CARE tool follows patients through continuum

Assessment instrument being tested

A patient assessment tool being tested in a Medicare demonstration project is intended to standardize the information providers share as patients transition from one level of care to another.

The Medicare Continuity Assessment Record and Evaluation (CARE) tool was developed by a range of experts with backgrounds that include case management, nursing, therapy, physiatry, cognition, neurology, and functional medicine. It is being rolled out for testing this year at 175 providers in acute care hospitals, inpatient rehabilitation centers, long-term acute care hospitals, skilled nursing facilities, and home health agencies in 10 markets across the country.

It will be up to Congress to decide when and how to implement the CARE tool after it receives a report from the Centers for Medicare & Medicaid Services (CMS) on the demonstration project in 2011.

CARE is a standardized assessment tool that measures medical, functional status, and cognitive status during treatment and as the patient moves across settings and is intended to replace three tools now in use at three distinct levels of care to minimize redundant collection of data and support comparing patient characteristics across the continuum and tracking outcomes.

The CARE tool has a core set of items to be completed for any Medicare beneficiary who is hospitalized or admitted to a post-acute care setting. The number of items to be completed depends on the patient's condition.

The tool contains a core set of items that are collected on all patients and a supplemental set that measures severity if a patient has a specific condition. Most of the items are commonly collected in each setting but the exact language may vary by site. The tool standardizes the language used with all Medicare admissions.

Each level of care has specific modules to complete. The acute care hospital has the shortest version, particularly for patients being discharged to home with limited need for continuing care services.

The content will follow the patient through the continuum, giving providers at each level of care access to information from other providers.

"The tool will make it possible to follow a patient's progress across an entire episode of care, something that has been lacking for some time. Unless a hospital has affiliated home care agencies or post-acute facilities, the hospital loses track of the patient once he or she is discharged," says Diane E. Holland, PhD, RN, clinical nurse researcher, department of nursing at the Mayo Clinic and assistant professor of nursing at the College of Medicine in Rochester, MN. Holland served as a member of the technical expert panel for development of the CARE tool.

The primary goal of the demonstration project is to provide CMS with information that will help better understand costs and outcomes across different post-acute care sites, says Barbara Gage, PhD, MPA, director of post-acute research at RTI International.

"The goal is to help identify patient characteristics that can impact on care decisions and resources needed," she says.

Although one of CMS' aims is payment reform for post-acute care, the development of the CARE tool has the potential to improve case management workflow and reduce queries from post-acute care providers, Gage says.

"Patients are moving across the continuum more rapidly than ever before. The tool aims to bridge the gaps that often occur between levels of care. If everybody is using the same language to measure acuity, providers will be able to share information as patients transition to another level of care, care needs will be better understood, and outcomes will be better managed," adds Jackie Birmingham, RN, BSN, MS, CMAC, vice president of professional services at Curaspan Health Group in Newton, MA.

Use of the CARE tool will provide more consistent and better directed discharge planning. In addition, the assessment performed during the most stressful time in the patient's episode of care will be better communicated to the next level of care, she adds.

When the CARE tool is fully implemented, it will be available to approved providers through a HIPAA-compliant web site.

The majority of the information already is being recorded on patients, especially if they are going to a post-acute setting, says Holland.

"When hospitals start using the tool, it will be a matter of working with the hospital information technology department to determine how to best access the information already recorded in the medical record," Holland says.

Having complete, standardized information about patient conditions and complexity should eventually help discharge planners identify the most appropriate level of care for similar patients, Holland says.

When the information collected by the CARE tool is aggregated, case managers will be able to use the data to show patients that people with similar conditions treated in a particular setting had good outcomes, she adds.

"Information will be consistent across institutions and delivery settings. Providers will have documented access to current information across the continuum, which will help streamline referrals and handoffs," she says.

The CARE tool may help hospitals better prepare patients for their recovery and improve the process of transitioning the patient from one level to the next, Holland says.

"As discharge planning clinicians, we know that the discharge planning assessment begins on admission, or in some cases, before the patient is admitted. The CARE tool allows us to pause at a very critical juncture to make sure that the planning for the patient's continuing care fits in with where the patient is at that time," Holland says.

"What is really important is that we will be able to help people make a decision about post-acute care, based on the best outcomes," she adds.