Improving Medicare Post-Acute Care Transformation Research Articles

HARMONIZATION OF CHRONIC CONDITIONS WAREHOUSE DATA FOR OUTCOMES RESEARCH ON GERIATRIC SYNDROMES

Abstract Geriatric syndromes such as cognitive impairment, falls, depression, urinary incontinence, pressure ulcers, and polypharmacy are common conditions and syndromes that affect older adults. Studying geriatric syndromes in Medicare beneficiaries may provide important insights for improving health outcomes and quality of life. As a result of the Improving Medicare Post-Acute Care Transformation Act of 2014, it is now easier to compare standardized geriatric assessment data (including information about geriatric syndromes) collected in post-acute and long-term care settings with corresponding data from claims, encounter, Part D, and durable medical equipment files. However, to our knowledge, methods to link and harmonize post-acute and long-term care assessment data (available for 75% of decedents) are yet to be utilized in the health services research community. The goal of this project is to develop harmonized datasets that can be used to identify geriatric syndromes and study their prevalence, cost, health outcomes, and service delivery factors over time. This work will allow our team and other researchers to fully leverage these data for use in predictive algorithms and artificial intelligence and machine learning (AI/ML) research. The project uses the five most recent years of data available from the Centers for Medicare and Medicaid Services (CMS) Chronic Conditions Data Warehouse. Data sources include Medicare and Medicaid claims, encounter, MedPAR, Hospice claims, Minimum Data Set (MDS), MDS-Swing Bed (SB), Outcome and Assessment Information Set (OASIS), Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI), Pharmacy (Part D), and Durable Medical Equipment (DME).

Medicare Hospice Policy Changes and Beneficiaries' Rate of Live Discharge and Length-of-Stay.

The 2014 Improving Medicare Post-Acute Care Transformation (IMPACT) Act systemized audits of long hospice stays, and the 2016 two-tier payment system decreased daily reimbursement rates after 60 days of enrollment. Both aimed to reduce long stays. Examine how live discharge rates and length of stay changed in relation to the policies. We computed monthly hospice-level percent live discharges and length of stay using 2008-2019 Medicare hospice claims. We compared prepolicies trends and postpolicies trends overall, within Alzheimer's disease and related dementias (ADRD) patients, within lung cancer patients, and stratified by hospice ownership (for-profit vs. nonprofit/government-owned). We included 10,539,912 and 10,453,025 episodes of care in the analytical samples for live discharge and length of stay analyses, respectively. Overall percent live discharges declined during the prepolicies period (-0.13 percentage-points per month, 95% CI: -0.14, -0.12), but exhibited no significant change during the postpolicies period. Trends were driven primarily by for-profits, with similar patterns within ADRD and lung cancer patients. Overall, mean length of stay increased over time, with greater rate of increase during the postpolicies period (0.41 days per month, 95% CI: 0.39, 0.42) compared to the prepolicies period (0.12 days per month, 95% CI: 0.10, 0.14). Length-of-stay increased faster among ADRD patients, but changed minimally for lung cancer patients. Live discharge rates declined significantly during the prepolicies period, but plateaued after implementation of the policies, driven by changes in for-profits. However, the policies did not reduce length of stay, which increased at faster rates, suggesting that postpolicies excess live discharges were not restricted to long-stay patients.

Characterizing Standardized Functional Data at Inpatient Rehabilitation Facilities.

The Improving Medicare Post-Acute Care Transformation Act of 2014 mandates using standardized patient functional data across post-acute settings. This study characterized similarities and differences in clinician-observed scores of self-care and transfer items for the standardized section GG functional domain and the functional independent measure (FIM) at inpatient rehabilitation facilities. We conducted secondary analyses of 2017 Uniform Data System for Medical Rehabilitation national data. Patients were assessed by clinicians on both section GG and FIM at admission and discharge. We identified 7 self-care items and 6 transfer items in section GG conceptually equivalent with FIM. Clinician-assessed scores for each pair of items were examined using score distributions, Bland-Altman plot, correlation (Pearson coefficients), and agreement (kappa and weighted kappa) analyses. In all, 408,491 patients were admitted to Uniform Data System for Medical Rehabilitation-affiliated inpatient rehabilitation facilities with one of the following impairments: stroke, brain dysfunction, neurologic condition, orthopedic disorders, and debility. Section GG and FIM. Patients were scored as more functionally independent in section GG compared with FIM, but change score distributions and score orders within impairment groups were similar. Total scores in section GG had strong positive correlations (self-care: r= 0.87 and 0.95; transfer: r= 0.82 and 0.90 at admission and discharge, respectively) with total FIM scores. Weak to moderate ranking agreements with total FIM scores were observed (self-care: kappa= 0.49 and 0.60; transfers: kappa= 0.43 and 0.52 at admission and discharge, respectively). Lower agreements were observed for less able patients at admission and for higher ability patients of their change scores. Overall, response patterns were similar in section GG and FIM across impairments. However, variations exist in score distributions and ranking agreement. Future research should examine the use of GG codes to maintain effective care, outcomes, and unbiased reimbursement across post-acute settings.

Evaluation of Federal Policy Changes to the Hospice Benefit and Use of Hospice for Persons With ADRD

Hospice is an important end-of-life service for patients with Alzheimer disease and related dementias (ADRD). To determine whether hospice use among patients with ADRD changed in association with recent policies aimed at reducing hospice misuse and long hospice stays, an outcome that may have disproportionately affected patients with ADRD because of their lengthy end-of-life trajectories. This observational cross-sectional study used Medicare hospice claims data from Medicare hospice episodes of care beginning between July 2008 and December 2019 among Medicare hospice beneficiaries 65 years or older at time of enrollment. Data analysis was conducted between September 2019 and June 2021. The 2014 Improving Medicare Post-Acute Care Transformation (IMPACT) Act, which systematized audits of hospices with a high proportion of long stays, and the 2016 2-tier payment system, which reduced daily reimbursement rates after 60 days. Monthly percentage of (1) new patient enrollees, (2) patient census, and (3) care days provided to patients with an ADRD code. The sample included 11 124 992 unique hospice episodes between 2008 and 2019; mean (SD) patient enrollment age ranged from 82.0 (8.2) years to 82.8 (8.7) years; the percentage of male patients ranged from 40.5% to 42.7%, and the percentage of Black, Hispanic, and White patients ranged from 7.7% to 8.2%, 1.5% to 2.0%, and 86.2% to 88.8%, respectively, across years. The percentage of new enrollees with an ADRD code dropped significantly during the months of IMPACT passage (-1.42 percentage points; 95% CI, -2.13 to -0.71) and implementation (-1.98 percentage points; 95% CI, -2.70 to -1.26) but rose again during the following months. While no significant changes were observed at the time of 2-tier payment implementation (0.15 percentage points; 95% CI, -0.21 to 0.51), the average rate of increase during the subsequent period was slower (0.01 percentage points per month; 95% CI, 0-0.02) than in earlier periods (0.05; 95% CI, 0.04-0.06 during the baseline period). Similar patterns were observed for the percentage of patient census and care days provided to patients with an ADRD code. The results of this cross-sectional study of Medicare hospice claims data suggested that recent Medicare policies were associated with immediate and lasting reductions in the share of patients receiving hospice care with an ADRD code compared with expectations from preimplementation trends. Future research should examine mechanisms through which hospices enacted change and consequences for quality of care.

Outcomes of Pharmacist-Conducted Admission Medication-Regimen Reviews in Long-term Care Facilities.

Objective To assess the outcomes of pharmacist-completed aMRRs. The 2018 installation of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act requires medication regimen reviews (aMRR) upon admission to long-term care (LTC) hospitals, nursing facilities, and inpatient-rehabilitation facilities. While the legislation does not require that pharmacists perform the reviews, pharmacists are aptly suited to add value to this practice. Design Retrospective analysis of residents admitted to LTC facilities. Setting Twenty-four LTC facilities located in Arizona served by one pharmacist-consult service. Patients, Participants Cohort of 603 LTC residents whose medical records were reviewed by consultant pharmacists during March 2020. Results For 603 residents, 1092 aMRRs were completed and 921 interventions were made. The most prevalent interventions were medication monitoring (N = 276), medications without appropriate indication (N = 130), and overdosage (N = 116). Of 921 interventions, 41 were classified as ECA Level 6, avoided hospital admission, and 30 as Level 7, avoided life-threatening event. Of 165 recommendations rated by both pharmacy student assessors and a supervising postgraduate year 2 resident, agreement occurred in 161 (97.6% agreement, kappa reliability = 0.934). Conclusion Pharmacist-conducted aMRRs identified clinically important threats to patient safety. Study results demonstrate potential for positive economic and resident care outcomes from pharmacist-performed aMRR interventions.

The IMPACT Act of 2014: Standardizing patient assessment data to support care coordination, quality outcomes, and interoperability.

The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) addressed the need for uniform, clinical, and demographic data in post-acute care (PAC) settings. Structured, uniform data enables potential interoperable data exchange, quality comparisons across PAC provider types, and the capacity to explore a Medicare unified PAC payment system. Standardized patient assessment data elements were developed for clinical domains such as cognitive function and mental status, special services, treatments, and interventions, and medical conditions and comorbidities to create a common language that can be used to bolster a patient's needs and goals to improve clinical outcomes. Clinical care, decision making, and care planning were at the center of all decisions made to standardize specific data elements. In addition, all standardized data were mapped to nationally accepted vocabulary standards to support electronic health information exchange. The standardized patient assessment data elements present the foundation for uniform language across the PAC continuum to promote a greater quality of care for every patient.

Developing standardized patient assessment data elements for Medicare post-acute care assessments.

To support interoperability and care planning across provider types, the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) requires the submission of standardized patient assessment data using the assessment instruments provided by the Centers for Medicare & Medicaid Services (CMS). CMS was tasked with developing standardized assessment data elements (SADEs) within clinical categories named in the IMPACT Act. We used environmental scans, subject matter expert, and stakeholder input to identify candidate SADEs; tested candidate data elements in alpha testing; revised SADEs and training protocols based on alpha analyses and stakeholder feedback; tested SADEs across post-acute care (PAC) settings in a national field test that included 3121 patients across 143 home health agencies, inpatient rehabilitation facilities, long-term care hospitals, and skilled nursing facilities in 14 markets across the United States; and analyzed data and stakeholder input from national testing. Field testing measured the time required for assessment, percent completion, and inter-rater reliability. We analyzed qualitative feedback from stakeholder focus groups and technical expert panels. We also obtained survey and focus group feedback from data collectors. We developed a mixed-method, multi-stakeholder procedure to identify and gather input on SADE for cross-setting use. This process yielded feasible and reliable SADEs for PAC settings that assess pain, cognitive status, mood, and medication reconciliation. The success of this work depended on working iteratively with diverse stakeholders and providing qualitative as well as quantitative evidence. The procedures applied in this project for developing and adopting SADEs for PAC, as well as the challenges and strategies to overcome challenges, should be considered in future item and quality measure development.

Occupational Therapy and the IMPACT Act: Part 2. A Systematic Review of Evidence for Functional Status, Medication Reconciliation, and Skin Integrity Interventions.

Interventions that promote function, medication reconciliation, and skin integrity assist occupational therapy practitioners in demonstrating professional value, improving quality, and reducing health care costs. In this systematic review, we focus on three outcome areas of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014: functional status, medication reconciliation, and skin integrity. We conducted a search of the literature published between 2009 and 2019 in CINAHL, Cochrane, MEDLINE, PsycINFO, OTseeker, and Scopus. We also hand searched the systematic reviews and meta-analyses in our search results for articles that met our inclusion criteria. Study Selection and Data Collection: This study used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We found 47 articles that address the three outcome areas. Regarding functional status, low strength of evidence is available for cognition and functional mobility interventions to support functional performance, moderate strength of evidence supports interventions for vision, and moderate evidence supports task-oriented and individualized interventions to promote activities of daily living (ADL) outcomes among people with neurological conditions. Strong strength of evidence supports individualized occupational therapy interventions focusing on medication adherence. Low strength of evidence was found for occupational therapy interventions to reduce pressure ulcers and promote skin integrity. Conclusion and Relevance: The evidence supports occupational therapy interventions to improve functional status in ADLs and medication management. Additional research is needed that examines the outcomes of occupational therapy interventions for other areas of function and skin integrity. What This Article Adds: We found evidence to support occupational therapy interventions that align with value-based measures in the three outcome areas of interest. The effectiveness of these interventions highlights the viability of occupational therapy as an essential profession and the worth of occupational therapy to the public, potential clients, and payers.

Occupational Therapy and the IMPACT Act: Part 1. A Systematic Review of Evidence for Fall Prevention and Reduction, Community Discharge and Reintegration, and Readmission Prevention Interventions.

Interventions that prevent falls, facilitate discharge after hospitalization, and reduce hospital readmissions assist occupational therapy practitioners in demonstrating professional value, improving quality, and reducing costs. In this systematic review, we address three outcome areas of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014: prevention and reduction of falls, facilitation of community discharge and reintegration, and prevention of hospital readmission. We conducted a search of the literature published between 2009 and 2019. Study Selection and Data Collection: We developed operational definitions to help us identify articles that answered the search question for each outcome area. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We found 53 articles that address the three outcome areas. Regarding the prevention and reduction of falls, low strength of evidence is available for interventions focusing on a single fall risk and for customized interventions addressing multiple risks. Moderate strength of evidence supports structured community fall risk prevention interventions. Low strength of evidence was found for community discharge and reintegration interventions that include physical activity and educational programming. Low to moderate strength of evidence was found for readmission prevention interventions for patients with four types of condition. Conclusion and Relevance: Several intervention themes in the three outcome areas of interest are supported by few studies or by studies with a moderate risk of bias. Additional research is needed that supports the value of occupational therapy interventions in these outcome areas. What This Article Adds: Our study provides important insights into the state of the evidence related to occupational therapy interventions to address three outcome areas of the IMPACT Act.

Occupational Therapy and the IMPACT Act: Part 1. A Systematic Review of Evidence for Fall Prevention and Reduction, Community Discharge and Reintegration, and Readmission Prevention Interventions.

Interventions that prevent falls, facilitate discharge after hospitalization, and reduce hospital readmissions assist occupational therapy practitioners in demonstrating professional value, improving quality, and reducing costs. In this systematic review, we address three outcome areas of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014: prevention and reduction of falls, facilitation of community discharge and reintegration, and prevention of hospital readmission. We conducted a search of the literature published between 2009 and 2019. Study Selection and Data Collection: We developed operational definitions to help us identify articles that answered the search question for each outcome area. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We found 53 articles that address the three outcome areas. Regarding the prevention and reduction of falls, low strength of evidence is available for interventions focusing on a single fall risk and for customized interventions addressing multiple risks. Moderate strength of evidence supports structured community fall risk prevention interventions. Low strength of evidence was found for community discharge and reintegration interventions that include physical activity and educational programming. Low to moderate strength of evidence was found for readmission prevention interventions for patients with four types of condition. Conclusion and Relevance: Several intervention themes in the three outcome areas of interest are supported by few studies or by studies with a moderate risk of bias. Additional research is needed that supports the value of occupational therapy interventions in these outcome areas. What This Article Adds: Our study provides important insights into the state of the evidence related to occupational therapy interventions to address three outcome areas of the IMPACT Act.

Understanding Missing Patterns in Standardized Patient Functional Data at Inpatient Rehabilitation Facilities

<h3>Research Objectives</h3> The Improving Medicare Post-Acute Care Transformation Act of 2014 adopts standardized functional assessment, known as Section GG, across post-acute settings. Section GG has multiple options for missing and much higher percentages of missing values compared to Functional independent Measure ® (R) (FIM) at the inpatient rehabilitation facilities (IRFs). This study examines missing patterns of Section GG in stroke to enhance our understanding of how to interpret and use Section GG scores. <h3>Design</h3> We analyzed 2018 Medicare data. Each individual was assessed by both Section GG and FIM at admission and discharge. We categorized patients with any Section GG missing into one of five missing patterns: refuse, no attempt, not applicable, no value and tie (patients had the same highest frequency for more than two types of missing). We compared FIM scores across five missing patterns. Multiple imputation was applied to calculate missing GG scores. We compared correlations and agreements between Section GG and FIM before and after multiple imputation. <h3>Setting</h3> IRFs. <h3>Participants</h3> Patients with stroke older than 66 years (N=42,789). <h3>Interventions</h3> None. <h3>Main Outcome Measures</h3> Section GG and FIM. <h3>Results</h3> The mean age of the patients was 78.7 (7.44), with the majority as male (52.3%), non-Hispanic White (80.3%), overweight (34.7%) and married (49.4%). Patients in the missing categories of ‘refused' and ‘not applicable' had higher FIM scores compared to other missing types (e.g. FIM self-care scores at discharge: refuse [25.4], not applicable [23.7], no value [20.6], not attempt [18.8] and tie [18.4]). Correlations and agreements between Section GG and FIM were improved after multiple imputation (correlations at discharge: 084 vs. 0.90, before and after imputation). <h3>Conclusions</h3> Patients had different functional levels when missing Section GG items, indicating different levels of assistance, resources and treatment approaches may be needed. Multiple imputation may be a potential solution to calculate missing Section GG values. Future study needs to examine how to adequately report variations of missing Section GG items, to ensure using standardized functional assessment can provide accurate patient assessment outcomes. <h3>Author(s) Disclosures</h3> No conflicts or interest declared by the authors.

The Importance of Electronic Health Record Access For Accurately Completing Drug Regimen Reviews.

OBJECTIVE: To challenge the standard of practice by evaluating the identification of medication discrepancies found depending on type of access to an electronic health record (EHR). In other words, is there a difference in the number of discrepancies between a pharmacist with only access to the postacute long-term care (PALTC) EHR (ie, single-access pharmacist [SAP]) compared with a pharmacist with access to both the PALTC and hospital EHRs (ie, dual-access pharmacist DAP) In October 2018, the Improving Medicare PostAcute Care Transformation (IMPACT) Act mandated admission drug review (DRR) upon admission to a postacute, long-term care (PALTC) facility.<br/> SUMMARY:This was a prospective study investigating the occurrence of medication therapy problems (MTP) identified by two different DRR processes; SAP versus DAP. Data were collected in a community hospital and a stand-alone PALTC facility. It was found that the DAP identified more safety-related medication needs and medication omissions than an SAP. There was a significant association between the type of access and whether a MTP (ie, yes or no) was discovered, the type of medication-related need, and MTP category.<br/> CONCLUSION: These results strongly suggest that current standard of practice should change to require access to both hospital and PALTC EHR systems for a pharmacist completing the medication reconciliation. Until the gap in EHR interoperability is closed, the potential breakdown in communication associated with SAP places patients transitioning from hospital to PALTC facilities at increased risk for medication problems and accompanying adverse medication events.

The Importance of Electronic Health Record Access For Accurately Completing Drug Regimen Reviews

OBJECTIVE: To challenge the standard of practice by evaluating the identification of medication discrepancies found depending on type of access to an electronic health record (EHR). In other words, is there a difference in the number of discrepancies between a pharmacist with only access to the postacute long-term care (PALTC) EHR (ie, single-access pharmacist [SAP]) compared with a pharmacist with access to both the PALTC and hospital EHRs (ie, dual-access pharmacist DAP) In October 2018, the Improving Medicare PostAcute Care Transformation (IMPACT) Act mandated admission drug review (DRR) upon admission to a postacute, long-term care (PALTC) facility.&lt;br/&gt; SUMMARY:This was a prospective study investigating the occurrence of medication therapy problems (MTP) identified by two different DRR processes; SAP versus DAP. Data were collected in a community hospital and a stand-alone PALTC facility. It was found that the DAP identified more safety-related medication needs and medication omissions than an SAP. There was a significant association between the type of access and whether a MTP (ie, yes or no) was discovered, the type of medication-related need, and MTP category.&lt;br/&gt; CONCLUSION: These results strongly suggest that current standard of practice should change to require access to both hospital and PALTC EHR systems for a pharmacist completing the medication reconciliation. Until the gap in EHR interoperability is closed, the potential breakdown in communication associated with SAP places patients transitioning from hospital to PALTC facilities at increased risk for medication problems and accompanying adverse medication events.

Preparing for the Improving Medicare Post-Acute Care Transformation Act: Incorporating A Sociotechnical Perspective to Enhance a Health Information Technology Evaluation Framework Applied to Post-Acute Care.

The Improving Medicare Post-Acute Care Transformation Act, which mandates electronic sharing of standardized patient data by post-acute care clinical settings, will likely spur further health information technology adoption and evaluation. To support evaluation, the study objective was to clarify components of an evidence-based health information technology evaluation framework, Health Information Technology Reference-based Evaluation Framework, by using the framework in home healthcare and incorporating a sociotechnical perspective in the health information technology evaluation. With 36 observations among three diverse home healthcare agencies, researchers conducted a recorded think-aloud process as nurses documented the home healthcare admission in the EHR. Thematic analysis revealed 15 themes that provided clarification for almost one-third of Health Information Technology Reference-based Evaluation Framework components and added a new concept. All themes reflected a sociotechnical perspective. The new theme added to the Health Information Technology Reference-based Evaluation Framework reflected the sociotechnical perspective: routine use. We anticipate the enhanced Health Information Technology Reference-based Evaluation Framework to be used by evaluators from diverse disciplines, to further facilitate context-dependent health information technology adoption in post-acute care settings.

Rehabilitation of Aging Persons: The Past, The Present &amp; The Promise

The 2020 Excellence in Rehabilitation of Aging Persons Award presentation will address my efforts over the past 35 years related to research methods, functional status, mobility, and self-care. Studies conducted in the past 25 years on disability and recovery in older adults with an emphasis on minority health will be presented. Research examining rehabilitation outcomes related to health care reform including the Improving Medicare Post-Acute Care Transformation (IMPACT) Act, and using Medicare files, will be described. The role of Data Science and Discovery, as defined by the NIH and related to rehabilitation in older adults, will also be presented.

Overlap Between Medicare's Comprehensive Care for Joint Replacement Program and Accountable Care Organizations

BackgroundOverlap between Medicare's Comprehensive Care for Joint Replacement (CJR) model and accountable care organizations (ACOs) may result in positive or negative synergies. In this study, we describe the overlap between the programs at the beneficiary and hospital levels. MethodsWe conducted a retrospective study of patient and hospital characteristics using data from 2016 Medicare claims, the US Census Bureau, the American Hospital Association annual survey, Hospital Compare, and the Centers for Medicare & Medicaid Services Improving Medicare Post-Acute Care Transformation file. On the beneficiary level, we conducted 2 comparisons: (1) among patients who received joint replacement at CJR hospitals, ACO patients (overlap) vs not (CJR-only) and 2) among patients who received joint replacement elsewhere, ACO patients (ACO-only) vs not (neither). On the hospital level, we compared hospitals in the top quartile of overlap rate (high overlap) vs those in the bottom 3 (low overlap). ResultsWe studied 14,519 overlap, 38,972 CJR-only, 26,872 ACO-only, and 68,945 neither beneficiaries. Compared with CJR-only patients, the overlap group was less likely to be older than 85, of black race, of low socioeconomic status, and burdened with clinical complications. Similar results were observed when the ACO-only group was compared with the neither group. Compared with low overlap hospitals, high overlap ones were more likely to be of nonprofit and less likely to be of safety net. ConclusionCJR-ACO overlap is associated with differences in beneficiary and hospital characteristics, which raises key issues for providers and policymakers.

Variation in Facility-Level Rates of All-Cause and Potentially Preventable 30-Day Hospital Readmissions Among Medicare Fee-for-Service Beneficiaries After Discharge From Postacute Inpatient Rehabilitation

The Improving Medicare Post-Acute Care Transformation Act of 2014 mandated a quality measure of potentially preventable 30-day hospital readmission for inpatient rehabilitation facilities (IRFs). Examining IRF performance nationally may help inform health care quality initiatives for Medicare beneficiaries. To examine variation in Centers for Medicare & Medicaid Services Quality Reporting Program measures for US facility-level risk-adjusted all-cause and potentially preventable hospital readmission rates after inpatient rehabilitation. This cohort study of Medicare claims data included 454 378 Medicare beneficiaries discharged from 1162 IRFs between June 1, 2013, and July 1, 2015. Data were analyzed March 23, 2018, through June 24, 2019. All-Cause Unplanned Readmission Measure for 30 Days Post Discharge From Inpatient Rehabilitation Facilities and the Potentially Preventable 30-Day Post-Discharge Readmission Measure for Inpatient Rehabilitation. Specifications from the Centers for Medicare & Medicaid Services were followed to identify the cohort, define outcomes, and calculate risk-standardized facility-level rates. Among a cohort of 454 378 patients, the mean (SD) age was 76.2 (10.6) years and 263 546 (58.0%) were women. The all-cause readmission rate was 12.3% (95% CI, 12.2%-12.4%), and the potentially preventable readmission rate was 5.3% (95% CI, 5.3%-5.4%). Across 1162 included IRFs, risk-standardized all-cause readmission rates ranged from 10.1% (95% CI, 8.9%-11.6%) to 15.9% (95% CI, 13.6-18.6%) and potentially preventable readmission rates ranged from 4.3% (95% CI, 3.7%-5.4%) to 7.3% (95% CI, 5.7%-8.3%). Using the All-Cause Unplanned Readmission Measure for 30 Days Post Discharge From Inpatient Rehabilitation Facilities, 16 IRFs (1.4%) had 95% CIs above the national mean rate, 1137 IRFs (97.9%) had 95% CIs containing the national mean rate, and 9 IRFs (0.8%) had 95% CIs below the national mean rate. Using the Potentially Preventable 30-Day Post-Discharge Readmission Measure for Inpatient Rehabilitation, 8 IRFs (0.7%) had 95% CIs above the national mean rate, 1153 IRFs (99.2%) had 95% CIs containing the national mean rate, and 1 IRF (0.1%) had a 95% CI below the national mean rate. This cohort study found that readmission rates were lower when using the Potentially Preventable 30-Day Post-Discharge Readmission Measure for Inpatient Rehabilitation and further reduced discrimination between facilities compared with the recently discontinued All-Cause Unplanned Readmission Measure for 30 Days Post Discharge From Inpatient Rehabilitation Facilities. This finding may indicate there is a lack of room for improvement in readmission rates. Given the rationale of the Centers for Medicare & Medicaid Services for removing measures that fail to discriminate quality performance, this suggests that the current readmission measure should not be implemented as part of the Inpatient Rehabilitation Quality Reporting Program.

Facility and Geographic Variation in Rates of Successful Community Discharge After Inpatient Rehabilitation Among Medicare Fee-for-Service Beneficiaries

The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 mandated a quality measure of successful community discharge for postacute care services. Examining variation in performance nationally can help identify opportunities for improving patient-centered quality of care. To examine US facility-level and geographic variation in rates of successful community discharges after inpatient rehabilitation. This retrospective cohort study of Medicare claims data from December 31, 2013, through October 1, 2015, included 1154 inpatient rehabilitation facilities submitting claims to the Centers for Medicare & Medicaid Services and a total of 487 862 Medicare fee-for-service beneficiaries discharged from inpatient rehabilitation facilities. Analyses were performed from December 8, 2017, through September 11, 2018. Successful community discharge as defined for the Discharge to Community-Post-Acute Care Inpatient Rehabilitation Facility Quality Reporting Program measure. To be considered a successful community discharge, patients had to discharge from the inpatient rehabilitation facility to the community (ie, home or self-care) and remain there without experiencing an unplanned rehospitalization or dying within the following 31 days. Centers for Medicare & Medicaid Services specifications were followed to identify the cohort, define the outcome, and calculate risk-standardized facility and state rates. Among the 487 862 patients included in the cohort, mean (SD) age was 76.4 (10.8) years, and 56.9% were female. The overall rate of successful community discharge after inpatient rehabilitation was 63.7% (95% CI, 63.6%-63.8%). Risk-standardized rates ranged from 42.9% to 83.6% across inpatient rehabilitation facilities. Two hundred sixteen facilities (18.7%) performed significantly better than the mean national rate and 203 (17.6%) performed significantly worse (P < .05). Risk-standardized state rates ranged from 55.9% to 73.3%. Rates were lowest in the Northeast (Massachusetts, 55.9%; New Hampshire, 57.0%) and highest in the West (Oregon, 70.3%; Hawaii, 73.3%). The observed variation suggests opportunities exist for improving this important, patient-centered national quality measure. Future research is needed to identify the aspects of care delivery and the community services and supports that facilitate successful community discharge. These findings can be used to guide care improvement efforts and further improve the consistency and quality of postacute care.

Pharmacists IMPACT Patient Care – an overview of the IMPACT Act

Pharmacists IMPACT Patient Care – an overview of the IMPACT Act

Inpatient Care for the Cancer Survivor: Opportunities to Develop and Deliver Standards for Care.

Cancer continues to evolve from a terminal diagnosis to a chronic medical condition. With improved survivorship rates, opportunities exist to deliver rehabilitation care throughout the oncology continuum. By definition, inpatient rehabilitation is generally considered postacute care and is provided either in inpatient rehabilitation facilities, in skilled nursing facilities, or in long-term care hospitals. Each institution is subject to specific regulations and legislation that help define appropriateness for admission based on diagnosis, medical necessity, and functional need. However, these criteria may present barriers to access care for the oncology survivor. As the healthcare landscape changes, and reimbursement structures shift from fee-for-service to those that emphasize effectiveness and efficiency in care, inpatient rehabilitation has a unique opportunity to improve value in terms of outcomes and cost. With the implementation of the Improving Medicare Post-Acute Care Transformation Act, standardization of measures throughout postacute care may allow for a more consistent approach to delivery of inpatient rehabilitation care. Further work will be necessary to define the parameters by which oncology survivors should be gauged in this framework.