Post-Acute Quality Initiatives: The Continuity Assessment Record and Evaluation (CARE) Item Set
Post-Acute Care Payment Reform Demonstration:
The Deficit Reduction Act (DRA) of 2005 directed CMS to develop a Medicare Payment Reform Demonstration (PRD) that used standardized patient information to examine the consistency of payment incentives for Medicare populations treated in various settings. The demonstration included Acute Care Hospitals and four Post-Acute Care settings: Long Term Care Hospitals (LTCHs), Inpatient Rehabilitation Facilities (IRFs), Skilled Nursing Facilities (SNFs), and Home Health Agencies (HHAs).
This demonstration provided standardized information on patient health and functional status, independent of site of care, and examined resources and outcomes associated with treatment in each type of setting. This allowed CMS to better understand the extent to which similar patients are treated in different settings. Similarly, information on resource use within each setting was needed to understand differences in patient treatment, outcomes, and costs of care in order to create appropriate payment reform recommendations.
The Medicare PRD was expanded under the Medicare, Medicaid, and the SCHIP Extension Act of 2007 (MMSEA), allowing additional providers to participate and authorizing CMS to examine the adequacy of the acute hospital payments for medically complex populations.
Information about the findings from the Medicare PRD can be found in the Downloads section at the bottom of this page.
The Continuity Assessment Record and Evaluation (CARE) Item Set:
As a part of the Medicare Post-Acute Care Payment Reform Demonstration (PAC-PRD), a standardized patient assessment tool was developed for use at acute hospital discharge and at post-acute care admission and discharge. This tool was named the Continuity Assessment Record and Evaluation (CARE) Item Set. Data collected using the CARE Item Set served as a major source of information in the demonstration. The CARE Item Set measures the health and functional status of Medicare beneficiaries at acute discharge, and measures changes in severity and other outcomes for Medicare post-acute care patients.
The CARE Item Set is designed to standardize assessment of patients’ medical, functional, cognitive, and social support status across acute and post-acute settings, including long-term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies (HHAs). The goal was to standardize the items used in each of the existing assessment tools while posing minimal administrative burden to providers. The CARE Item Set builds on prior research and incorporates lessons learned from clinicians treating the continuum of patients seen in all settings. The CARE Item Set targets a range of measures that document variations in a patient’s level of care needs including factors related to treatment and staffing patterns such as predictors of physician, nursing, and therapy intensity.
The CARE Item Set incorporated findings from CMS and the 2006 Recommendations for a Uniform Patient Assessment for Post-Acute Care (Kramer and Holthaus, 2006) in an effort to update existing federal assessment tools including: (1) the IRF-Patient Assessment Instrument (IRF-PAI) (Gage, Bernard, Constantine, et al., 2005); (2) the Minimum Data Set (MDS); (3) the Outcome and Assessment Information Set (OASIS); and (4) other measurement initiatives related to geriatric care. The CARE Item Set is designed to measure outcomes in physical and medical treatments while controlling for factors that affect outcomes, such as cognitive impairments and social and environmental factors. Many of the items are already collected in hospitals, SNFs, and HHAs, although the exact item form may be different.
See additional information under the Useful Links and Downloads section at the bottom of this page.
The CARE Item Set includes two types of items:
1) core items which are asked of every patient in that setting, regardless of condition; and
2) supplemental items which are only asked of patients having a specific condition. The supplemental items measure severity or degree of need for those who have a condition.
These supplemental items provide more granular measurement of severity for those who have a condition. By standardizing the language that clinicians use across sites of care, advances can be gained in measuring acuity, treatment needs, and outcomes as well as improving information transfer between settings.
For example, in skin integrity, having one or more unhealed pressure ulcers at stage 2 or greater is a core question asked of everyone; items that describe those ulcers are supplemental - they only apply to patients who do have one or more stage 2 or higher pressure ulcers.
The Development and Testing of the Continuity Assessment Record and Evaluation (CARE) Item Set:
The CARE Item Set was developed over a period of 14 months. The CARE Item Set was created to standardized assessment items based on the scientific literature and the experiences with the currently mandated assessment items in the Medicare payment systems—including those in the IRF-PAI, MDS, and OASIS instruments—and used only items related to patient severity, payment, or monitoring quality of care. Thus, the CARE Item Set is a framework for a standard set of items that can be made available through an item bank. Items from the existing MDS and OASIS tools that were used only for care planning were excluded from CARE Item Set. Most of the items in CARE Item Set are typically recorded in patients’ medical records, though the format or formality of the medical record, location of the data in the medical record, and individual(s) or clinician(s) designated to collect the data may vary. Items were evaluated and selected to maximize reliability, validity, and breadth of application (to minimize floor and ceiling effects) and to minimize incentives that might encourage provider behavior inconsistent with best practices for care.
Reports and more information about the CARE Item Set development and reliability analysis can be found in the Useful Links and Downloads sections at the bottom of this page.
B-CARE is a streamlined version of the Continuity Assessment and Record Evaluation (CARE) Item Set, which is being considered for use within the Bundled Payments for Care Improvement (BPCI) Initiative. B-CARE would provide consistent information across BPCI models and care settings to monitor the effect of care redesign on beneficiaries’ health status and outcomes of care. B-CARE information may also be used to understand impact of patient mix on results from different BPCI models and settings.
More information about BPCI can be found in the Useful Links section at the bottom of this page.
Continuity Assessment Record and Evaluation (CARE) Item Set: Video Reliability Testing. (PDF)
CARE: Institutional Admission Assessment Tool (PDF)
CARE: Home Health Admission Assessment Tool (PDF)
CARE: Discharge Assessment Tool (PDF)
CARE: Expired Assessment Tool (PDF)
Continuity Assessment Record and Evaluation (CARE) Item Set: Additional Provider-Type Specific Interrater Reliability Analyses (PDF)