Marie Johnson, Danielle Holthaus, Jennie Harvell, Eric Coleman, Theresa Eilertsen and Andrew Kramer
University of Colorado Health Sciences Center
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. For additional information about the study, you may visit the DALTCP home page at http://aspe.hhs.gov/daltcp/home.shtml or contact the ASPE Project Officer, Jennie Harvell, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. Her e-mail address is: Jennie.Harvell@hhs.gov.
The authors thank the following people for helpful comments on earlier drafts of the report: Arlene Bierman, AHQR; John Thomas/Lisa Hines/Carolyn Rimes/Laurence Wilson, HCFA; Joyce Brown-Moore/Ruth Katz/Floyd Brown/Kamal Hijjazi/Henry Krakauer, ASPE.
Understanding the quality of post-acute care is more important and has become more challenging than ever before. 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. The Office of the Assistant Secretary for Planning and Evaluation (ASPE) has implemented a research strategy designed to examine the quality of Medicare post-acute care services (i.e., services provided in rehabilitation hospitals/units, skilled nursing facilities, and home health agencies). Rapidly rising Medicare post-acute care expenditures was one factor driving the interest in post-acute care quality. In addition, the impact that recently enacted payment changes for Medicare post-acute care services may have on the quality of care stimulated increasing interest in measuring the quality of Medicare post-acute care.
As an integral part of ASPEs research strategy, this project sought to identify measures that could be used to determine the quality of post-acute care services. The project identified a mixture of both global and disease-specific outcome and process measures relevant to post-acute care. It focused on measures relevant to patients who, following a hospital stay, receive post-acute care for conditions that required either intense medical or rehabilitation management. The conditions targeted in this study were congestive heart failure, pneumonia, stroke, and back and neck conditions. Through discussions with expert clinicians and researchers and a review of the literature, post-acute care process and outcome measures were identified. They included traditional measures of physical function, utilization, and mental health, as well as measures emphasizing symptom relief, specific therapies and other processes of care, satisfaction, and health-related quality of life, including role resumption.
During the course of this study, it was determined that existing administrative data (including patient assessment instruments) do not contain information needed to adequately measure the quality of care within and across post-acute care settings. While existing data systems include information needed for some of these measures (e.g., utilization and functional measures) many of the measures identified as important in understanding quality of post-acute care are not included in existing administrative data (e.g., mental health, quality of life, satisfaction, and role resumption). In addition, while existing data systems measure functional status (i.e., information that was considered important across all conditions), existing patient assessment instruments measure functional status in different ways and at different times across post-acute care settings. Further, the differences in patient assessment instruments and processes make if difficult to identify whether similar patients are, in fact, treated across different settings, and if so, what are their relative outcomes of care. Finally, patient assessment data is collected only as long as a patient is treated in any particular post-acute care setting. However, many outcomes that the expert clinicians and researchers identified as important may not be present until after the patient is discharged from the post-acute care setting. Thus, while existing data systems may serve a variety of purposes, they were not found to include information needed to measure post-acute care quality and outcomes.
As a result, this project developed four quality assessment instruments, one for each of the targeted conditions. These instruments, which will be used in future research measuring the quality of post-acute care, derives data from hospital and post- acute care medical records and two patient surveys (i.e., one upon admission to post-acute care and the other at a specified point in time following post-acute care admission).