On April 7 and 8, 2016, Powers Principal Peter Thomas took part in a CMS Technical Advisory Committee, “Development and Maintenance of Post-Acute Care Cross-Setting Standardized Patient Assessment Data.” Read Peter’s report below.
On April 7 and 8, 2016, I participated in a Technical Expert Panel (TEP) convened by the Centers for Medicare and Medicaid Services (CMS) in Baltimore through a contract with RAND Health. The TEP was entitled, “Development and Maintenance of Post-Acute Care Cross-Setting Standardized Patient Assessment Data” and is required under the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014. RAND has been tasked by CMS with development and testing of standardized post-acute care (PAC) assessment data elements that could meet the requirements of the IMPACT Act and contribute to care planning, quality measurement, cost estimation, better care transitions and interoperable data exchange.
The feedback sought from the TEP involved potential data elements that will inform RAND’s work on seven domains of data reporting and quality measurement which will be implemented across post-acute care (PAC) settings including:
- Cognitive Status
- Depressed Mood
- Hearing and Vision
- Medication Reconciliation
- Care Preferences, and
- Bladder and Bowel Continence
RAND provided a comprehensive notebook of materials that summarized the work they have accomplished to date. The notebook provided information specific to the seven domains that describes data elements pertinent to these domains as identified by a literature review and by expert advisors to RAND. The TEP’s charge was to assess a wide range of established quality measures in each of the seven domains, rank order each quality measurement set in the following four major areas, and offer any additional observations:
- Potential for Improving Quality (improving transitions, patient-centered care, safety)
- Validity and Reliability (inter-rater reliability and capturing the construct measured)
- Feasibility for Use in the PAC settings (appropriateness across PAC settings)
- Utility for Describing Case Mix (potential use for payment models)
The TEP was led by RAND Senior Natural Scientist, Debra Saliba, MD, MPH, a geriatrician at UCLA. Barbara Gage, PhD, clearly has a lead role in the development of this work as well. A large number of other RAND scientists are deployed on this project and many of them were in the room observing the two days of deliberations by the TEP. Representatives from CMS, including Stella Mandl, RN, who appeared to be the most senior CMS official attending the TEP, also participated.
The Technical Expert Panel itself was comprised of representatives of each of the post-acute care settings at issue, including Long-Term Acute Care Hospitals (LTAC), Inpatient Rehabilitation Hospitals and Units (IRF), Skilled Nursing Facilities (SNF), and Home Health Agencies (HHA). The SNF sector appeared to be heavily represented but each setting had its share of effective spokespersons. The IRF sector was primarily represented by two of the 14 members of the TEP and included Chloe Slocum, a physician from Spalding Rehabilitation Hospital and a spinal cord injury specialist, and Janet Herbold from Burke Rehabilitation Hospital. Mark Rothman, Chief Medical Officer for Kindred, was also on the panel and offered numerous insightful comments including several very favorable toward inpatient rehabilitation provided in a hospital setting, but Dr. Rothman also had experience in LTAC and other settings of post-acute care. For whatever reason, none of the long-standing leaders in rehabilitation medicine were included on the panel.
I was the only consumer representative on the TEP and spoke of the need to include more consumer representatives on such TEPs in the future. For instance, despite the fact that the TEP discussed many issues involving geriatrics during the course of the two-day meeting, there was no consumer representing the senior Medicare population, which totals more than 40 million people. RAND must have had trouble fielding qualified consumer representatives as I was recruited to the panel, not nominated.
In providing context for this TEP, RAND’s lead psychometrician, Maria Orlando Edelman, stated that this TEP’s work was the culmination of the information gathering phase of the project, which is now complete. The TEP’s debate and analysis of the seven domains will be condensed into a report which RAND intends to publish by this summer. The next phase will focus on item refinement and testing of the selected measures in the seven domains. RAND staff will examine what it learned during the TEP and field test a number of existing measures, combinations of measures, or, potentially, new measures that RAND develops as a result of the feedback they received. There were numerous important points made during the TEP but the themes were consistent; ensure that all measures are patient centered, truly improve clinical practice and patient outcomes, and are as efficient and least burdensome as possible for both patients and providers.
In response to questions raised about the absence of functional measures being considered by the TEP, RAND representatives stated that CMS has already formulated functional measures and that they are being tested currently. The principal functional measures under consideration address mobility and self-care but do not address some of the most critical aspects of functional status, such as the level of function to which they will be able to return after a reasonable period of recovery and rehabilitation. While mobility and self-care are both important measures in all post-acute care settings, patients typically want to know the answers to questions such as:
- Will I be able to return to my previous level of function?
- Will I be able to live independently with or without assistance?
- Will I be able to return to work?
- Will I be able to reengage in community activities?
While appreciation for the importance of these issues was expressed, a full discussion of functional measurement was outside the scope of the TEP.
Each of the seven domains mentioned above were discussed for between 60 and 90 minutes and presentations on each section were followed by open discussion lead by a facilitator who prompted discussion by asking specific questions. A wide variety of views were obtained. On balance, the representatives of the LTAC sector were concerned that the measures did not adequately reflect the level of medical acuity of patients in their setting. The home health agencies were concerned that several of the measures would be far more difficult to achieve high scores in the home setting based on the fact that patients are not under the providers’ control at all times.
There was significant discussion about the burden of the existing MDS 3.0 in SNFs (currently over 40 pages long) and the IRF-PAI in IRFs (now 18 pages long) and how these new measure sets would either supplant or supplement those existing data collection tools. There was also discussion of how the CARE Tool allows data collection across the four settings of PAC. A RAND speaker stated that the CARE Tool “serves as a good first step toward standardization, but the goal is to reach an ideal assessment state for PAC settings.”
Many of the measure sets in each of the seven domains the TEP examined were aimed at collecting similar types of data but the questions in each measure set were often framed or stated differently. Some measurement tools were simply too long to expect them to be feasible and useful in the four PAC settings; other measure sets, such as the cognitive set of measures, were intended to be used as screening tools to ensure that patients with various forms of cognitive deficits caused by conditions such as delirium, dementia, and brain injury were identified in order to be treated later and assessed in greater depth at a subsequent point.
Again, a written report on the TEP’s deliberations is expected to be published by RAND by this summer and the testing phase of optimal measure sets in the seven domains mentioned above is scheduled to begin soon.