The landscape of post-acute care is complex, involving a diverse array of settings from Long Term Care Hospitals (LTCHs) to Skilled Nursing Facilities (SNFs) and Home Health Agencies (HHAs). To ensure consistent and effective care across these settings, standardized methods for assessing patient needs are crucial. The Centers for Medicare & Medicaid Services (CMS) recognized this need and initiated the Post-Acute Care Payment Reform Demonstration (PAC-PRD) as part of the Deficit Reduction Act of 2005. A key outcome of this initiative was the development of the Continuity Assessment Record and Evaluation (CARE) Item Set, a vital Acuity Measurement Tool For Long Term Care and other post-acute care settings.
This standardized patient assessment tool was designed to be used at acute hospital discharge and during post-acute care admission and discharge. The CARE Item Set aimed to provide a consistent measure of patient health and functional status, irrespective of the care setting. By implementing this acuity measurement tool for long term care, CMS sought to gain a clearer understanding of how similar patients are treated across different facilities and to inform payment reform recommendations based on resource utilization, patient outcomes, and costs of care.
The CARE Item Set is more than just a data collection tool; it represents a significant step towards standardized acuity measurement in the post-acute care continuum, including long term care. It was developed to assess patients’ medical, functional, cognitive, and social support status across various care environments. The objective was to create a unified set of assessment items that could be integrated into existing assessment tools, minimizing the administrative burden on healthcare providers while maximizing the comparability of patient data.
The development of this acuity measurement tool for long term care was informed by extensive research and clinical experience across the spectrum of post-acute care. The CARE Item Set draws upon previous work and insights from clinicians who treat patients in diverse settings. It focuses on capturing the variations in patients’ care needs, including factors that influence treatment and staffing patterns, such as predictors of physician, nursing, and therapy intensity.
The CARE Item Set’s design incorporated recommendations from CMS and the 2006 Recommendations for a Uniform Patient Assessment for Post-Acute Care. It aimed to update and harmonize existing federal assessment tools, including:
- The IRF-Patient Assessment Instrument (IRF-PAI)
- The Minimum Data Set (MDS)
- The Outcome and Assessment Information Set (OASIS)
Furthermore, it considered measurement initiatives related to geriatric care. This comprehensive approach ensures that the CARE Item Set serves as a robust acuity measurement tool for long term care, capable of evaluating outcomes in physical and medical treatments while accounting for crucial factors like cognitive impairments, social determinants, and environmental influences. Notably, many of the items included in the CARE Item Set were already being collected in hospitals, SNFs, and HHAs, though the format may have varied, making adoption more streamlined.
The CARE Item Set distinguishes between two types of items to ensure comprehensive acuity measurement:
- Core Items: These are fundamental questions asked for every patient within a specific care setting, regardless of their particular condition. They provide a baseline acuity assessment.
- Supplemental Items: These are condition-specific questions, asked only when a patient presents with a particular condition. These items offer a more detailed and granular acuity measurement for patients with specific needs, enhancing the tool’s sensitivity in capturing varying levels of severity.
For instance, in the domain of skin integrity, a core item would be whether a patient has one or more unhealed pressure ulcers at stage 2 or greater. If the answer is yes, supplemental items would then delve into the specifics of these ulcers, providing a deeper acuity measurement related to skin conditions. By standardizing the clinical language used across different care settings, the CARE Item Set facilitates more accurate and consistent acuity measurement, improves the understanding of treatment needs and patient outcomes, and ultimately enhances information exchange between acute and post-acute care providers, including those in long term care.
The development of the CARE Item Set spanned 14 months and prioritized items relevant to patient severity, payment considerations, and quality of care monitoring. It was designed as a framework for a standard set of items that could be accessed through an item bank. Items primarily used for care planning in existing tools like MDS and OASIS were intentionally excluded to focus on acuity measurement and related factors. While most items in the CARE Item Set are typically documented in patients’ medical records, the tool aimed to standardize the format and collection process to ensure consistency and reliability in acuity measurement data.
B-CARE: A Streamlined Approach to Acuity Measurement
Building upon the foundation of the CARE Item Set, B-CARE emerged as a streamlined version. B-CARE is currently under consideration for use within the Bundled Payments for Care Improvement (BPCI) Initiative. This adaptation seeks to provide consistent data across various BPCI models and care settings to effectively monitor how care redesign impacts patient health status and care outcomes. B-CARE’s application in BPCI underscores the importance of standardized acuity measurement in value-based care models. Furthermore, B-CARE data can be used to analyze the influence of patient mix on the results achieved in different BPCI models and settings, highlighting its utility as an acuity measurement tool for comparative analysis.
In conclusion, the CARE Item Set and its streamlined version, B-CARE, represent significant advancements in acuity measurement tools for long term care and the broader post-acute care spectrum. By standardizing patient assessments and focusing on key factors related to patient severity and outcomes, these tools contribute to a more informed and effective healthcare system. For further information and detailed reports, refer to the Useful Links and Downloads sections provided by CMS, which offer comprehensive resources on the development, testing, and implementation of the CARE Item Set.
Useful Links:
- Overview of the Medicare Post-Acute Care Payment Reform Initiative
- Section 5008. Post-Acute Care Payment Reform Demonstrations Program. Deficit Reduction Act of 2005
- Post-Acute Care Payment Reform Demonstration: Final Report
- Report to Congress: Post Acute Care Payment Reform Demonstration (PAC-PRD) (PDF)
- Post-Acute Care Payment Reform Demonstration Report to Congress Supplement-Interim Report (PDF)
- Post-Acute Care Payment Reform Demonstration: Final Report. (PDF) Volume 2 of 4 (PDF)
- Bundled Payment for Care Improvement (BPCI)
