How to Measure Quality in Post-Acute Care

Published January 2, 2018

On October 6, 2014, President Obama signed into law the Improving Medicare Post-Acute Care Transformation (IMPACT) Act. The Act is focused on improving care coordination, continuity of care, and transparency across the continuum, particularly among Post-Acute Care (PAC) Providers.  This group includes skilled nursing facilities, long-term care hospitals, home health agencies, and inpatient rehabilitation facilities, all of which are possible post-discharge options for patients leaving acute care hospitals. The Centers for Medicare and Medicaid Services (CMS) adds that IMPACT aims to improve outcomes for Medicare beneficiary, provide access to longitudinal information to facilitate coordinated care, enable comparable data and quality across PAC settings, and to improve hospital discharge planning.

What is CMS measuring?

IMPACT measures five broad domains in patients discharged from acute care: skin integrity, particularly pressure ulcers that are frequent in bedridden patients; functional status, particularly cognitive function; medication reconciliation, as medication errors are a substantial cause of death and unplanned hospitalization; major falls, another major source of bad outcomes; and transfer of health information and care preferences when an individual transitions from one facility to another.

Home care agencies and long-term care facilities have been reporting outcomes data to CMS since October 2016. One year later, in October 2017, CMS began returning confidential performance evaluations to providers. This information is slated to become public in 2018.

Carrots and sticks

For skilled nursing facilities (SNFs), the stakes are high. According to Seniors Housing Business, CMS projects that implementation of IMPACT will cost each SNF an average of $40,685. The investment may be worth their while: reimbursement rates are scheduled to rise 2.1% in 2018. Failure to comply with reporting requirements will result in a 2% cut in reimbursements to SNFs.

Although not stated explicitly by CMS, all of the data generated from the five major domains will presumably be used by policy makers to create a set of best practices for post-acute care, with the aim of improving outcomes while simultaneously reducing costs. However, defining best practices requires accumulation of data. If nothing else, IMPACT will generate an enormous database that can be analyzed with tools made possible by the advent of machine learning algorithms. This database might house a gold mine: according to consulting giant McKinsey & Company, machine learning algorithms can generate on the order of $100B in value to the health care industry.

Improving what you measure

In the healthcare industry, it is a commonplace that one can only improve outcomes that are measured. If nothing else, IMPACT mandates creation of a great measurement tool. But the legislation promises to improve outcomes beyond preventing pressure ulcers and major falls. The mere act of paying attention to outcomes may help improve outcomes that IMPACT was not designed to measure, such as quality-of-life measurements, possibly even longevity. Nevertheless, IMPACT may create some pitfalls that the industry should be careful to avoid. The temptation to cut corners should be strenuously resisted. For example, compliance reporting should not become a scramble to fill in boxes on a work sheet, but rather should reflect actual benefits to patients. And since a large amount of funding is at stake, the risk of fraud looms in the future. It is hoped that the legislation will have a positive “impact.”