 substantial, and 0.81–1 almost perfect »Continuous items: Pearson Correlation

36 36 IRR: Results Overall, the vast majority of Kappas (weighted and unweighted) found were above 0.60 Prior functioning and history of falls: Skin integrity: »Pressure ulcers – 7 of 8 categorical items 0.67 or higher »Length and width correlations – approx 0.6 »Major wounds – 0.64 and higher »Turning Surfaces – 3 of 5 above 0.6, 4 of 5 above 0.5

37 37 IRR: Results Cognitive status and Mood: 26 of 29 above 0.6 Pain: »Interview items – all 5 above 0.6, 4 above 0.79 »Observational assessment – 4 of 5 above 0.6

38 38 IRR: Results Impairments: »Bladder and bowel: –Current status items higher than 0.7 –Prior status items higher than 0.65 »Swallowing signs and symptoms: NPO (0.97), None (0.84), coughing (0.68), loss of liquids and holding food in mouth all low prevalence ranged »All hearing, weight bearing, respiratory and endurance items had kappas above 0.6

39 39 IRR: Results Functional status: (calculated with and without letter codes) »Core (self-care and mobility including walk and wheel): all above 0.6 except ‘tube feeding’ and ‘walk 150 feet’ »Supplemental Self Care: all above 0.63 except ‘roll left and right’ »Supplemental Mobility: all above 0.63 except ‘walk 50 feet with two turns’ ‘walk 10 feet on uneven surface’ and the wheel long and short ramps

40 40 40 IRR: Results Functional status (cont’d): (calculated with and without letter codes) »IADLs: all above 0.7 excluding letter codes except ‘laundry’ and ‘light shopping’; all above 0.6 when including letter code, except ‘use public transportation’ Overall plan of care: above 0.6

41 41 IRR: Summary IRR results indicate substantial to almost perfect agreement for the majority of items evaluated The few lower kappa scores tend to be for low prevalence items IRR results for CARE items are in line with the majority of IRR results available for equivalent items on MDS, OASIS, and FIM

42 42 CARE Item Reports 2 website URLs »http://cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care- Quality-Initiatives/CARE-Item-Set-and-B-CARE.htmlhttp://cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care- Quality-Initiatives/CARE-Item-Set-and-B-CARE.html » Quality-Initiatives/Functional-Measures-.htmlhttp://cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-Care- Quality-Initiatives/Functional-Measures-.html The Development and Testing of the Continuity Assessment Record and Evaluation (CARE) Item Set: Final Report on the Development of the CARE Item Set. Volume 1 of 3 [PDF, 8MB] The Development and Testing of the Continuity Assessment Record and Evaluation (CARE) Item Set: Final Report on the Development of the CARE Item Set. Volume 1 of 3 [PDF, 8MB] The Development and Testing of the Continuity Assessment Record and Evaluation (CARE) Item Set: Final Report on Reliability Testing. Volume 2 of 3 [PDF, 2MB] The Development and Testing of the Continuity Assessment Record and Evaluation (CARE) Item Set: Final Report on Reliability Testing. Volume 2 of 3 [PDF, 2MB] The Development and Testing of the Continuity Assessment Record and Evaluation (CARE) Item Set: Final Report on the Development of the CARE Item Set and Current Assessment Comparisons. Volume 3 of 3 [PDF, 2MB] The Development and Testing of the Continuity Assessment Record and Evaluation (CARE) Item Set: Final Report on the Development of the CARE Item Set and Current Assessment Comparisons. Volume 3 of 3 [PDF, 2MB] Continuity Assessment Record and Evaluation (CARE) Item Set: Additional Provider-Type Specific Interrater Reliability Analyses [PDF, 902KB] Continuity Assessment Record and Evaluation (CARE) Item Set: Additional Provider-Type Specific Interrater Reliability Analyses [PDF, 902KB] Continuity Assessment Record and Evaluation (CARE) Item Set: Video Reliability Testing. [PDF, 348KB] Continuity Assessment Record and Evaluation (CARE) Item Set: Video Reliability Testing. [PDF, 348KB] »ASPE Report: Analysis of Crosscutting Medicare Functional Status Quality Metrics Using the Continuity and Assessment Record and Evaluation (CARE) Item Set. Final Report [PDF, 2MB]ASPE Report: Analysis of Crosscutting Medicare Functional Status Quality Metrics Using the Continuity and Assessment Record and Evaluation (CARE) Item Set. Final Report [PDF, 2MB]

43 43 On-Going Efforts with standardized CARE Item Set Developing setting-agnostic quality measures Quality Reporting Programs for IRF, LTCH, and hospice E-specification of “Best in Class” by CMS/ONC standards &interoperability groups

44 44 On-Going Efforts with Standardized CARE Item Set Developing Outpatient Therapy Payment Alternatives –CARE-C: community therapy –CARE-F: NF therapy B-Care (subset of standardized items for Bundled Payment Initiatives) LTSS Care Items (add items for long term social support programs)

45 45 For More Information: Barbara Gage or Stella Mandl


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