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Documentation in Long-Term and Home Healthcare Setting01:29

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The two sources for collecting information are primary and secondary. After gathering information, interpretation and validation help to complete the data. The purpose of assessment is to establish data with the initial information, to interpret data about the patient's perceived needs and health problems, and to respond to these problems identified.
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Developing standardized patient assessment data elements for Medicare post-acute care assessments.

Emily K Chen1, Maria O Edelen2,3, Tara McMullen4

  • 1RAND Corporation, Arlington, Virginia, USA.

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|March 2, 2022
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Summary

The Improving Medicare Post-Acute Care Transformation Act (IMPACT Act) mandated standardized patient assessment data (SADEs) for interoperability. This study developed feasible and reliable SADEs for post-acute care settings, focusing on pain, cognition, mood, and medication reconciliation.

Keywords:
IMPACT Act of 2014interoperabilitypost-acute carestandardized patient assessment data elements

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Area of Science:

  • Health Services Research
  • Health Informatics
  • Patient Assessment

Background:

  • The Improving Medicare Post-Acute Care Transformation Act (IMPACT Act) of 2014 mandates standardized patient assessment data elements (SADEs) for interoperability.
  • Centers for Medicare & Medicaid Services (CMS) was tasked with developing these SADEs across clinical categories.

Purpose of the Study:

  • To develop and validate standardized assessment data elements (SADEs) for post-acute care (PAC) settings.
  • To ensure these SADEs support interoperability and care planning across different provider types.

Main Methods:

  • Utilized environmental scans, expert input, and stakeholder engagement to identify candidate SADEs.
  • Conducted alpha and national field testing across PAC settings (home health, IRF, LTCH, SNF) with 3121 patients.
  • Employed mixed-methods approach, analyzing quantitative data (time, completion, reliability) and qualitative feedback.

Main Results:

  • Successfully developed feasible and reliable SADEs for PAC settings.
  • Identified key areas for assessment: pain, cognitive status, mood, and medication reconciliation.
  • Demonstrated the value of iterative, multi-stakeholder collaboration in SADE development.

Conclusions:

  • The developed procedures for SADE creation and adoption offer a model for future health data element development.
  • Highlighting challenges and strategies encountered is crucial for future quality measure development.
  • Iterative work with diverse stakeholders and mixed-methods evidence are key to successful SADE implementation.