4 - frequently incontinent US Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation. Melzack R. The McGill pain questionnaire: major properties and scoring methods. The CES-D was developed for a younger, healthier population. However, for comparative purposes at this stage of the study we are focusing on outcome domains and not specific measures. Either hip fracture or stroke should be included in the study because they are the major conditions treated in both rehabilitation hospitals and skilled nursing facilities. Gresham GE, Duncan PW, Stason WB. However, different outcome measures were used depending upon the condition and study. 1 - usually continent Wunderlich GS, Kohler PO, editors. https://doi.org/10.1002/phar.1630, The Hong Kong Polytechnic University, Hong Kong, China, You can also search for this author in Lumbar laminectomy alone or with instrumented or noninstrumented arthrodesis in degenerative lumbar spinal stenosis. Hip fracture and back and neck procedures are grouped together because a high proportion of patients with these conditions received physical therapy and occupational therapy, and a low proportion of these patients receive respiratory therapy and IV services. For example, acute stroke care involves diagnosis of the type of stroke and extent of neurologic damage, life support and acute interventions such as thrombolytic agents to minimize the extent of brain damage, and intensive monitoring of neurologic signs. Pneumonia and AMI are both acute. Moreover, many stroke and hip fracture episodes involve relatively high use of multiple post-acute care providers. 2 - physical help limited to transfer only Actual hours per day for services provided in parentheses are based on literature. An alternative measure could be "symptom-free at time x". 200 Independence Avenue, SW Reardon J, Awad E, Normandin E, Vale F, Clark B, ZuWallack RL. In addition, she suggested accounting for renal function, prior hospitalization for any condition, terminal illness other than heart failure, and documentation of dementia. Clin Interv Aging 10:413420, Naylor MD et al (1999) Comprehensive discharge planning and home follow-up of hospitalized elders: a randomized controlled trial. As a result, the baseline patient interview will not be used to assess function at the time of entry into post-acute care because of the difficulties encountered when trying to ask patients or proxies to describe their functional capacity at two separate time points, both one month prior to hospitalization and at the time of post-acute care admission. Instrument Design and Selected Measures. About one-third of the episodes for those DRGs involved use of some combination of SNF, HHA and RF care. As a quality indicator, delirium itself may not be an appropriate measure. Further, the expert panelists indicated that many important outcomes cannot be measured within the time frames over which post-acute services are typically provided in most settings. Given these three needs, the MMSE was retained despite the time necessary for completion. Outcome of patients cared for in a ventilator-dependent unit in a general hospital. Assessment of LV Function There was strong support for the addition of separate indicators for: (1) Physical Therapy Evaluation; (2) Occupational Therapy Evaluation; (3) Speech Therapy Evaluation. BACK AND NECK CONFERENCE CALL Monitoring the Changes in Use of Medicare Posthospital Services. RAND Report MR-153-HCFA. Official websites use .govA Large national study comparing quality in three settings. Therefore, throughout the remainder of this report, we will refer to the former back and neck condition as lumbar spinal stenosis. We have considered an alternative strategy of giving a written satisfaction survey to subjects and asking them to mail it at the end of their post-acute stay. Surgical results and complications in elderly patients with benign lesions of the spinal canal. Based on input from expert clinicians and researchers, and a review of the literature, the project found that existing administrative data do not contain information needed to measure important outcomes within and across post-acute care settings, and across a span of time over which important post-acute care outcomes may mature. Caregiver stress was added as a separate indicator. Hypertension Control ( Spine 1993;18(11):1463-70. Lesher E, Whelihan W. Reliability of mental status instruments administered to nursing home residents. Too long a period will run into subsequent post-acute episodes in a significant proportion of subjects. For each outcome measure, the necessary data items, the data sources, approaches to applying the measures across episodes of care, and risk factors will be specified. The dropped indicators, and our reasons for dropping each, are included in Appendix E. Appendix F includes the final list of quality indicators that were selected by at least four panel members; it is organized by global indicators (indicators that were selected by four or more panel members for three or four of the conditions) and disease-specific indicators (indicators that were selected by four or more panel members for only one condition). The cardiologist on the panel noted that his research group has developed a tool for assessing patient knowledge in CHF. Because acute, post-acute, and chronic care represent different phases of illness requiring different types of care, a unique set of quality measures is required for each. Improving the quality of long-term care. Share sensitive information only on official, secure websites. Feasibility testing was conducted in two phases. This definition will determine when the follow-up measures are administered. Collecting data at different points in time makes it difficult to compare patient characteristics and outcomes across post-acute settings. In addition, utilization characteristics of back and neck procedure DRGs are somewhat similar to those of hip fracture cases (e.g., low hospital readmissions, high costs). In addition, we will develop methods to stratify patients within a condition for the purpose of comparing similar patients across settings, and also approaches to testing the validity and reliability of the outcome measures that are proposed. Analytical practicality. Respiratory failure in the elderly: analysis of outcome after treatment with mechanical ventilation. Over the past year, the Centers for Medicare & Medicaid Services (CMS) developed a plan to improve Medicare's payment for post-acute care services and the coordination of these services. With regard to measures, the Nottingham Health Profile was not rated highly initially, yet this instrument has been used extensively in Britain and has been compared directly with the SF-36 in the setting of Stroke. The indicator was redefined as evaluation of medication compliance: patient education and intervention to assist compliance. Lyness J, Noel T, Cox C, King D, Conwell Y, Cain E. Screening for depression in elderly primary care patients: a comparison of the center for epidemiologic studies-depression scale and the geriatric depression scale. Hence, we will not restrict the selection to only conditions that can be observed in all three settings. Archives of Physical Medicine and Rehabilitation 1988; 69:583-590. We evaluated each of the conditions based on the literature and further analysis of Medicare claims data. 2 - usually continent Variations in utilization patterns. The proposed rule would require IRFs to complete the MDS-PAC on days 4, 11, 30, and 60 after admission; and upon discharge. Well-being Such information could be used to support the current payment methodologies across post-acute care settings or could provide the foundation for alternative payment approaches. These checks are generally done during the process of other evaluations, such as physical therapy. Applied Nursing Research 1991; 4(3):107-112. Downloads Post Acute Care Reform Plan (PDF) Page Last Modified: 12/01/2021 07:02 PM Help with File Formats and Plug-Ins For our study, he suggested including patients with a primary or secondary diagnosis of pneumonia, but recommended verifying the diagnosis with x-ray report. San Francisco, CA, University of California, Department of Social and Behavioral Sciences. Days of limited activity is a very common, well-regarded quality indicator for PAC. Education: breathing retraining, work simplification, nutrition, medication, relaxation, stress management. The multiple and ongoing changes to Medicare post-acute care payment policies create a dynamic environment in which measuring the effect of service delivery is particularly difficult. ) In an ASPE sponsored study, Liu et al. lead to reductions in hospital readmissions, shorter lengths of stay, decreased costs and improved health outcomes. Based on literature review and expert panel members input, the types of measures that are relevant to post-acute care (e.g., HRQL, mental health and depression, physical and social/role function, satisfaction with care) require patient input. The Oswestry low back pain disability questionnaire. Returning home with the aid of a home health nurse may also be an option. In addition, the Health IT Playbook has implementation resources for LTPAC providers. It may be more appropriate to measure "deconditioned at discharged". Type of services referred to the specific services provided within the PAC setting. Rather, the payment system under development disregards the realities of the post-COVID-19 pandemic landscape, and thus will not reflect . 1 - set up help only Similarly, questions on instruments used in home care are not easily translated to older patients who are not residing in their homes. Additional hospital chart review items to be collected for risk adjustment for patients with pneumonia include evaluation for delirium, blood gas results, abnormal vital signs, and lab parameters.84. Anderson C, Mhurchu CN, Rubenach S, Clark M, Spencer C. Home or hospital for stroke rehabilitation? Each PPS varies in terms of key design features such as the unit of payment (per diem, per discharge, every 60 days), classification schemes (e.g., RUGs, HHRGs, and case mix groups), and patient assessment instruments and processes used for patient classification (e.g., MDS, OASIS, and MDS-PAC). This is likely to be a common diagnosis in an elderly population and would allow a more reasonable comparison of the quality of care in different post-acute settings by assembling a more homogeneous study population. Results of a randomized controlled trial: II: cost minimization analysis at 6 months. Assuming that some physician contact is desirable, one may be able to define certain minimum standards of care that would vary by setting. On a second form, we presented the ranked list of quality indicators in descending order of average rating. Narrowed the eight conditions down to four based on framework of clinical criteria. Assisted Living is a living environment focused on maintaining independence in a supervised setting. which results in the item being collapsed into categories. Although we had been successful with this method of patient recruitment for past studies, many of the facility staff and administrators we spoke with indicated that pressures under PPS had placed increasing demands on their time and available resources. A differentiation must be made between whether we examine patient satisfaction with care or patient satisfaction with where they are currently (or current status). Ultimately, we decided to ask three satisfaction questions during the 90-day follow-up telephone interview. Neu, C.R. Although risk adjustment strategies will be used in the eventual study, that process cannot fully compensate for potential variability of a given condition. Next, we organized the quality indicators by domain to provide a basic structure for reviewing the indicators. Michael Fine's scoring mechanism for mortality and LOS from the PORT may or may not be applicable to post-acute setting, but the technique is worth considering for risk adjustment. Self care was divided into ADLs and IADL/Household. In November 2000, HCFA proposed that IRFs be reimbursed on a per episode basis -- based on case mix groups. Numbness Of those 20 conditions, 5 are relatively well distributed across SNFs, HHAs, and RFs. Looking at the distributions of the DRGs by provider type, it is apparent that rehabilitation facilities are not frequent providers for many of them. Kramer examined the outcomes of hip fracture and stroke patients, selected on the basis of hospital diagnoses representing the two conditions. First, these global instruments were not designed for use in older, frailer populations, much less populations receiving post-acute care. Both conditions are acute and studied outcome domains are largely functional, return to community living and mortality, with some additions for stroke (i.e., psychological and quality of life). W, Kraan J, van Atena R, Koeter GH, Postma DS. Practically, some delivery systems arbitrarily use a two-week time interval to evaluate response to therapy. Hospital-based outpatient cardiac rehab (exercise+ teaching , teaching only) vs Home walking program. Amer J Med 1994;97:50-55. We employed data from the 5-percent sample of 1995 Medicare claims data to examine episodes of post-acute care use. In fact, many researchers focused on patient-centered outcomes believe that functional outcomes should derive from patients, as their perception of their function is more important than so-called objective measures of function. Quality of care process, and outcomes in elderly patients with pneumonia. The following sections (Sections B through D) discuss the indicators selected, and instrument development and refinement. One identified limitation was that it places a large emphasis on distress, moreso than SIP or SF-36. Health Services Research 1976; 11:478-507. One important impact was that the hospital PPS led to decreased lengths of hospital stay. Chest pain is seen only in about 50% of pneumonia patients, and the prevalence and severity of chest pain decreases with increasing age. Do you have any experience with particular mental status instruments in post-acute care? However, even among cognitively impaired subjects, proxy input on such outcome measures is more likely to reflect the needs and values of patients than provider assessment. In addition, substantial variation in the utilization of post-acute care across geographic regions creates additional challenges in understanding the relative outcomes associated with different post-acute care options.28;29;30 Our lack of understanding about the relative effectiveness of post-acute care use creates questions regarding the appropriateness of current payment and coverage policies.29;30 Complicating our ability to evaluate the quality of post-acute care, and determine relationships between post-acute care settings and outcomes, is the fact that a large proportion (17% as of 1996) of Medicare beneficiaries receive post-acute care in more than one setting. Such an indicator might suggest that more individuals should be treated for it, and thats not at all clear. It is poorly understood how the mix and intensity of these services vary across provider types and the impact of these differences on length of post-acute care stays, quality of care, and outcomes. With respect to outcomes, we were interested in the types of outcome measures used for the different conditions (e.g., functional status, mortality, quality of life, symptoms). These two quality indicators were combined into a single indicator based on the recommendation of the expert panels. Gage B. 113. Vale F, Reardon JZ, ZuWallack RL. Shaughnessy PW, Kramer AM. However, other measures were chosen for this same purpose (e.g., obtaining blood cultures, appropriate antibiotic use) and should suffice. This indicator does not apply to home health care, however. To generate the initial sets of post-acute care quality indicators for each of the four conditions, we conducted an extensive review of the medical literature, which was supplemented by clinical experience. Health-Related Quality of Life With respect to PAC outcomes, only hip fracture and stroke have been studied in some depth. [Full Report]. All in all, though, it is difficult to know if SNF admission is a good or bad outcome in CHF, so by itself it is not a very good quality indicator. Linking clinical variables with health-related quality of life. Ciol MA, Deyo RA, Howell E, Kreif S. An assessment of surgery for spinal stenosis: time trends, geographic variations, complications, and reoperations. Journal of the American Geriatrics Society 1975; 23:433-441. Thus, the four conditions we recommend for development of quality measures include stroke, pneumonia, congestive heart failure, and ventilator-dependent patients. While post-acute care is beneficial and necessary, it is also expensive. The Charlson Index is comprised of a formula that provides a weighting of chronic illnesses. Stapleton DC, Kaplan SJ, Manard, B. Ventilator dependent unit demonstration: outcome evaluation and assessment of post acute care. Hood SA, Weigl K. Lumbar spinal stenosis: surgical intervention for the older person. This report was prepared under contract #HHS-100-97-0010 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and The Urban Institute. Journal of Cardiopulmonary Rehabilitation 1995;15(4):269-76. Population Division, Department of Economics and Social Affairs, United Nations, New York, NY, USA, Department of Population Health Sciences, Department of Sociology, Duke University, Durham, NC, USA, Department of Applied Social Sciences, The Hong Kong Polytechnic University, Hong Kong, China, Leung, D.Y.P. The Maine lumbar spine study, part II: 1-year outcome of surgical and nonsurgical management of sciatia. Medicare beneficiary access to home health agencies: 2000. Function was the most widely studied outcome domain for the eight conditions. Make B, Gilmartin M, Brody JS, Snider GL. Hospital and post-acute care charts were obtained on these subjects and reviewed using the chart review instruments. The back and neck instrument has been supplemented with these questions accordingly. Recommended including more assessment items related to higher order function (such as visiting with grandchildren). HCFA proposed that patients would be assigned to case mix groups based on patient data derived from a new patient assessment instrument, the MDS for Post-Acute Care (MDS-PAC). In other cases, the need for post-acute care persists throughout the remainder of the patient's life. 12 week home rehab program managed by multidisciplinary team (MDT): pulmonologist, physiotherapist, nurse, general practitioner. Third, the validity of the satisfaction measures included in these instruments -- as of all health care satisfaction measures -- is subject to factors such as the subjects reluctance to discuss quality of medical care, reduced expectations, unwillingness to complain, and fear of retaliation. 1 - continent with catheter (NA) We compiled the panels' final ratings, enumerating the indicators for each condition in descending order based on the number of panel members who selected each (see Appendix E). In particular, the 5-point scale proved to be too cumbersome for subjects to answer. In general, the panel as a whole placed a moderate-to-high level of importance on this indicator, yet struggled initially to understand how it was similar to role resumption. For quality measurement purposes, it is is important that study groups are relatively homogeneous so that differences in outcomes are related to site of care and not underlying medical needs. Please comment on the balance between the global and disease-specific measures in the patient survey and chart review instruments for the respective condition. They also included a combination of both global quality indicators (those applicable to all four conditions) and condition/disease-specific quality indicators. Testing and refinement of the MDS-PAC and OASIS conversions are underway. The Functional Communication Profile is an older measure that requires advanced training for scoring. Dorsal root ganglionectomy for failed back surgery syndrome: A 5-year Follow-Up Study. 2000. Under the Setting criterion, we assigned hip fracture and stroke to the same category because both are primarily treated in rehabilitation hospitals, skilled nursing facilities and home health agencies, and secondarily in long term hospitals. On this form, we indicated those quality measures that were frequently recommended by panel members. During both phases of feasibility testing, ongoing difficulties were encountered in identifying and recruiting patients. 1994. Global process measures: With regard to global process quality measures, the panels recommended that regardless of condition or post-acute setting, an evaluation by a licensed physical therapist and occupational therapist are important and essential elements of high quality post-acute care. Although there is currently no hard data to support any specific figures, one might propose the following: We refined the definition of the indicator to be a process measure instead of a utilization measure. Recognizing that the claims may underestimate the percent of patients receiving IV care as well as other services, the important point is that relatively more therapy services were provided for these patients. How could potential subjects be identified in the absence of information derived from the MDS/MDS-PAC/OASIS? DeBusk RF, Haskell WL, Miller NH, Berra K, Taylor CB, Burger WE III, Lew H. Medically directed at home rehabilitation soon after clinically uncomplicated acute myocardial infarction: A new model for patient care. This final step involves making selections based on the profiles in Table 4, that summarizes the results from all the previous tables. The BBRA and BIPA delayed the application of the 15% reduction on HHA payments. Trends in post-acute care from the 1st half of 2023 Medicare expenditures for post-acute care have consumed an increasing share of total Medicare payments. Back and neck patients are similar to ventilator-dependent patients in that they both have somewhat unique profiles across treatment settings, chronicity, outcome domains, and services required (see Table 4). Since symptoms will have differing times until resolutions and differing severities, each will have to be asked separately, and we will ask duration separately from severity. We then considered various combinations of the conditions to select the final four conditions. However, post-acute care refers to the period of care that follows an acute event. This section discusses the rationale behind our selection. With respect to physical function particularly as it relates to stroke outcomes, panel members recommended including a more thorough assessment of higher order function (i.e., IADLs) in addition to basic ADL function, which would allow better discrimination between patients with varying degrees of functional ability as well as recovery of higher level functions following stroke. We have some concern that the claims data are not 100% accurate, as facilities are ultimately reimbursed based on year-end cost report data rather than interim claims data. Self Perceived Ability to Participate in Social/Recreational Activities Finally, where possible, validated and reliable measures were chosen, particularly if they had been evaluated in older, frailer patients and in post-acute settings.