CARE Tool: Continuity Assessment Record & Evaluation Tool December 14, 2012 By: Jessica Koster, OT/S

Overview of PAC-PRD ● Post-Acute Care Payment Reform Demonstration (PAC-PRD) was mandated by Congress in the 2005 Deficit Reductions Act ● Part of the project required coming up with a standardized tool to uniformly collect data on patients being D/C'd from acute to 1 of 4 PAC settings: LTCHs, IRFs, SNFs, & HHAs ● The assessment tool would also be used to measure pt-specific costs, resource expenditures, and treatment outcomes ● The overall project goal was to “provide information that will support the future creation of payment methods that pay appropriately for similar patients irrespective of the setting chosen and provide consistent incentives across the four payment systems.”

Purpose of the CARE Tool ● A multi-disciplinary outcome measure that will: 1) Uniformly measure the health and functional status of Medicare Beneficiaries over time and across health care settings 2) Provide data to support equitable, timely, and cost- effective patient-centered care ● Includes 3 components: 1) Patient assessment instrument 2) Web based electronic reporting system 3) Payment reform demonstration

Current Assessment System ● Medicare mandates assessment data from IRFs, Nursing facilities, and HHAs to determine payment groups, generate quality measures, and monitor regulatory compliance. Instruments used: – IRF= IRF-PAI – Nursing facilities= Minimum Date Set (MDS) – HHA= OASIS – LTCHs & Acute hospitals= None ● These systems have incompatible formats and different data collection time frames, making it very difficult to share data electronically across the continuum of care. ● The CARE Tool seeks to minimize these problems...

CMS's Goals Develop a standardized assessment tool that: ● Helps clinicians provide safe, efficient, effective, and equitable patient-centered care ● Grounded in science and evidence ● Interoperable across care settings ● Provides measurable outcomes ● Flexible to accommodate clinical and technological advances and multiple users ● Will replace current tools: IRF-PAI (rehab centers), MDS (SNF's), and OASIS (home health care); and consolidate into 1 tool.

History of Development ● Mandated by Congress in 2005 ● The demonstration was to be in place by early 2008, with a report submitted to Congress in ● Began with 2 pilot tests in Chicago area during development phase, and then spread nation-wide ● Over 200 providers from Acute hospitals and 4 PAC settings collected data over 3 yrs of demonstration, completing 53,952 CARE assessments ● Final report was submitted in March 2012 ● The project was conducted by RTI International under contract with CMS

Overview of Tool ● Requires 2 day assessment window for all settings ● Estimated 30mins completion time for healthier patients and 60mins in LTCHs or SNFs for complex patients Includes 4 clinical domains: 1) Medical Status/Clinical Complexity= diagnoses, resource use, medications, skin integrity, physiologic factors 2) Functional Status= impairments, self-care, mobility, safety- related functions 3) Cognitive Status= memory/recall, delirium, behavioral symptoms, depression signs, pain 4) Social Support Factors= structural barriers, living situation, caregiver availability, need for assistance

Benefits to Care Providers ● Support more efficient care with a standardized set of data transferred with the patient in real time ● Save time obtaining medical information and performing follow-up calls ● Improve accuracy and ease of communication across the continuum of care without sacrificing patient privacy ● Improves upon weaknesses in current functional status measures by providing greater specificity for measuring change ● Shows good inter-rater reliability and validity

Benefits to Care Providers ● Decrease risk for errors in the medication reconciliation process and polypharamacy ● Provide longitudinal data across settings to determine how communities care for patients ● Provides input into future Federal policy development to create a better healthcare system in the U.S. ● Allows providers to contribute to the development of it before fully implementing it

Sample CARE tool ●

Proposed Case Mix Classification System

Next Steps... ● ASPE Report to come out publicly in next several weeks ● Implementation timeline has not been formally announced, but research on the CARE Tool continues to move forward ● CARE data are continuing to be used by CMS to consider payment reform quality measures to be used across settings in a standardized and neutral method. ● This demonstration objectively showed the many successes of a uniform assessment system across all 5 settings, in hopes that a similar system will be implemented nation wide

Resources ● Gage, B., Smith, L., Morley, M., Drozd, E., Abbate, J., Coots, L., et al. (May 2011). Post-Acute Care Payment Reform Demonstration (PAC-PRD) Report to Congress Supplement- Interim Report. Research Triangle Intstitute: funded by the Centers for Medicare & Medicaid Services. Reports/Reports/Downloads/GAGE_PACPRD_RTC_Supp_Materials_May_2011.pdfhttp:// Reports/Reports/Downloads/GAGE_PACPRD_RTC_Supp_Materials_May_2011.pdf ● Gage, B., Morley, M., Smith, L., Ingber, M., Deutsch, A., Kline, A., et al. (March 2012). Post-Acute Care Payment Reform Demonstration: Final Report. Research Triangle Intstitute: funded by the Centers for Medicare & Medicaid Services. Items/PAC_Payment_Reform_Demo_Final.html Items/PAC_Payment_Reform_Demo_Final.html ● Deutsch, A., Heinemann, A., Baum, C., & Tulsky, D. ( ). Validity of the CARE Tool cognitive items for persons with stroke, SCI, and TBI. Rehabilitation Institute of Chicago: funded by the National Institute of Disability and Rehabilitation Research (NIDRR). ● Research Triangle Institute(RTI) International (2012). Post Acute Care Payment Reform Demonstration. ● Butterfield, S., Triller, D., Stegel, C., & Agramonte, V. Introduction to the Continuity Assessment Record & Evaluation (CARE) Tool [powerpoint presentation]. Prepared by: IPRO under contract with The Centers for Medicare and Medicaid Services.

Questions or Comments??? Thanks for listening!