兰德-Development-and-Maintenance-of-Standardized-Cross-Setting-Patient-Assessment-Data-for-Post_127页_925kb

Summary of "Development and Maintenance of Standardized Cross Setting Patient Assessment Data for Post-Acute Care"

Core Content

This report presents the findings from the first Alpha 1 feasibility test of a proposed set of standardized patient assessment items for post-acute care (PAC) settings. The test was conducted between August and October 2016 and aimed to evaluate the reliability and feasibility of items in seven focus areas: vision and hearing, cognitive status, depressed mood, pain, care preferences, medication reconciliation, and bladder and bowel continence. These items are part of the effort to standardize assessment data under the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014, which seeks to improve care coordination, data interoperability, and patient outcomes across PAC settings.

The test involved 133 patients, with assessments conducted by both facility nurses and research nurses to evaluate interrater reliability (IRR). Items were also assessed for feasibility, including time to complete and clarity of instructions. Some content areas included additional metrics such as adherence to skipping rules and data sources used.

Main Findings

Category 1: Depressed Mood, Pain, and Bladder and Bowel Continence

• IRR: High, with IRR scores above 0.9 for mood and pain items, and generally high for bladder and bowel items.
• Feasibility: Items were easy to administer, taking minimal time (1–6 minutes).
• Feedback: Assessors requested additional training on scoring the PHQ-2 and PHQ-9. Some suggested simplifying the term "continence" for patient understanding and clarifying scoring when family and patient accounts differ.

Category 2: Vision and Hearing, Cognitive Status, and Care Preferences

• IRR: Moderate to almost perfect for vision and hearing items, with the highest IRR for hearing aid use (Cohen’s kappa = 0.92). Cognitive status items showed excellent IRR, and care preferences had perfect IRR.
• Feasibility: Items were generally easy to complete, taking 1–7 minutes.
• Feedback: Confusion was noted about when to ask for the date of the most recent vision or hearing test. Assessors requested clarification on the wording and scoring of some items. For cognitive tasks, there was a need for more guidance on administering and scoring specific tasks like the Trail Making Task and Serial 7's Task. Care preferences items also needed wording adjustments and collapsing of similar response levels.

Category 3: Medication Reconciliation

• IRR: Lowest among all categories, with kappas below 0.3 for many items.
• Feasibility: Items were more time-consuming, taking 15–20 minutes on average.
• Feedback: Assessors noted a steep learning curve, requiring clearer instructions and better understanding of data sources. Items were revised to focus on medication discrepancies rather than potential adverse drug events, and the number of items was reduced to improve efficiency.

Key Metrics

• IRR was calculated using Cohen’s kappa for categorical variables and weighted kappa for ordinal variables.
• Feasibility was assessed based on:
  • Time to complete items.
  • Clarity of instructions.
  • Adherence to skipping rules.
  • Use of data sources.

Project Structure

• Project Leadership:

  • Maria Orlando Edelen (Project Director, RAND)
  • Barbara Gage (Project Co-Director, George Washington University)
  • Susan Paddock (Lead Statistician, RAND)
  • Debra Saliba (Senior Clinical Adviser, RAND)

• RAND Project Staff:

  • Included lead project managers, task leads, and support staff with expertise in various PAC settings and data collection methods.

• Abt Associates and Qualidigm:

  • Provided additional support with nursing and research expertise.

Next Steps

• The findings from Alpha 1 will be combined with stakeholder feedback to inform the Alpha 2 test, which will refine the items further.
• Beta testing will then be conducted nationally to evaluate item performance across all four PAC settings: Home Health Agencies (HHAs), Inpatient Rehabilitation Facilities (IRFs), Long-Term Care Hospitals (LTCHs), and Skilled Nursing Facilities (SNFs).
• Items will be revised based on the feedback and quantitative results to enhance reliability and feasibility.

Conclusion

The Alpha 1 feasibility test was successfully completed, with most items showing strong reliability and feasibility. Items in Category 1 are ready for Beta testing with minimal changes. Category 2 items require minor adjustments. Category 3 items, particularly medication reconciliation, need substantial refinement. The project aims to support person-centered care, efficiency, and improved outcomes for Medicare beneficiaries through standardized assessment data.

Appendix and References

• The report includes Appendix A (Alpha 1 Assessment Protocol), Appendix B (Assessor Feedback Interview Protocol), and Appendix C (Item History and Current Usage).
• A list of abbreviations is provided for clarity, including references to BIMS, CARE, PHQ, and TEP.

Final Notes

The project is supported by the Centers for Medicare & Medicaid Services (CMS) under contract No. HHSM-500-2013-13014I. The goal is to develop a national standard for patient assessment data that can be used across all PAC settings, ultimately improving care transitions, data sharing, and policy development.