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Presented by: Barbara Gage, PhD

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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 Data Assessment Elements Goal
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 Achieving Uniformity to Facilitate Effective Communication for Better Care of Individuals and Communities

4 CARE: Concepts Guiding Principles and Goals: 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

5 To Be: Uniform Assessment Data Elements
As Is To Be Transition As Is: Multiple Incompatible Data Sources Outpatient Settings No Standard Data Set Nursing Homes MDS LTCHS LTCH CARE Data Set Physicians No Standard Data Set Inpatient Rehab Facilities IRF-PAI Hospitals No Standard Data Set Home Health Agencies OASIS GOAL: Uniform Data Elements Across Providers Standardized Nationally Vetted 2008 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

6 CMS Vision for Quality Measurement
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

7 CMS Framework for Measurement
Care Coordination Patient and family activation Infrastructure and processes for care coordination Impact of care coordination Clinical Quality of Care 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 Population/ Community Health Care type (preventive, acute, post-acute, chronic) Conditions Subpopulations Health Behaviors Access Physical and Social environment Health Status Function Person- and Caregiver- Centered Experience and Outcomes Efficiency and Cost Reduction Patient experience Caregiver experience Preference- and goal-oriented care Safety Cost Efficiency Appropriateness All-cause harm HACs HAIs Unnecessary care Medication safety 7

8 Building the Future State
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

9 Keeping in Mind, the Ideal State
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

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

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 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 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

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

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 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 Common Domains in Existing Assessment Tools
Administrative Information Social Support Information Medical Diagnosis/Conditions Functional Limitations Physical Cognitive

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

19 Functional Item Comparisons
Tools No. of Functional Items Scale Levels Assessment Periods IRFPAI 18 7 Past 3 days MDS 3.0 12 8 Past 5 days OASIS varies Assessment day

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 Incomparable 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

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

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

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 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 This project was charged with the development of an instrument that did not differ by site of care, yet recognized the wide range of patient abilities that would need to be captured. To this end, we have identified a core set of items that would be used to evaluate all patients, regardless of functional level. Additional items would be administered based on patients’ functional level e.g. bedfast, self-care, basic mobility, IADLs. It is intended that this approach minimizes burden while maximizing the range of patient ability captured (i.e., avoiding floor and ceiling effects). The core items make up a range of ability, have been shown to work well and be easily scored in existing instruments, and play a role clinically in discharge planning decisions.

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

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

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)

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

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 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 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 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 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 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 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 CARE Item Reports 2 website URLs
Quality-Initiatives/CARE-Item-Set-and-B-CARE.html  http://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 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] 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] 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 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 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 For More Information: Barbara Gage Bgage@Brookings.edu or Stella Mandl


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