The landscape of healthcare is constantly evolving, with a growing emphasis on efficient and effective patient care, particularly in the post-acute care (PAC) sector. To address the complexities of patient transitions and ensure consistent, high-quality care across different settings, the Centers for Medicare & Medicaid Services (CMS) has been at the forefront of developing standardized assessment tools. One such crucial tool is the Continuity Assessment Record and Evaluation (CARE) Item Set, and a streamlined version known as the B-care Tool. This article delves into the significance of the B-CARE tool, its origins, purpose, and how it contributes to improved patient outcomes and healthcare payment models.
The Genesis of CARE: Addressing Payment Reform in Post-Acute Care
The journey towards standardized patient assessment in post-acute care began with the Deficit Reduction Act (DRA) of 2005. This legislation mandated CMS to initiate a Medicare Payment Reform Demonstration (PRD) program. The core objective was to utilize standardized patient data to analyze the consistency of payment incentives within Medicare for patients receiving treatment across various healthcare environments. This demonstration encompassed acute care hospitals and four key post-acute care settings: Long Term Care Hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs), and Home Health Agencies (HHAs).
The Medicare PRD aimed to achieve several crucial goals. Primarily, it sought to establish a uniform method for assessing patient health and functional status, irrespective of the care setting. This standardization allowed for a more accurate comparison of resource utilization and patient outcomes across different care environments. By understanding how similar patient populations were being treated in diverse settings, CMS could gain valuable insights into the efficiency and effectiveness of care delivery. Furthermore, analyzing resource use within each setting was vital to identify variations in treatment approaches, outcomes, and associated costs. This comprehensive understanding was essential for formulating evidence-based recommendations for payment reform.
The scope of the Medicare PRD expanded under the Medicare, Medicaid, and the SCHIP Extension Act of 2007 (MMSEA). This expansion enabled broader provider participation and authorized CMS to evaluate the adequacy of acute hospital payments, particularly for patients with complex medical needs. Findings from the Medicare PRD have been made available by CMS, offering valuable data and insights into post-acute care payment reform.
The CARE Item Set: A Foundation for Standardized Assessment
Central to the Medicare Post-Acute Care Payment Reform Demonstration (PAC-PRD) was the development and implementation of a standardized patient assessment tool: the Continuity Assessment Record and Evaluation (CARE) Item Set. This tool was designed for use at critical transition points in patient care – at the time of discharge from acute care hospitals and upon admission and discharge from post-acute care settings. The data collected through the CARE Item Set became a cornerstone of the demonstration, providing essential information about the health and functional status of Medicare beneficiaries. It enabled the measurement of changes in patient severity and other outcomes throughout the post-acute care journey.
The CARE Item Set’s primary objective is to standardize the assessment of patients’ medical, functional, cognitive, and social support status across the continuum of care, spanning acute and post-acute settings, including LTCHs, IRFs, SNFs, and HHAs. This standardization effort aimed to harmonize the items used in existing assessment tools while minimizing the administrative burden on healthcare providers. The CARE Item Set is built upon extensive prior research and incorporates practical insights from clinicians involved in patient care across various settings. It encompasses a range of measures designed to document variations in patients’ care needs, including factors influencing treatment and staffing patterns, such as predictors of physician, nursing, and therapy intensity.
The development of the CARE Item Set was informed by CMS findings and the 2006 Recommendations for a Uniform Patient Assessment for Post-Acute Care. It aimed to update and refine existing federal assessment tools like the IRF-Patient Assessment Instrument (IRF-PAI), the Minimum Data Set (MDS), the Outcome and Assessment Information Set (OASIS), and other geriatric care measurement initiatives. The CARE Item Set is structured to evaluate outcomes in physical and medical treatments while accounting for factors that can influence these outcomes, such as cognitive impairments and social and environmental determinants. Notably, many items within the CARE Item Set were already being collected in hospitals, SNFs, and HHAs, although the specific format of these items may have varied.
The CARE Item Set is composed of two distinct types of items:
- Core items: These are fundamental questions asked of every patient within a given setting, regardless of their specific condition.
- Supplemental items: These items are condition-specific and are only administered to patients who present with a particular condition. They are designed to provide a more detailed and nuanced measurement of severity or the extent of need for patients with specific conditions.
By incorporating supplemental items, the CARE Item Set offers a more granular assessment of patient needs. Crucially, by standardizing the clinical language used across different care settings, the CARE Item Set facilitates advancements in measuring patient acuity, treatment requirements, and outcomes. This standardization also enhances the seamless transfer of critical patient information between different healthcare environments, leading to better coordinated and safer care transitions.
For instance, in the domain of skin integrity, a core item might be whether a patient has one or more unhealed pressure ulcers at stage 2 or greater. Supplemental items would then delve into the specifics of these ulcers, such as their stage, size, and location, but only for patients who are identified as having pressure ulcers through the core item.
Introducing B-CARE: Streamlining Assessment for Bundled Payments
Building upon the foundation of the CARE Item Set, B-CARE emerges as a streamlined and focused version of this comprehensive assessment tool. The B-CARE tool is specifically being considered for implementation within the Bundled Payments for Care Improvement (BPCI) Initiative. The rationale behind B-CARE is to provide consistent and comparable patient information across various BPCI models and diverse care settings. This consistent data stream is crucial for effectively monitoring the impact of care redesign initiatives on beneficiaries’ health status and the outcomes of care they receive.
Furthermore, information gathered through the B-CARE tool can be instrumental in understanding how patient mix influences the results observed across different BPCI models and settings. By providing a standardized and efficient method for assessing patient characteristics and health status, the B-CARE tool is poised to become a vital component in value-based healthcare models, particularly those centered around bundled payments and care improvement initiatives. Its focus on core elements of patient assessment ensures that critical data is captured without adding undue administrative complexity, making it a practical and valuable asset in the pursuit of enhanced post-acute care quality and efficiency.
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)
