IMPACT Act: Standardized Patient Assessment Data Activities

March 29, 2017

Disclaimer

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Acronyms in this Presentation • DE – Data element

HHAs – Home health agencies• IMPACT Act – Improving Medicare Post-Acute Care

Transformation Act of 2014• IRFs – Inpatient rehabilitation facilities• IRF-PAI – IRF-Patient Assessment Instrument• LCDS – LTCH CARE Data Set• LTCHs – Long-term care hospitals• MDS – Minimum Data Set• OASIS – Outcome and Assessment Information Set• PAC – Post-acute care• PAC-PRD – Post-Acute Care Payment Reform

Demonstration• QRP – Quality reporting program• SNFs – Skilled nursing facilities• TEP – Technical Expert Panel

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BS – Home and Community Based Services •

• FASI – Functional Assessment Standardized Items• HC

Agenda

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• The Goal of the IMPACT Act • Timeline of Activities • Alpha 1 Results • Alpha 2 Progress • Plans for Beta Test • How to Get Involved

Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014

• Bipartisan bill passed on September 18, 2014 and signed into law by on October 6, 2014

• Requires standardized patient assessment data across Post-Acute Care (PAC) settings to enable: ‒ Improvements in quality of care and outcomes ‒ Comparisons of quality across PAC settings ‒ Information exchange across PAC settings ‒ Enhanced care transitions and coordinated care ‒ Person-centered and goals-driven care planning and

discharge planning

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Purposes of the IMPACT Act

• Improve Medicare beneficiary outcomes• Facilitate comparable data and quality across PAC

settings• Support provider access to longitudinal information

to facilitate coordinated care• Develop payment models based on patient

characteristics

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Providers Covered by the IMPACT Act

• Skilled Nursing Facilities (SNFs) • Home Health Agencies (HHAs) • Inpatient Rehabilitation Facilities (IRFs) • Long-Term Care Hospitals (LTCHs)

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IMPACT Act Identifies Categories that Require the Use of Standardized Data

• Function (e.g., self care and mobility) • Cognitive function (e.g., express & understand

ideas; mental status, such as depression and dementia)

• Special services, treatments & interventions (e.g., need for ventilator, dialysis, chemotherapy, and total parenteral nutrition)

• Medical conditions and co-morbidities (e.g., diabetes, heart failure, and pressure ulcers)

• Impairments (e.g., incontinence; impaired ability to hear, see, or swallow)

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IMPACT Act Identifies Domains for Quality Measures that Use Standardized Assessment Data

• Functional status, cognitive function, and changes in function and cognitive function

• Skin integrity and changes in skin integrity • Medication reconciliation • Incidence of major falls • Communicating and providing for the transfer of

health information and care preferences of an individual when the individual transitions

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Current Assessments

• 4 Different Settings, 4 Different Assessment Tools • Skilled Nursing Facilities (SNF) Minimum Data Set

(MDS) • Home Health Agencies (HHA) Outcome and

Assessment Information Set (OASIS) • Inpatient Rehabilitation Facilities (IRF) IRF-Patient

Assessment Instrument (IRF-PAI) • Long Term Care Hospitals (LTCH) LTCH CARE

Data Set (LCDS) • Overlapping domains and purposes but specific

items measuring common domains differ across settings

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IRF-PAI

LTCH CARE

Data Set

OASIS-C

MDS 3.0

Data Elements

HCBS FASI

Uniformity

Data Elements: Standardization

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Standardized Assessment Data Elements One Question: Much to Say → One Response: Many Uses

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Care Planning/ Decision Support

Payment

Quality Reporting

QI

Care Transitions

Data Element & Response Code

Scope of Work and Timelines

Overview of the RAND Contract

• Project goal is to develop, implement, and maintain standardized PAC patient assessment data

• Project phases: 1. Information Gathering: Sep 2015 – Apr 2016 2. Pilot Testing (Alpha 1 and Alpha 2): Aug 2016 –

July 2017 3. National Beta Testing: Begins Fall 2017

• Focus on 6 domains: cognitive status, mental status, medical conditions, impairments, care preferences, medication reconciliation

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Project Timeline

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Information Gathering

• Identify candidate data elements for testing• Based on:

‒ Literature review ‒ Focus groups (winter 2016) ‒ Technical Expert Panels (TEPs) (April 2016, Jan. 2017) ‒ Ongoing stakeholder engagement

• Candidate data elements evaluated on:‒ Potential for improving quality ‒ Validity and reliability ‒ Feasibility for use in PAC ‒ Utility for describing case mix

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Development and Implementation of Data Elements

• Track 1: Blueprint Public Comment Data Elements ‒ Strong evidence for feasibility and reliability in PAC settings ‒ Tested and performed well in PAC PRD ‒ Posted for public comment in August 2016

• Track 2: Alpha 1 Data Elements ‒ Rated highly by the TEP (in April 2016) and stakeholders, but

require feasibility testing in PAC settings ‒ Tested in cross-setting PAC facility field test

• Track 3: Alpha 2 Data Elements ‒ Identified and developed during Summer - Fall 2016 ‒ Rated highly by the TEP (in Jan. 2017) and stakeholders ‒ Will be tested in upcoming cross-setting PAC facility field test

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Alpha 1 Field Test

Alpha 1 Field Test

• August – October 2016 • 8 facilities in Greater Hartford, Connecticut area

‒ 2 LTCH, 2 IRF, 2 SNF, and 2 HHA providers • 120 admission assessment forms collected

• (~15 per setting) • Debrief interviews with facility staff and research

nurses

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Alpha 1 Data Elements

• Alpha 1 Data Elements being tested include‒ Medical Conditions – Pain ‒ Impairments – Hearing and Vision ‒ Impairments – Bladder and Bowel Continence ‒ Cognitive Function ‒ Mental Status - Mood ‒ Medication Reconciliation ‒ Care Preferences

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Alpha 1 Data Element Pain

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Alpha 1 Data Element Impairments – Hearing and Vision

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Alpha 1 Data Element Impairments – Bladder and Bowel Continence

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Alpha 1 Data Element Impairments – Bladder and Bowel Continence

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Alpha 1 Data Element Impairments – Bladder and Bowel Continence

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Alpha 1 Data Element Cognitive Function

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Alpha 1 Data Element Mental Status - Mood

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Alpha 1 Data Element Medication Reconciliation

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Alpha 1 Data Element Medication Reconciliation

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Alpha 1 Data Element Care Preferences

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Alpha 1 Data Element Care Preferences

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Alpha 1 Data Elements: Reliability and Time

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Domain Data Elements Reliability Kappa Time to Range Complete

Pain Severity; frequency; effect on sleep, activities, & therapy; relief

Excellent (0.96 – 1.0) Reasonable (3.6 minutes)

Hearing & Vision Use of hearing aid and glasses, last exam? Excellent ( 0.69 – 0.92) Reasonable

(1.6 minutes)

Device use, device type, when placed, Moderate/Excellent Reasonable Bowel & Bladder reason for device, need for assistance, (0.54 – 1.0) (6-7 minutes)

incontinent frequency & burden

Cognitive Status Trail-Making Task, Serial 7’s, Complex sentences

Excellent (0.89 – 0.97) Reasonable (4 minutes)

Excellent (0.88 – 1.0) Reasonable Mental Status - mood PHQ-2 to 9 (1-2 min if neg;

6 min if pos)

Medication Reconciliation

Low/Varied 11 items to document 5 steps: obtain, (0.20 – 0.83) compare, derive, communicate, notify

Extremely time consuming (15-20 minutes)

Care Preferences Preferences for Involvement Excellent ( 0.9 – 1.0) Reasonable

(6 minutes)

Alpha 1 Data Elements: Feedback

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Domain Feedback from Assessors

Pain Straightforward, easy to complete

Hearing & Vision

Some recommendations for clarification of instructions and alternate wording of items

Bowel & Bladder

Some difficulty getting consistent information from patients/residents and caregivers

Cognitive Status

Comments indicated several revisions to instructions needed; difficult for some patients resulting in frustration

Mental Status Comments indicated need for clarification of instructions

Medication Reconciliation Comments indicated several revisions to instructions and items needed

Care Preferences Relatively straightforward overall

Alpha 1 Data Elements: Next Steps

• Data elements and instructions are beingrevised per alpha 1 results‒Some data elements may be removed from further

consideration • Revised data elements will be

‒ Posted for public comment on the MMS Public Comment Webpage ‒ Considered for inclusion in beta testing

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Upcoming Field Tests

Alpha 2 Field Test

• Field test: April – July 2017 • Three US markets:

‒ Houston, Texas ‒ Chicago, Illinois ‒ Denver, Colorado

• 16 facilities: ‒ 4 LTCH, 4 IRF, 4 SNF, and 4 HHA providers ‒ 120 observational assessments ‒ 120 interview admission assessments ‒ 60 interview discharge assessments

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Alpha 2 Data Elements

• Revised items from Alpha 1 ‒ Medication Reconciliation ‒ Care Preferences

• New items to assess Cognitive Function • Observation items for patients/residents who are

unable to communicate to assess: • Pain • Cognitive Function • Depressed Mood

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Alpha 2 Analyses

• Feasibility of items will be evaluated based on same criteria used for alpha 1 ‒ Correspondence between research and facility nurse

assessors ‒ Time to complete ‒ Qualitative feedback from assessors

• Report of results will be generated in early fall 2017

• Will hold webinar for provider participants to review results and lessons learned from field test

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National Beta Test: Oct 2017-May 2018

• Goal is to obtain a national sample that reflects US provider and patient/resident variability

• Data from national test will provide setting-specific reliability and validity data on included items

• Items will be based on alpha 1 and alpha 2 test results and feedback from public comment

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Beta Design

• National sample will include: ‒ 210 PAC facilities from 14 geographic/metropolitan areas ‒ 28 IRFs, 28 LTCHs, 84 SNFs, and 70 HHAs ‒ An average of 2 IRFs, 2 LTCHs, 6 SNFs, and 5 HHAs per

PAC market • Providers will be randomly selected to participate • Patients/residents will be enrolled upon admission • Design will include admission and discharge

assessments • Subset of patients/residents will be double-assessed

by research and facility staff (as in Alpha test) to evaluate reliability

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Beta Test Market Areas

• Boston, MA • Chicago, IL • Dallas, TX • Durham, NC • Fort Lauderdale, FL • Harrisburg, PA • Houston, TX

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14 geographic/metropolitan areas for Beta include:

• Kansas City, MO • Los Angeles, CA • Nashville, TN • Philadelphia, PA • Phoenix, AZ • St. Louis, MO • San Diego, CA

Benefits of Participating

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• Understand/influence cross-setting PAC assessment items with implications for quality reporting and value-based payment

• Increase staff skills in quality improvement, use of data to improve care, and support professional development/retention for high value employees

• Internal and external publicity to emphasize your commitment to quality and participation in national standard setting/showcase innovation in post-acute care

• National visibility/networking with peer organizations and national stakeholders participating in the testing and rollout

• Research experience to support future grant applications, potential for additional collaboration with national stakeholders and policy-makers, and recruitment of candidates for key staff positions

How to Get Involved

Ongoing Outreach Activities

• Stakeholder meetings • Professional conference participation • Public comment on proposed items

‒ Blueprint ‒ Item list distributions (via email) ‒ Formal public comment

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Beta Recruitment Activities/ Opportunities

• Mailings to be sent out in late April early May 2017 to invite providers to participate in beta

• Recruitment outreach calls from Abt Associates team members will closely follow mailings

• Providers will need to identify clinical teams to participate as assessors

• Field period runs from October 2017 – May 2018 • Debrief activities will occur in early summer 2018

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Points of Contact

• CMS IMPACT Mailbox for comments/ideas: ‒ PACQualityInitiative@cms.hhs.gov

• IMPACT item development general information: ‒ impactact@rand.org

• Field testing and recruitment information: ‒ impactsignup@abtassoc.com

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For More Information

• IMPACT Act website • PAC QRP listserv- https://public-

dc2.govdelivery.com/accounts/USCMS/subscriber/new?topic_id=USCMS_12265

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