Which medicare advantage enrollees are at highest one-year mortality risk?

BACKGROUND: While a number of tools exist to predict mortality among older adults, less research has described the characteristics of Medicare Advantage (MA) enrollees at higher risk for 1 year mortality. OBJECTIVES: To describe the characteristics of MA enrollees at higher mortality risk using patient survey data. RESEARCH DESIGN: Retrospective cohort. SUBJECTS: MA enrollees completing the 2019 MA Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey. MEASURES: Linked demographic, health, and mortality data from a sample of MA enrollees were used to predict 1-year mortality risk and describe enrollee characteristics across levels of predicted mortality risk. RESULTS: The mortality model had a 0.80 c-statistic. Mortality risks were skewed: 6 % of enrollees had a ≥ 10 % 1-year mortality risk, while 45 % of enrollees had 1 % to < 5 % 1-year mortality risk. Among the high-risk (≥10 %) group, 47 % were age 85+ versus 12 % among those with mortality risk <5 %. 79 % were in fair or poor self-rated health versus 29 % among those with mortality risk of <5 %. 71 % reported needing urgent care in the prior 6 months versus 40 % among those with a mortality risk of 1 to<5 %. CONCLUSIONS: Relatively few older adults enrolled in MA are at high 1-year mortality risk. Nonetheless, MA enrollees over age 85, in fair or poor health, or with recent urgent care needs are far more likely to be in a high mortality risk group.

Assessing the accuracy of race-and-ethnicity data in the Outcome and Assessment Information Set.

BACKGROUND: Limitations in the quality of race-and-ethnicity information in Medicare's data systems constrain efforts to assess disparities in care among older Americans. Using demographic information from standardized patient assessments may be an efficient way to enhance the accuracy and completeness of race-and-ethnicity information in Medicare's data systems, but it is critical to first establish the accuracy of these data as they may be prone to inaccurate observer-reported or third-party-based information. This study evaluates the accuracy of patient-level race-and-ethnicity information included in the Outcome and Assessment Information Set (OASIS) submitted by home health agencies. METHODS: We compared 2017-2022 OASIS-D race-and-ethnicity data to gold-standard self-reported information from the Medicare Consumer Assessment of Healthcare Providers and Systems® survey in a matched sample of 304,804 people with Medicare coverage. We also compared OASIS data to indirect estimates of race-and-ethnicity generated using the Medicare Bayesian Improved Surname and Geocoding (MBISG) 2.1.1 method and to existing Centers for Medicare & Medicaid Services (CMS) administrative records. RESULTS: Compared with existing CMS administrative data, OASIS data are far more accurate for Hispanic, Asian American and Native Hawaiian or other Pacific Islander, and White race-and-ethnicity; slightly less accurate for American Indian or Alaska Native race-and-ethnicity; and similarly accurate for Black race-and-ethnicity. However, MBISG 2.1.1 accuracy exceeds that of both OASIS and CMS administrative data for every racial-and-ethnic category. Patterns of inconsistent reporting of racial-and-ethnic information among people for whom there were multiple observations in the OASIS and Consumer Assessment of Healthcare Providers and Systems (CAHPS) datasets suggest that some of the inaccuracies in OASIS data may result from observation-based reporting that lessens correspondence with self-reported data. CONCLUSIONS: When health record data on race-and-ethnicity includes observer-reported information, it can be less accurate than both true self-report and a high-performing imputation approach. Efforts are needed to encourage collection of true self-reported data and explicit record-level data on the source of race-and-ethnicity information.

Differential associations of mask mandates on COVID-19 infection and mortality by community social vulnerability.

BACKGROUND: The COVID-19 pandemic in the United States has disproportionately impacted communities deemed vulnerable to disease outbreaks. Our objectives were to test (1) whether infection and mortality decreased in counties in the most vulnerable (highest) tercile of the Social Vulnerability Index (SVI), and (2) whether disparities between terciles of SVI were reduced, as the length of mask mandates increased. METHODS: Using the New York Times COVID-19 and the Centers for Disease Control and Prevention SVI and mask mandate datasets, we conducted negative binomial regression analyses of county-level COVID-19 cases and deaths from 1/2020-11/2021 on interactions of SVI and mask mandate durations. RESULTS: Mask mandates were associated with decreases in mid-SVI cases (IRR: 0.79) and deaths (IRR: 0.90) and high-SVI cases (IRR: 0.89) and deaths (IRR: 0.88). Mandates were associated with the mitigation of infection disparities (Change in IRR: 0.92) and mortality disparities (Change in IRR: 0.85) between low and mid-SVI counties and mortality disparities between low and high-SVI counties (Change in IRR: 0.84). DISCUSSION: Mask mandates were associated with reductions in COVID-19 infection and mortality and mitigation of disparities for mid and high-vulnerability communities. CONCLUSIONS: Ongoing COVID-19 response efforts may benefit from longer-standing infection control policies, particularly in the most vulnerable communities.

Implementation of US Post-Acute Care Payment Reform and COVID-19 Policies: Examining Experiences of Health System Leaders, Staff, Patients, and Family Caregivers-A Protocol.

In fiscal year 2020, new national Medicare payment models were implemented in the two most common post-acute care settings (i.e., skilled nursing facilities (SNFs) and home health agencies (HHAs)), which were followed by the emergence of COVID-19. Given concerns about the unintended consequence of these events, this study protocol will examine how organizations responded to these policies and whether there were changes in SNF and HHA access, care delivery, and outcomes from the perspectives of leadership, staff, patients, and families. We will conduct a two-phase multiple case study guided by the Institute of Medicine's Model of Healthcare Systems. Phase I will include three cases for each setting and a maximum of fifty administrators per case. Phase II will include a subset of Phase I organizations, which are grouped into three setting-specific cases. Each Phase II case will include a maximum of four organizations. Semi-structured interviews will explore the perspectives of frontline staff, patients, and family caregivers (Phase II). Thematic analysis will be used to examine the impact of payment policy and COVID-19 on organizational operations, care delivery, and patient outcomes. The results of this study intend to develop evidence addressing concerns about the unintended consequences of the PAC payment policy during the COVID-19 pandemic.

Dementia Care Is Widespread In US Nursing Homes; Facilities With The Most Dementia Patients May Offer Better Care.

More than three million US nursing home residents were diagnosed with Alzheimer's disease and related dementias (ADRD) between 2017 and 2019. This number is expected to increase as the population ages and ADRD prevalence increases. People with ADRD require specialized care from trained staff. This study addressed two questions: Are residents with ADRD concentrated in nursing homes where they are the majority? If not, what are the implications for their quality of care and life? We answered the first question by determining the ADRD census for each nursing home in the country during the period 2017-19. Using the Minimum Data Set and Medicare claims, we compared characteristics of nursing homes with high and low ADRD census along several dimensions, including staffing, resident outcomes, and resident characteristics. We found that residents with ADRD were dispersed throughout all nursing homes, with fewer than half residing in nursing homes where residents with ADRD accounted for 60-90 percent of the census. Furthermore, only facilities exceeding 90 percent of residents with ADRD seemed to offer better care. These findings raise concerns about the quality of care and life for the majority of residents with ADRD, suggesting that current National Institutes of Health dementia research initiatives and the Biden administration's policies to improve nursing home care should be coordinated.

Barriers and Facilitators to Home- and Community-Based Services Access for Persons With Dementia and Their Caregivers.

OBJECTIVES: The United States has seen increasing shifts toward home- and community-based services (HCBS) in place of institutional care for long-term services and supports. However, research has neglected to assess whether these shifts have improved access to HCBS for persons with dementia. This paper identifies HCBS access barriers and facilitators, and discusses how barriers contribute to disparities for persons with dementia living in rural areas and exacerbate disparities for minoritized populations. METHODS: We analyzed qualitative data from 35 in-depth interviews. Interviews were held with stakeholders in the HCBS ecosystem, including Medicaid administrators, advocates for persons with dementia and caregivers, and HCBS providers. RESULTS: Barriers to HCBS access for persons with dementia range from community and infrastructure barriers (e.g., clinicians and cultural differences), to interpersonal and individual-level barriers (e.g., caregivers, awareness, and attitudes). These barriers affect the health and quality of life for persons with dementia and may affect whether individuals can remain in their home or community. Facilitators included a range of more comprehensive and dementia-attuned practices and services in health care, technology, recognition and support for family caregivers, and culturally competent and linguistically accessible education and services. DISCUSSION: System refinements, such as incentivizing cognitive screening, can improve detection and increase access to HCBS. Disparities in HCBS access experienced by minoritized persons with dementia may be addressed through culturally competent awareness campaigns and policies that recognize the necessity of familial caregivers in supporting persons with dementia. These findings can inform efforts to ensure more equitable access to HCBS, improve dementia competence, and reduce disparities.

Association of Staffing Instability With Quality of Nursing Home Care.

Importance: Recent work suggests that instability in nursing home staffing levels may be an important marker of nursing home quality. Whether that association holds when controlling for average staffing levels is unknown. Objective: To examine whether staffing instability, defined as the percentage of days below average staffing levels, is associated with nursing home quality when controlling for average staffing levels. Design, Setting, and Participants: This quality improvement study of 14 717 nursing homes used the merged Centers for Medicare & Medicaid Services Payroll Based Journal, Minimum Data Set, Nursing Home Care Compare, and Long-Term-Care Focus data for fiscal years 2017 to 2019. Statistical analysis was performed from February 8 to November 14, 2022. Main Outcomes and Measures: Linear, random-effect models with state fixed effects and robust SEs were estimated for 12 quality indicators as dependent variables, percentage of below-average staffing days as independent variables, controlling for average staffing hours per resident-day for registered nurses, licensed practical nurses, and certified nurse aides. Below-average staffing days were defined as those 20% below the facility average, by staffing type. Quality indicators included deficiency citations; long-stay residents receiving an antipsychotic; percentage of high-risk long-stay residents with pressure ulcers (2 different measures for pressure ulcers were used); and percentage of long-stay residents with activities of daily living decline, mobility decline, emergency department visits, and hospitalizations; and short-stay residents with new antipsychotic medication, mobility decline, emergency department visits, and rehospitalizations. Results: For the 14 717 nursing homes in this study, the mean (SD) percentage of days with below-average staffing was 30.2% (12.0%) for registered nurses, 16.4% (11.3%) for licensed practical nurses, and 5.1% (5.3%) for certified nurse aides. Mean (SD) staffing hours per resident-day were 0.44 (0.40) for registered nurses, 0.80 (0.32) for licensed practical nurses, and 2.20 (0.50) for certified nurse aides. In regression models that included average staffing, a higher percentage of below-average staffing days was significantly associated with worse quality for licensed practical nurses in 10 of 12 models, with the largest association for decline of activities of daily living among long-stay residents (regression coefficient, 0.020; P < .001). A higher percentage of below-average staffing days was significantly associated with worse quality for certified nurse aides in 9 of 12 models, with the largest association for short-stay functioning (regression coefficient, 0.030; P = .01). Conclusions and Relevance: This study suggests that holding average staffing levels constant, day-to-day staffing stability, especially avoiding days with low staffing of licensed practical nurses and certified nurse aides, is a marker of better quality of nursing homes. Future research should investigate the causes and potential solutions for instability in staffing in all facilities, including those that may appear well-staffed on average.

Dual impacts of Medicare payment reform and the COVID-19 pandemic on therapy staffing in skilled nursing facilities.

BACKGROUND: Implementation of new skilled nursing facility (SNF) Medicare payment policy, the Patient Driven Payment Model (PDPM), resulted in immediate declines in physical and occupational therapy staffing. This study characterizes continuing impacts of PDPM in conjunction with COVID-19 on SNF therapy staffing and examines variability in staffing changes based on SNF organizational characteristics. METHODS: We analyzed Medicare administrative data from a national cohort of SNFs between January 2019 and March 2022. Interrupted time series mixed effects regression examined changes in level and trend of total therapy staffing minutes/patient-day during PDPM and COVID-19 and by type of staff (therapists, assistants, contractors, and in-house staff). Secondary analyses examined the variability in staffing by organizational characteristics. RESULTS: PDPM resulted in a -6.54% level change in total therapy staffing, with larger declines for assistants and contractors. Per-patient staffing fluctuated during COVID-19 as the census changed. PDPM-related staffing declines were larger in SNFs that were: Rural, for-profit, chain-affiliated, provided more intensive therapy, employed more therapy assistants, and admitted more Medicare patients before PDPM. COVID-19 resulted in larger staffing declines in rural SNFs but smaller early declines in SNFs that were hospital-based, for-profit, or received more relief funding. CONCLUSIONS: SNFs that historically engaged in profit-maximizing behaviors (e.g., providing more therapy via lower-paid assistants) had larger staffing declines during PDPM compared to other SNFs. Therapy staffing fluctuated during COVID-19, but PDPM-related reductions persisted 2 years into the pandemic, especially in rural SNFs. Results suggest specific organizational characteristics that should be targeted for staffing and quality improvement initiatives.

Provider discussion of health goals and psychosocial needs: Comparing older to younger veteran experience.

OBJECTIVE: To examine by age, the veterans' report on whether components of age-friendly health systems were discussed during primary care visits. DATA SOURCES AND STUDY SETTING: Veterans Affairs (VA) Survey of Healthcare Experience of Patients from October 2015 to September 2019. STUDY DESIGN: Cross-sectional survey of VA users by age group (18-44 years, 45-64 years, 65+ years; N = 1,042,318). We used weighted logistic regression models to evaluate disparities in whether veterans discussed with anyone in their provider's office: health goals, depression symptoms, stress, personal problems, and medications. Models were adjusted for socio-demographic characteristics (sex, socioeconomic status, education, rurality) and comorbidity. DATA COLLECTION/EXTRACTION METHOD: Surveys were administered by mail and online. Additional veteran characteristics were extracted from VA administrative data. PRINCIPAL FINDINGS: In unadjusted analyses, VA users age 18-44 had a higher (-8.2%; CI: -9.0, -7.3) and users aged 45 to 64 had lower (4.0%; CI: 3.7, 4.3) predicted, probably discussing health goals compared to age 65+. Fewer VA users age 65+ reported discussing depression symptoms, personal problems, and stress than other age groups, whereas more VA users age 65+ discussed medications. Results were unchanged after adjusting for socio-demographics and comorbidity. CONCLUSIONS: Delivery of goal-concordant care relies on understanding the needs of individual patients. Lower rates of discussing what matters and mood represent potential missed opportunities to deliver age-friendly care for older veterans.

The hospital care experiences of older patients compared to younger patients.

BACKGROUND: Hospitals may provide less positive patient experiences for older than younger patients. METHODS: We used 2019 HCAHPS data from 4358 hospitals to compare patient-mix adjusted HCAHPS Survey scores for 19 experience of care items for patients ages 75+ versus 55-74 years and tested for interactions of age group with patient and hospital characteristics. We contrasted the age patterns observed for inpatient experiences with those among respondents to the 2019 Medicare CAHPS (MCAHPS) Survey of overall experience. RESULTS: Patients 75+ years (31% of all HCAHPS respondents) reported less-positive experiences than those 55-74 (46% of respondents) for 18 of 19 substantive HCAHPS items (mean difference -3.3% points). Age differences in HCAHPS top-box scores were large (>5 points) for 1 of 3 Nurse Communication items, 1 of 3 Doctor Communication, 2 of 2 Communication about Medication items, 1 of 2 Discharge Information items, and 2 of 3 Care Transition items. In contrast, for MCAHPS, those 75+ reported similar experiences to younger adults. The magnitude of age differences varied considerably across hospitals; some hospitals had very large age disparities for older patients (age 75+ vs. ages 55-74), while others had none. These age differences were generally smaller for patients in government and non-profit than in for-profit hospitals, and in the Pacific region than in other parts of the United States. This variation in age disparities across hospitals may help to identify best practices. CONCLUSIONS: Patients ages 75+ reported less-positive experiences than patients ages 55-74, especially for measures of communication. These differences may be specific to inpatient care. Further study should investigate the effectiveness of hospital staffs' communication with older patients. Hospital protocols designed for younger patients may need to be adjusted to meet the needs of older patients. There may also be opportunities to learn from outpatient interactions with older patients.

Standardized assessment of medication reconciliation in post-acute care.

BACKGROUND: Medication reconciliation (MR) facilitates safety during transitions of care, which occur frequently across post-acute care (PAC) settings. Under the intent of the IMPACT Act of 2014, the Centers for Medicare & Medicaid Services contracted with the RAND Corporation to develop and test standardized assessment data elements (SADEs) that assess the MR process. METHODS: We employed an iterative process that incorporated stakeholder input and three rounds of testing to identify, refine, and evaluate MR SADEs. Testing took place in 186 PAC sites (57 home health agencies, 28 inpatient rehabilitation facilities, 28 long-term care hospitals, and 73 skilled nursing facilities). There were 2951 patients in the final test. Novel MR SADEs, based on the Joint Commission's framework, were refined. The final SADEs assessed whether: patient was taking high-risk medications; an indication was noted for each medication class; discrepancies were identified; patient or family/caregiver was involved in addressing discrepancies; discrepancies were communicated to physician (or designee) within 24 h; recommended physician actions regarding discrepancies were implemented within 24 h after physician response; and the reconciled list was communicated to patient, prescriber, and/or pharmacy. Two assessors per facility collected data for each patient. Analyses described completion time, data missingness, and interrater reliability, as well as feedback on assessor burden. RESULTS: Time to complete the MR SADEs was 3.2 min. Missing data were <5%. Interrater reliability was moderate to high (κ: 0.42 [whether a reconciled list was communicated to prescribers] to 0.89 [identifying patients taking hypoglycemics]). For identifying high-risk medication classes, interrater reliability was high (κ: 0.72-0.89). There were minimal differences by setting. CONCLUSIONS: This is the first set of MR SADEs that have been assessed across the PAC settings. Results demonstrate feasibility, based on missing data and completion time, and moderate to strong reliability, based on interrater comparisons, of assessing MR.

Who receives post-acute care? Characteristics of national population and field test sample.

BACKGROUND: Each year millions of Medicare beneficiaries in the United States receive post-acute care (PAC) in skilled nursing facilities (SNFs), inpatient rehabilitation facilities (IRFs), long-term care hospitals (LTCHs), and home health agencies (HHA). We describe, overall and by PAC setting, the national population of facilities and patients, evaluate the representativeness of a national field test sample, and describe patient characteristics in the national field test sample. METHODS: We analyzed the 2016 Provider of Service file, 2016 patient assessment data reported by PAC providers to Centers for Medicare & Medicaid, and data collected from PAC providers participating in a national field test. National data included 27,234 PAC settings and 5,033,820 beneficiaries receiving PAC. The national field test sample consisted of 143 facilities across 14 markets with 25-30 patients sampled from each facility (n = 3669). We describe PAC facility and patient characteristics for both the national and field test sample. RESULTS: Nationally, PAC facilities were more likely for-profit versus not for-profit, have an average nurse-to-bed ratio between 1:10 to 1:1 (lowest in SNFs) and be in metropolitan versus other areas. PAC patients were more likely to be white, female, and 75-89 years of age; heart failure as a primary medical condition tended to be more common than stroke or sepsis. There was limited variability across setting types. In the national field test, patients in LTCHs demonstrated a greater likelihood of cognitive impairment, positive depression screening, bowel and bladder appliance use, higher rates of medication drug classes taken, and use of therapeutic diets and IV medications. CONCLUSION: The national field test facility and patient samples were fairly representative of the national population overall and across settings with a few exceptions. Moreover, differences according to PAC setting on patient characteristics in the national field test aligned with general differences in patient populations.

Development and testing of a standardized pain interview assessment for use in post-acute care.

OBJECTIVES: Pain is highly prevalent among patients in post-acute care (PAC) settings and can affect quality of life, treatment outcomes, and transitions in care. Routine, accurate assessment of pain across settings is important for pain management and care planning; however, existing PAC assessment instruments do not assess patient pain in a standardized manner. METHODS: We developed and tested a set of pain interview data elements for use across PAC settings (skilled nursing facilities, inpatient rehabilitation facilities, long term care hospitals, home health agencies) as part of a larger effort undertaken by the Centers for Medicare & Medicaid Services to develop standardized assessment data elements to meet the requirements of the IMPACT Act of 2014. The interview assessed six pain constructs: presence; frequency; interference with sleep; interference with rehabilitation therapies [if applicable]; interference with daily activities; worst pain; and pain relief from treatments/medications). A total of 3031 PAC patients at 143 PAC settings (across 14 U.S. geographic/metropolitan areas in 10 states) participated in a national field test of standardized data elements from November 2017 to August 2018. We assessed item response distributions, time to complete interviews, inter-assessor agreement, and, for a subset of patients, change in responses between admission and discharge assessments. We also conducted focus groups with nurse assessors about their experiences administering the items. RESULTS: For patients reporting any pain, average time to complete the pain interview was 3.1 min (SD = 1.3), and interrater reliability was excellent for all data elements (kappa range: 0.95-0.99). Findings were similar across types of PAC settings. Qualitative data from nurses emphasized ease of administration and high perceived clinical utility. CONCLUSION: Findings provide support for feasibility of implementing a standardized pain interview assessment in PAC settings. This tool can support tracking of patient needs across settings and interoperability of data in electronic medical records.

Standardized assessment of cognitive function of post-acute care patients.

BACKGROUND: The assessment of cognitive function in post-acute care (PAC) settings is important for understanding an individual's condition and care needs, developing better person-directed care plans, predicting resource needs and understanding case mix. Therefore, we tested the feasibility and reliability of cognitive function assessments, including the Brief Interview for Mental Status (BIMS), Confusion Assessment Method (CAM©), Expression and Understanding, and Behavioral Signs and Symptoms for patients in PAC under the intent of the IMPACT Act of 2014. METHODS: We conducted a national test of assessments of four standardized cognitive function data elements among patients in PAC. One hundred and forty-three PAC settings (57 home health agencies, 28 inpatient rehabilitation facilities, 28 long-term care hospitals, and 73 Skilled Nursing Facilities) across 14 U.S. markets from November 2017 to August 2018. At least one of four cognitive function data elements were assessed in 3026 patients. We assessed descriptive statistics, percent of missing data, time to complete, and interrater reliability between paired research nurse and facility staff assessors, and assessor feedback. RESULTS: The BIMS, CAM©, Expression and Understanding, and Behavioral Signs and Symptoms demonstrated low rates of missing data (less than 2%), high percent agreement, and substantial support from assessors. The prevalence of Behavioral Signs and Symptoms was low in our sample of PAC settings. CONCLUSION: Findings provide support for feasibility of implementing standardized assessment of all our cognitive function data elements for patients in PAC settings. The BIMS and CAM© were adopted into federal Quality Reporting Programs in the fiscal year/calendar year 2020 final rules. Future work could consider implementing additional cognitive items that assess areas not covered by the BIMS and CAM©.

Standardized assessment of cognitive function, mood, and pain among patients who are unable to communicate.

BACKGROUND: Assessments of patients have sought to increase the patient voice through direct patient interviews and performance-based testing. However, some patients in post-acute care (PAC) are unable to communicate and cannot participate in interviews or structured cognitive tests. Therefore, we tested the feasibility and reliability of observational assessments of cognitive function, mood, and pain for patients who are unable to communicate in PAC settings. METHODS: We conducted a national test of observational assessments of cognitive function, mood, and pain in 143 PAC facilities (57 home health agencies, 28 Inpatient Rehabilitation Facilities, 28 Long-Term Care Hospitals, and 73 Skilled Nursing Facilities) across 14 U.S. markets from November 2017 to August 2018. For the 548 patients identified as unable to make themselves understood, we assessed descriptive statistics, percent of missing data, time to complete, and inter-rater reliability (IRR) between paired research nurse and facility staff assessors. RESULTS: Most sampled non-communicative patients were administered all three observational assessments. Among assessed patients, overall missing data was high for some items within the Staff Assessment for Mental Status (2.9% to 33.5%) and Staff Assessment of Patient Mood (12.4% to 44.3%), but not the Observational Assessment of Pain or Distress (0.0% to 4.4%). Average time to complete the data elements ranged from 2.4 to 3.5 min and IRR was good to excellent for all items (kappa range: 0.74-0.98). CONCLUSION: The three observational data elements had acceptable reliability. Although results revealed varying feasibility, there was support for feasibility overall in terms of implementing a standardized observational assessment of pain for patients in PAC settings. Additional work is needed for the Staff Assessment for Mental Status and the Staff Assessment of Patient Mood to improve the observable nature of these data elements and enhance instructions and training for standardizing the assessments.

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

BACKGROUND: 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. METHOD: 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. RESULTS: 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. CONCLUSIONS: 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.

Standardized assessment of depression symptoms in post-acute care: A screening threshold approach.

BACKGROUND: Depression symptoms have impacts on quality of life, rehabilitation and treatment adherence, and resource utilization among patients in post-acute care (PAC) settings. The PHQ-2 and PHQ-9 are instruments for the assessment of depression, previously used in PAC settings, that have tradeoffs in terms of measurement depth versus respondent/assessor burden. Therefore, the present study tested a gateway version of the protocol (PHQ-2 to 9). METHODS: In 143 PAC settings in 14 U.S. markets across 10 states from November 2017 to August 2018, facility and research nurses administered the PHQ-2 to communicative patients (n = 3010). Nurses administered the full PHQ-9 if the patient screened positive for either of the two cardinal symptoms assessed by the PHQ-2 (depressed mood and anhedonia). We assessed the prevalence and frequency of depression symptoms using the PHQ-2 to 9, associations between depression screening results and patient characteristics and clinical conditions, and feasibility indicators. RESULTS: More than 1 in 4 patients (28%) screened positive on the PHQ-2. Only 6% of those completing the full PHQ-9 had a score indicating "minimal" severity. The average score (M = 11.9) met the threshold for moderate depression. Positive PHQ-2 screening was associated with age, female gender, disposition at discharge, septicemia/severe sepsis, and dependence for ADLs of toileting and lying to sitting mobility. Age was also associated with full PHQ-9 scores; patients ages 45-64 had the highest mean score. Length of stay was not associated with PHQ-2 screening results or full PHQ-2 to 9 scores. Missing data were minimal (<2.4%). The average time to complete was 2.3 min. Interrater reliability and percent agreement were excellent. CONCLUSIONS: These findings suggest the feasibility of a gateway scoring approach to standardized assessment of depression symptoms among PAC patients, and that depression symptoms are relatively common among this inpatient population.