1. 1 1440 Main Street Suite 310 Waltham, MA 02452-1623 Phone 781-434-1717E-mail bgage@rti.orgFax 781-434-1701 Post Acute Care: Patient Assessment Instrument and Payment Reform Demonstration Presented to AHA September 19, 2007 Presented by Barbara Gage, PhD Melissa Morley, PhD RTI International

2. 2 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 sites Single comprehensive assessment at acute hospital discharge Standardized assessment in all PAC settings to measure health and functional status and other treatment factors Collection of information on resources/patient

3. 3 CMS Post Acute Demonstration Three components: Development of a Patient Assessment Instrument Development of a web-based, electronic reporting system Implementation of a Payment Reform Demonstration

4. 4 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

5. 5 Project Overview Year 1: Gain input from the providers/research community Open Door Forums Tool development based on existing assessment tools Technical 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

6. 6 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

7. 7 Current Tools for Measuring Patients Across the Continuum in Medicare n Acute Hospitals no standard tool n Long-Term Care Hospitals no standard tool n Inpatient Rehabilitation Facilities IRFPAI n Skilled Nursing Facilities MDS n Home Health Agencies OASIS

8. 8 Common Domains in Current Assessment Tools n Administrative Information n Social Support Information n Medical Diagnosis/Conditions n Functional Limitations Physical Cognitive

9. 9 Differences in Tools Individual Items to measure each concept Scales used to measure each item Look-back or assessment periods Unidimensionality of individual items

10. 10 Continuity Assessment Record and Evaluation (CARE) Tool Development 4 Clinical Workgroups Medical acuity/continuity of care Functional impairment Cognitive impairment Social/Environmental support

11. 11 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

12. 12 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

13. 13 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

14. 14 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.

15. 15 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

16. 16 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

17. 17 PAC PRD Timeline Market Selection: Fall 2007 Provider Enrollment: Market 1: November, 2007 Market 2-10: December, 2007-March 2008

18. 18 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

19. 19 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

20. 20 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

21. 21 Your Input is invited Questions or requests to Participate in Demonstration –email to: PAT-COMMENTS@RTI.ORG