Health Care Management: Medicare and Medicaid


Quality care delivery is a priority for Centers for Medicare & Medicaid Services (CMS). Various initiatives launched aim at assuring quality care for all people through increased accountability and transparency. These quality initiatives primarily focus on enhancing quality measures in hospitals, nursing homes, and other health facilities. Successful quality initiatives are dependent on collaboration between many healthcare practitioners and researchers. In essence, the main objective of the CMS quality initiatives is to enhance quality care to Medicare beneficiaries in the wake of rising concerns over care quality under the Medicare and Medicaid programs (CMS, 2010, p. 342). A clinical quality initiative entails a methodology for evaluating the quality and safety of the clinical services offered to a patient at an appropriate time.

Quality initiatives provide information about the quality of patient care, which drives reforms in the healthcare to achieve optimal patient outcomes. Thus, the quality initiatives help to ensure that quality patient care is delivered to achieve optimal patient satisfaction. To improve patient care, the quality initiatives have to be evaluated appropriately to inform the providers and the beneficiaries on the best policy decisions. Among the CMS quality initiatives, is the Post Acute Care (PAC) and it primarily concerns the care provided to patients recovering from serious medical procedures or chronic illnesses (CMS, 2010, P. 351). The increased fragmentation of healthcare, inadequate safety of care transitions and the challenge of determining the cost-effective settings for PAC patients are because of lack of a coordinated patient assessment mechanism. An effective assessment instrument integrated within PAC systems would cover a large spectrum of patients across many care settings including Metropolitan Jewish Health System (MJHS). The assessment instrument should be an integrated mechanism relying on real-time data for the assessment.

The Goal of the PAC Assessment Instrument

The absence of a uniform patient assessment tool coupled with healthcare fragmentation and unsafe transitions for PAC patients raises much concern over the quality of care given. In addition, the mechanism of determining the cost-effective care and care settings for patients discharged to PAC is often problematic.

This proposal provides various recommendations that MJHS can use to develop an assessment tool for evaluating the PAC patient care needs after discharge from a hospital. The goal of the assessment tool will specifically cover inpatients admitted to PAC facilities such as MJHS nursing home. The main aims of this PAC assessment tool will be to aid in decision-making over patient care needs, enhance the quality and the safety of care during transitions by ensuring access to essential information by the receiving provider, and facilitate health follow-up for PAC patients (Jette, & Haley, 2010, p. 342).

The Development of the Patient Assessment Instrument

For MJHS, the assessment instrument will provide information on the care needs of prospective patients and the best standards of practice. In this way, necessary measures to improve quality care and meet the patient needs can be implemented. The instrument will serve to assess the level of care needed for the beneficiaries of PAC services from this care facility. To develop a uniform care assessment instrument, various parameters will be taken into account. The proposed care assessment instrument will be able to measure patient care needs, resources requirement and the care plan for the patient. Currently, various assessment tools are available for PAC that applies specially for Medicare beneficiaries such as OASIS and MDS (Jette, Haley, & Ni, 2008, p. 15). However, these instruments do not cover a large spectrum of patients across multiple care settings. In developing the new assessment instrument, the current instruments as well as other quality measures will be combined to develop a single functional assessment.

Additionally, the assessment instrument will be able to offer relevant information regarding the most suitable care plan and assess the resource requirement of the PAC for effective CMS reimbursement. To ensure that the instrument serves many PAC patients, the instrument will be web-based to access data from multiple care settings. In this way, it will be easy to incorporate data and health information such as specified records of acute care episodes, and pharmaceutical records essential for optimal PAC (Guterman et al., 2009, p. 117). In this context, the instrument will primarily involve the health information system of Metropolitan Jewish Health System and the hospital. The new instrument, being web-based, will eventually replace the existing assessment instruments at the hospital.

The patient assessment instrument will also be useful in evaluating the patient care needs to ensure quality and cost-effective care. Specifically, a patient care coordinator will administer the assessment instrument before the patient receives care. In this way, the practitioners can give appropriate care to achieve good patient outcomes. Furthermore, for patients seeking PAC services without prior hospitalization, the assessment instrument administered by the care coordinator will help in the evaluation of his or her care needs. Using an integrated assessment instrument, the care coordinator can identify the specific patient care needs and meet them.

Various PAC assessment instruments are available: the item Response Theory (IRT), Activity-Measure for PAC (AM-PAC) and the Computer Adaptive Technology (CAT). However, all these instruments have a limited scope and cannot be used across many care settings (Glass, & Stensland, 2009, P. 80). Other uniform assessment instruments available can cover many settings but do not yield accurate measures of all patients in the selected domains. Thus, an integrated approach that assesses discharge planning, care transitions as well as assessing the outcome based on data from different sources is essential. The uniform PAC assessment instrument can be a pivotal mechanism for measuring the care quality based on patient outcomes.

The PAC assessment instrument will also be valuable for development of a care plan MJHS. It will provide essential information for the development of a care plan and in discharge or re-admission decisions. In addition, the instrument will assess the quality indicators of MJHS and the patient outcomes based on care given. Since the assessment instrument is web-based, it will serve to collect and analyze data to determine care needs to calculate the PAC payment rates for Medicare beneficiaries.

The Staff to implement the PAC Assessment Instrument

The implementation of the assessment instrument will involve a care coordinator. The care provider, who in this case, will be Metropolitan Jewish Health System, will perform the care coordinator’s role. The care coordinator’s roles may involve carrying out the initial patient assessment to facilitate placement of the patient from a hospital setting to a PAC provider, developing, and implementing the patient plan of care during admission. The health information specialists will also be beneficial in collecting and analyzing patient data through the electronic health records (EHR). The nurses and other practitioners in MJHS will play a significant role in providing the specific patient information into the assessment instrument.

The affected care agencies following the implementation of the integrated assessment instrument will include the providers that offer access to PAC outside the MJHS. These include the care facilities that offer inpatient rehabilitation, nursing homes and home health facilities (Coster, Haley, & Jette, 2009, P. 772). In addition, the Medicare systems will also be affected by the new PAC system, as the instrument will determine the payment and coverage of the program.

Skills necessary for the Change Process

The care practitioners at MJHS will have the necessary skills to access relevant patient information and integrate it into the Metropolitan Jewish Health System assessments. The software technology for the assessment instrument will be refined to ensure efficient transmission and receipt of the assessment. All the care quality measures for PAC will also be refined to ensure an efficient and functional assessment of the PAC settings.

The patient responses with regard to the care given will be compared with proxy items responses to determine the quality of PAC offered at MJHS. In addition, during the implementation of the assessment instrument, investigation of the care transitions from one practitioner to another will take place to determine the ways of improving the care quality and patient safety. Outcome measures, determined by the examination of the various patient care conditions and episodes, will be an indication of the effectiveness MJHS PAC, with regard to care delivery. By using a uniform assessment instrument that coordinates discharge, informs the other receiving PAC providers and assess the cost-effectiveness of the care, CMS will be able to evaluate the cost, as well as the care quality for patient across PAC settings.


The issue of a fragmented care delivery system, coupled with concerns over care quality and safety of care transitions for PAC episodes, is a serious challenge that faces CMS. However, a uniform PAC assessment instrument that aids in assessment of PAC patient care needs will enhance the quality and safety of the care given by PAC settings such as MJHS.

Reference List

Centers for Medicare and Medicaid Services. (CMS). (2010). Medicare and Medicaid Programs; Electronic Health Record Incentive Program: Final Rule. Federal Register, 75(144) 314-355.

Coster, W., Haley, S., & Jette, A. (2009). Measuring patient-reported outcomes after Discharge from inpatient rehabilitation settings. Journal of Rehabilitation Medicine, 20(6), 771-774.s

Glass, D., & Stensland, J. (2009). Accountable Care Organizations. MedPAC, 79-81.

Guterman, S., Davis, K., Schoen, C., & Stremikis, K. (2009). Reforming Provider Payment: Essential Building Block for Health Reform. The Commonwealth Fund Commission on a High Performance Health System, 114-117.

Jette, A., Haley, S., & Ni, P. (2008). Comparison of functional status tools used in post-Acute care. Health Care Financing Review, 24(3), 13-24.

Jette, M., & Haley, S. (2010). Contemporary measurement techniques for rehabilitation Outcomes assessment. Journal of Rehabilitation Medicine, 37(6), 339-345.

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