On October 6, 2014, a bipartisan bill on Improving Medicare Post-Acute Care Transformation (IMPACT) was signed. The IMPACT Act seeks to standardize assessments for vital care issues across the gamut of post-acute care (PAC) providers and builds a framework to ensure that the delivered care is mindful of the patient needs; thereby eliminating the current silo-focused approach to quality measurement and resource utilization.

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Transforming Post-Acute Care with IMPACT
26 August, 2017 | Author: Shardul Rane| Manager
CitiusTech Thought
Leadership

2. 2
 Overview
 PAC Providers and Assessment Instruments
 Need for Data Standardization
 Requirement for Standardized Assessment Data
 IMPACT Timelines
 Measurement Implementation Phases
 Standardized Assessment Categories – Project Overview
 Guidance for PAC Providers
 References
Agenda

3. 3
Overview:
On October 6, 2014, a bipartisan bill on Improving Medicare Post-Acute Care Transformation
(IMPACT) was signed. The IMPACT Act seeks to standardize assessments for vital care issues
across the gamut of post-acute care (PAC) providers and builds a framework to ensure that the
delivered care is mindful of the patient needs; thereby eliminating the current silo-focused
approach to quality measurement and resource utilization.
Objectives:
 Reporting of standardized, interoperable assessment data by PAC providers
 Using common standards and definitions, to provide access to longitudinal information for
such providers
 Developing and implementing quality measures for at least five specified domains
 Establishing payment rates according to the individual characteristics of the patient,
irrespective of PAC setting
 Improving hospital discharge planning
 Facilitating coordinated care and improve Medicare beneficiary outcomes
Stakeholders:
PAC Providers, CMS and National Quality Forum (NQF)
Overview

4. 4
PAC providers under the Ambit of IMPACT
Home Health Agency (HHA)
 Agency providing healthcare services to
individuals at their place of residence
with the goal of enabling the individual
to become as self-sufficient as possible
 Services include – Care for pressure
ulcers, surgical wounds, patient and
caregiver education, intravenous or
nutrition therapy, monitoring unstable
health status
Long-term Care Hospital (LTCH)
Skilled Nursing Facility (SNF)
 Facility which provides skilled nursing
care and/or rehabilitation to
individuals having health problems
which are severe to manage at HHA
or Assisted Living
 Services include - Rehabilitation
therapy, custodial care, general
wound care, providing terminal illness
care as a service at hospice
 Certified acute-care hospitals which
focus on patients (mostly transferred
from ICU) who, on average, stay more
than 25 days
 Services include - Respiratory therapy,
head trauma treatment and pain
management
Inpatient Rehabilitation Facility (IRF)
 Freestanding rehabilitation hospitals
and rehabilitation units in acute care
hospitals
 Services include – Intensive
rehabilitation programs, including
physical, occupational, speech therapy

5. 5
PAC Assessment Instruments
Assessment instruments are questionnaires which capture patient care information and serve as
building blocks for computing quality measures.
HHA
Outcome and Assessment Information Set (OASIS)
Represents core items of a comprehensive assessment for an adult
home care patient
SNF
Minimum Data Set (MDS)
Assessment for facilitating care management in nursing homes (NHs)
and non-critical access hospital swing beds (SBs)
IRF
Patient Assessment Instrument (PAI)
Assessment data collected on patients receiving services under
Medicare Part A fee-for-service from inpatient rehab unit or hospital
LTCH
Continuity Assessment Record and Evaluation Data Set (CARE)
Instrument LTCH providers use to collect patient assessment data for
quality measure calculation and payment determination

6. 6
Data Standardization across PAC Assessment Instruments
OASIS
MDS
IRF-PAI
LTCH
CARE
Data Items
Standardized Assessment Data
 Each PAC setting has its own
instrument for recording
assessment data
 However, certain data items or
questions are common
between the instruments or
common across all instruments
 Currently, there is scope to
further standardize more data
items across the PAC settings
IMPACT seeks to standardize data items which contribute to the development of quality
measures which represent vital patient care outcomes across PAC settings.

7. 7
Need for Data Standardization – Example
OASIS
MDS
Data Item responses for the same domain concept differ across assessment instruments.
For example, MDS has 5 options for response to data item pertaining to vision whereas
OASIS has only 3

8. 8
Concept to Assessment Instrument
 Domain Concept forms the
cornerstone of an assessment
instrument. For e.g. Vision
 The data items or questions
are elicited after evaluating
the concept in the context of
the PAC setting
 The data item response or
answers can include options
(single or multiple choice) or
scales which record severity of
a medical condition
 Quality measures are
computed after aggregating
assessment data at various
levels of abstraction
 An assessment instrument
encapsulates all of the above
Assessment Instrument
Quality Measure
Data Item – Response(s)
Data Item - Question(s)
Domain Concept

9. 9
Reporting of Standardized Assessment Data
IMPACT mandates PAC providers to report the following data to CMS
 The data procured from assessment instruments
 The measures computed from the data.
Standardized Patient
Assessment Categories
 Functional status
 Cognitive function
 Special services,
treatments, and
interventions
 Medical conditions and
co-morbidities
 Impairments
Quality Measures
 Functional status,
cognitive function
 Skin integrity
 Medication reconciliation
 Incidence of major falls
 Accurately
communicating and
transferring health
information and care
preferences
Resource Use and Other
Measures
 Medicare spending per
beneficiary
 Discharge to
community
 All-condition risk-
adjusted potentially
preventable hospital
readmission rates
Data Reporting
Requirements

10. 10
Timelines: Measures Implementation across PAC Providers
Measures HHA SNF IRF LTCH
Functional Status Jan 1, 2019 Oct 1, 2016 Oct 1, 2016 Oct 1, 2018
Skin Integrity Jan 1, 2017 Oct 1, 2016 Oct 1, 2016 Oct 1, 2016
Medication Reconciliation Jan 1, 2017 Oct 1, 2018 Oct 1, 2018 Oct 1, 2018
Incidence of Major Falls Jan 1, 2019 Oct 1, 2016 Oct 1, 2016 Oct 1, 2016
Transfer of Health
Information
Jan 1, 2019 Oct 1, 2018 Oct 1, 2018 Oct 1, 2018
Medicare Spending per
Beneficiary
Jan 1, 2017 Oct 1, 2016 Oct 1, 2016 Oct 1, 2016
Discharge to Community Jan 1, 2017 Oct 1, 2016 Oct 1, 2016 Oct 1, 2016
Potentially Preventable
Hospital Readmission Rates
Jan 1, 2017 Oct 1, 2016 Oct 1, 2016 Oct 1, 2016

11. 11
Measurement Implementation Phases
Initial Phase
 Measure specification, including informing the public of the measure’s
numerator, denominator and exclusions
 Data collection, including, in the case of quality measures, requiring PAC
providers to report data elements needed to calculate such a measure
 Data analysis, including, in the case of resource use and other measures, the
use of claims data to calculate such a measure
 Provision of confidential feedback reports to PAC providers on measure
performance on at least quarterly basis or annual basis (in case of applicable
measures)
Second Phase
Third Phase
 Public reporting of PAC providers’ performance on applicable measures
 PAC provider has the opportunity to review and submit corrections before the
data is made public, which is not later than 2 years after the specified
application date applicable to the measure and provider
Note: This is applicable for data reporting requirements pertinent to Quality Measures and
Resource Use and Other Measures.

12. 12
Quality Measure Development Lifecycle and Timespan
MONTH1 5 12 21 27
Conceptualization Generate a list of concepts to
be developed
Specification
Draft measure specifications
and conduct feasibility analysis
Testing
Develop and implement
comprehensive measure
testing plan
Implementation
Support measure rollout, federal
rulemaking, NQF endorsement,
education and outreach
Use,
Evaluation,
Maintenance
Assess measure
performance and
conduct maintenance

13. 13
Standardized Assessment Categories – Project Overview
CMS is collaborating with RAND Corp. to develop, implement and maintain standardized PAC patient
assessment data as mandated by IMPACT Act.
Sep Jan May Sep Jan May Sep Jan May Sep
Year 1 Year 2 Year 3 Year 42015 2018
Information Gathering - literature review,
focus groups, case studies
Alpha 1 – Nurse and Facility Training
Alpha 1 – Data Collection - 120
assessment forms across 8 PAC facilities
Alpha 1 – Nurse and Facility Training
National Beta – Nurse and Facility Training
National Beta – Data
Collection - 210 PAC facilities
across 14 metropolitan areas
Final Reports
Alpha 1 – Data Collection - 300
assessment forms across 16 PAC facilities
Track 1
Track 2
Track 3
Track 4
Track 5
Completed
Completed
Completed
Scheduled
Scheduled
STATUS

14. 14
Guidance for PAC Providers
 PAC providers will need to configure, implement, and report data to CMS for Quality Measures,
Resource Use and Other Measures as mandated by IMPACT Act
 Failure to effectively collect and report data will attract market basket payment penalty of 2%
 The standardization of assessment categories will result in major changes in the data items across
various PAC instruments
 Crosswalks need to be implemented for tracking data item changes across different versions of
assessment instrument, a prerequisite for data analytics
 Organizations which capture data for more than one assessment instrument will need to
implement solution for collating information from standardized data items across instruments and
make it patient-centric
 PAC providers will require a flexible, scalable and configurable solution for managing measure
development, monitoring and reporting

15. 15
References
 https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Post-Acute-
Care-Quality-Initiatives/IMPACT-Act-of-2014/IMPACT-Act-of-2014-Data-Standardization-and-
Cross-Setting-Measures.html
 https://www.aanac.org/Today-in-Long-Term-Care/post/cms-moves-closer-to-new-impact-act-
data-elements/2017-04-06
 https://remingtonreport.com/ceo-resources/58-the-impact-act-quality-measure-domains.html
 https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/HomeHealthQualityInits/Downloads/OASIS-C2-AllItems-10-2016.pdf
 https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-
Instruments/NursingHomeQualityInits/Downloads/Archive-Draft-of-the-MDS-30-Nursing-Home-
Comprehensive-NC-Version-1140.pdf
 https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/LTCH-
Quality-Reporting/Downloads/Proposed-LTCH-CARE-Data-Set-V-400-Effective-April-1-2018.zip
 https://www.ahcancal.org/advocacy/issue_briefs/Issue%20Briefs/IMPACT-IB.pdf

16. Thank You
Author:
Shardul Rane
Manager - QA
thoughtlleaders@citiustech.com
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