Get Ready for IMPACT New Medicare regulations require a more extensive assessment of patients, and SLPs may be called on to help. Here’s what you need to know. Policy Analysis
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Policy Analysis  |   February 01, 2017
Get Ready for IMPACT
Author Notes
  • Sarah Warren, MA, is ASHA director of health care regulatory advocacy. swarren@asha.org
    Sarah Warren, MA, is ASHA director of health care regulatory advocacy. swarren@asha.org×
Article Information
Regulatory, Legislative & Advocacy / Policy Analysis
Policy Analysis   |   February 01, 2017
Get Ready for IMPACT
The ASHA Leader, February 2017, Vol. 22, 26-27. doi:10.1044/leader.PA1.22022017.26
The ASHA Leader, February 2017, Vol. 22, 26-27. doi:10.1044/leader.PA1.22022017.26
You’re a speech-language pathologist in a skilled nursing facility (SNF), and for several months you’ve been required to complete parts of the Minimum Data Set (MDS)—the standard assessment tool for facility residents. The MDS had always been the responsibility of the nursing staff, and you’re not sure why you’re being pulled from clinical care to help.
This change—seen not only in SNFs but also in home health agencies (HHAs), inpatient rehabilitation facilities (IRFs) and long-term care hospitals (LTCHs)—stems from a provision in the 2014 Improving Post-Acute Care Transformation (IMPACT) Act that requires these four types of facilities to collect standardized data in their patient assessments.
The goal is to provide data that the Centers for Medicare and Medicaid Services (CMS) can use to more effectively compare quality and cost across post-acute care settings.
To conform with the requirement to collect certain standardized data, CMS added new and expanded sections to the existing standardized assessments for each setting (see box below). Only nurses, SLPs, physical therapists and occupational therapists may complete these assessment tools—historically most often completed by nurses—but the changes have left many facilities scrambling to avoid penalties by ensuring that assessments are thoroughly and accurately completed.

To conform with the requirement to collect certain standardized data, CMS added new and expanded sections to the existing standardized assessments for each setting.

Changes
Before IMPACT took effect in October 2016, some facilities did not collect certain types of assessment data. In addition, each setting collected data on quality domains, such as functional status, in different ways. IMPACT requires standardized assessment data for several quality domains, with varying implementation dates:
  • Functional status, cognitive function, and changes in functional status and cognitive function (IRFs and SNFs: in effect; LTCHs: Oct. 1, 2018; home health: Jan. 1, 2019).

  • Skin integrity and changes in skin integrity (in effect in all settings).

  • Medication reconciliation (home health: in effect; IRFs, SNFs and LTCHs: Oct. 1, 2018).

  • Incidence of major falls (IRFs, LTCHs and SNFs: in effect; home health: Jan. 1, 2019).

  • Accurately communicating the existence of and providing for the transfer of health information and care preferences (IRFs, SNFs and LTCHs: Oct. 1, 2018; home health: Jan. 1, 2019).

  • Resource use (in effect in all settings).

The addition of standardized items for functional status associated with self-care and mobility increased an assessment tool from eight to 18 pages in one year.

Impact
CMS has made significant progress in implementing the changes, but the provider burden associated with collecting this data has increased significantly. The addition of standardized items for functional status associated with self-care and mobility, for example, increased the IRF assessment tool from eight to 18 pages in one year.
The financial implications associated with these requirements are significant. Each setting is subject to a data-completion threshold for the quality sections of its assessment tool. Failure to meet the threshold incurs a 2-percent payment reduction.
As a result of these financial implications, ASHA members report that facilities are asking clinical staff, including SLPs, to complete the sections of the assessment tool clinically relevant to their specialty.
The data completion thresholds are as follows:
  • IRF: 95 percent of IRF-PAI quality-assessment data and 100 percent of quality data reported through the Centers for Disease Control’s National Health Safety Network (CDC-NHSN).

  • SNF: 80 percent of MDS quality assessment data, effective fiscal year 2018 (Oct. 1, 2017–Sept. 30, 2018).

  • LTCH: 80 percent of LTCH-CARE data and 100 percent of CDC-NHSN data.

  • HHA: Not yet established.

Anecdotally, ASHA members are identifying the sections of MDS Section GG (functional abilities and goals) related to eating as an area they have been asked to help complete. In some instances, they are asked to complete a full evaluation on the patient for this purpose. SLPs should not be asked to conduct a full swallowing evaluation merely for the purpose of completing the MDS. A full swallowing evaluation should be conducted only if there is a clinical reason to do so and if the skills of an SLP are required.
Training materials
Clinicians in these facilities often have little explanation about or training on completing the assessments. In response, CMS has developed resource centers that include quality reporting training materials for each of the assessment tools:
Assessment Tools: Why and What

The Centers for Medicare and Medicaid Services (CMS) requires clinical assessment of all patients in post-acute care facilities as part of the Medicare prospective payment system for each facility type. The assessment information is used to place each patient into a diagnostic group that, in turn, determines the payment for that patient’s episode of care.

Each facility type uses a different assessment tool. The tools do not necessarily collect the same types of data, nor do they measure all domains—such as functional status—in the same way. IMPACT requires certain standardized data be included in all of the tools so that CMS can compare quality and cost across settings.

IMPACT has led to changes in these assessments:

  • Skilled nursing facilities—Minimum Data Set (MDS)

  • Inpatient rehabilitation facilities—Inpatient Rehabilitation Facility Patient Assessment Instrument (IRF-PAI)

  • Long-term care hospitals—Long-Term Care Hospital Continuity Assessment Record Evaluation (LTCH-CARE)

  • Home health agencies—Outcome and Assessment Information Set (OASIS)

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February 2017
Volume 22, Issue 2