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Advanced Illness and Post-Acute Care

With its focus on improving quality of life, advanced illness and/or post-acute care are distinct from care intended to cure an illness or condition, although it can be delivered concurrently with curative therapies. Advanced illness care focuses on medical care for people living with a serious illness. It aims to address the symptoms or stress related to the illness and improve the overall experience and/or quality of life for patients, caregivers, and family members. Advanced illness care may also include palliative and hospice care, which includes comprehensive care that addresses medical, emotional, spiritual, and social needs during the last stages of a person’s terminal illness.

 

Post-acute care includes medical or supportive care provided to individuals after leaving an acute care setting, such as a hospital, but they are not ready to return home. This includes rehabilitation and even palliative care services.

 

The Advanced Illness and Post-Acute Care committee considers measures that address post-acute care and advanced illness, including cancer and end-stage disease (e.g., end-stage renal disease). Subtopics may include advanced illness management, the assessment of physical, emotional, social, psychological, and spiritual aspects of care, access to and timeliness of care, patient and family experience with care, patient and family engagement, care planning, hospice care, palliative and end-of-life care, chemotherapy, rescue, and intensive care unit (ICU) care.

Valid for Measure Submission

Continuity of Care After Inpatient or Residential Treatment for Substance Use Disorder

The Continuity of Care After Inpatient or Residential Treatment for Substance Use Disorder measure evaluates the percentage of discharges from inpatient or residential treatment for diagnoses of substance use disorders (SUD) among Medicaid or Medicare-Medicaid beneficiaries, aged 18 years and older, which were followed by a treatment service for SUD.

CBE ID
3453

CoreQ: AL Family Satisfaction Measure

The measure calculates the percentage of family or designated responsible party for assisted living (AL) residents who are satisfied. This consumer reported outcome measure is based on the CoreQ: AL Family Satisfaction questionnaire that has three items.

CBE ID
3422

CoreQ: AL Resident Satisfaction Measure

The measure calculates the percentage of Assisted living (AL) residents, those living in the facility for two weeks or more, who are satisfied. This patient reported outcome measure is based on the CoreQ: AL Resident Satisfaction questionnaire that is a four-item questionnaire.

CBE ID
3420

Cross-Setting Discharge Function Score for Inpatient Rehabilitation Facilities

This outcome measure estimates the percentage of Inpatient Rehabilitation Facility (IRF) Medicare patient stays that meet or exceed an expected discharge function score. The expected discharge function score is a risk-adjusted estimate that accounts for patient characteristics. The measure includes patients who are 18 years of age or older and the timeframe for the measure is 12 months.

CBE ID
4630

Cross-Setting Discharge Function Score for Long-Term Care Hospitals

This outcome measure estimates the percentage of Long-Term Care Hospital (LTCH) patient stays that meet or exceed an expected discharge function score. The expected discharge function score is a risk-adjusted estimate that accounts for resident characteristics. The measure includes patients 18 years of age or older and the measure timeframe is 12 months.

CBE ID
4635

Cross-Setting Discharge Function Score for Skilled Nursing Facilities

This outcome measure estimates the percentage of Medicare Part A skilled nursing facility stays that meet or exceed an expected discharge function score. The expected discharge function score is a risk-adjusted estimate that accounts for resident characteristics. The measure includes patients who are 18 years of age or older and the measure timeframe is 12 months.

CBE ID
4640

Cross-Setting Discharge Function Score – for Home Health Agencies

This outcome measure estimates the percentage of Home Health (HH) Medicare patients (18+) who meet or exceed an expected discharge function score over a 12-month period.

The expected discharge function score is a risk-adjusted estimate that accounts for patient characteristics.

CBE ID
4645

E&M Advanced Illness and Post-Acute Care Advisory Group Meeting

The purpose of this meeting is for Advisory Group members to raise questions and share perspectives verbally regarding the measures under endorsement review for their respective E&M committee. No voting occurs during these virtual meetings. Rather, Advisory Group members will be asked to review the measures assigned to their respective committee and come to the meeting to ask questions and provide feedback regarding the strengths and limitations of the measures.