The uniform postacute assessment tool: systematically evaluating the quality of measurement evidence

The U.S. Congress has mandated that the Centers for Medicare & Medicaid Services develop a uniform assessment instrument that characterizes patients' needs for postacute services. What scientific criteria should be used to evaluate the evidence for such a tool? The validity of a measure can be accurately graded only if the constructs measured and their applications are clearly defined. We argue that improving postacute placement is the main purpose of the uniform postacute assessment (recently renamed the Continuity Assessment Record and Evaluation). We argue that placement itself needs to be better defined and measured in terms of transitions in the level and type of treatment and care. Domains that should be measured to provide appropriate rehabilitative placement recommendations include level of skilled medical and nursing care, therapies, routine living support, family support, ability to participate in self-care, and patient preference. Almost no research has been performed to quantify and predict the needed intensity of rehabilitative therapy, a major lacuna in evidence. Criteria and examples are provided for research that will provide minimal, probably adequate, or strong evidence for the validity of systems that recommend care transitions. A long-term program of research and systematic evidence synthesis is needed to support guidelines that improve postacute placement.