Tuesday, 27 September 2016 05:25

What Impact Will the IMPACT Act Have? Depends on What We Do Now

Written by Robert Latz, PT, DPT, CHCIO

The first sentence of the Improving Medicare Post-Acute Care Transformation Act (IMPACT Act) of 2014 includes the following language: “for standardized post-acute care assessment data for quality, payment, and discharge planning, and for other purposes.” The legislation had strong bipartisan support and became law when signed by President Obama on Oct. 6, 2014. Although the document is short by legislative standards, at only 20 pages, the reach of this law is enormous.

Beginning Oct. 1, 2016, almost two years to the day after the legislation was enacted, many post-acute care providers finally will begin submitting data to comply with the law. Even more, the data provided during these first three months may affect their Medicare reimbursement for all of the 2018 fiscal year.  

The IMPACT Act names and directly affects four post-acute care (PAC) settings: inpatient rehabilitation facilities (IRFs), home health agencies (HHs), long-term care hospitals (LTCHs), and skilled nursing facilities (SNFs). Acute-care hospitals are not directly affected by the IMPACT Act. However, many believe that the acute settings might choose to adopt the standardized language to improve their discharge planning even further.

Recently, the Centers for Medicare & Medicaid Services (CMS) and a contractor, RAND Corporation, held a special open door forum for consumers on the IMPACT Act. With over 600 people listening in, they began by providing an overview of the Act and then opened the lines to listen and learn from attendees. They were hoping to hear ideas related to the kind of information that would be most valuable during transitions from one care setting to another, particularly as it pertained to improving care coordination. Although CMS received several good ideas, and it plans to hold additional calls in the future, if you have any suggestions or ideas related to this important topic, you may email them to This email address is being protected from spambots. You need JavaScript enabled to view it. .

A few of the questions and suggestions resulting from this call are summarized below. We follow these summaries with a discussion of the practical application of the IMPACT Act.

In response to one question related to the standardized data elements, Barbara Gage from the RAND Corporation shared that they are currently in a first phase of testing, and plans are in place for a second phase of testing in January. They are also outlining plans for a “full reliability test” of items that pass those first two phases. They expect that this will take place by the end of next summer.

In response to a suggestion that all ICD-10 Dx codes be provided at the time of discharge from the acute setting, the caller was directed to review the draft of the Hospital Conditions of Participation. Evidently, this idea is outlined therein.  

One important concern was shared by another caller who suggested that “moving to the lowest common denominator” of language might result in decreased quality of care. Charlayne Van from CMS agreed that this is a risk. For this reason, CMS is proceeding as slowly as they can, given the constraints of the timeline provided in this legislation. Even so, many agree that there is great opportunity in finding a common language and still allowing each provider setting to utilize additional assessment tools for their setting.

Another caller asked for greater transparency of information, especially for NH admissions in the prior 365 days. The suggestion was to create a single database with continuity of care documents (CCDs), claims data, and a discharge summary that is also HIPAA-compliant and easy to access. The example provided was the instance of a pneumococcal vaccine given two years ago (good for five years) that does not show up in data from an episode of the past 90 days. Without this information, there is unnecessary duplication of care. The CMS reps shared that they are working on this.

Most of the rest of the questions were related to learning more about the IMPACT Act itself. For this reason, the rest of this article is intended to focus on practical application of the IMPACT Act, with the hope that this might trigger additional suggestions for you to send to CMS.

The IMPACT Act requires ”standardized assessment data.” The availability of this data is expected to encourage interoperability, facilitate care coordination, improve discharge planning, and allow for comparison of quality across PAC settings. In addition, CMS expects to use findings from this data to create or modify future alternative payment models.

Within the legislation, there are several “categories” or domains identified as required for this standardized data. These include function (self-care and mobility); cognitive function and mental status; special services, treatments, and interventions; medical conditions and co-morbidities; impairments; and other categories. These domains are being used to better measure the complexity of an individual’s condition, which will provide three key capabilities: a) allow better determination of resource needs; b) create enhanced ability to monitor outcomes; and c) influence methods to pay providers equitably.

In my opinion, the IMPACT Act creates an opportunity for providers. The opportunity is to identify and verify the health status of an individual as they transition from one setting to another. As referenced by the speakers of this forum, a standardized terminology will allow one to measure patient complexity at any point in time during any stay at any PAC setting and, potentially, in the acute setting as well.

In short, 20 percent of Medicare fee-for-service (FFS) beneficiaries are admitted to an acute-care hospital each year. Of this number, 42 percent will then transfer to at least one PAC setting, and a substantial number will use two or more PAC services during a single episode of care.  

IF we have a standardized set of data, we can then communicate across the continuum, and during this episode. We can evaluate changes in status from admission to discharge, measure costs more equitably, and set reimbursement accordingly. Ultimately, as stated by the forum speakers, CMS hopes to learn if similar patients are being discharged to different types of PAC settings. If they are, then we can learn if outcomes for these similar patients differ by the type of PAC used.

In addition, if we are using a similar set of language, we can improve communication with PAC liaisons about patient complexity before the transfer even occurs. This can allow the receiving PAC setting to better prepare for the arriving resident. An agreed-upon, standardized language might also reduce the current delay in transfer of information about the patient’s medical status, functional status, cognitive status, and care preferences.

For clarification, currently there are standards for CCDs. And in fact, some organizations are using these documents. However, when we utilize different words or tools to assess an individual as he or she moves through the continuum of care, we still may have communication problems.

For a moment, let’s consider Ms. Smith, a resident of an assisted living facility (ALF) who has a fall resulting in a hip fracture. Because of this, she is admitted to a hospital. Upon discharge from the hospital, Ms. Smith might go to a SNF. The SNF might even be on the same campus as the ALF. Ms. Smith might be at the SNF until she improves enough to return to her home at the ALF. Even then, she might still need home healthcare services.

In each of these transitions from one setting to another, the information about Ms. Smith needed by the receiving facility might be different from the information initially provided by the sending facility. This is not intentional. Instead, it is based on the types of care provided in each setting and the language of the services provided. For instance, in an ALF, the goal is for less of a medical presence and more of a normal home routine. With this in mind, the documentation requirements are very different from those of the hospital. This results in the sending facility (the ALF, in this case), might send historical data related to prior medical conditions. Instead, the hospital might be looking for immediate information from the past 24 hours.

Also, the goal of the hospital setting is different from that of the ALF. For instance, in the ALF, the goal is for the individual to be comfortable as they go about their normal life. Once the patient is transferred to the acute setting, the goals are to keep the person alive, stabilize them, and then transition them to another care setting. In the SNF setting, the goal is to return patients to a state in which they are as functional as possible. In other words, once a patient is stabilized, the goal is less about keeping the person alive and more about giving them a life to live. The focus changes to improving functional ability so the individual can return to normal activities, in this case moving back to their home at the ALF.

Carrying this example a step further, it is as if a different language is being spoken in each care setting. For instance, the ALF speaks a version of French; the acute setting speaks a version of Spanish; and the SNF setting speaks a version of German. Each language works for the specific requirements of that setting, but when a person transitions from one setting to another, the translations don’t always work as well as we would all like.

Returning to the IMPACT Act, as mentioned, the intention is to create a standardized set of data. This would create a consistent language that can be used across all settings. So, continuing with the analogy above, we are trying to use consistent terms (maybe all in a version of Latin) that have the same definition in each setting for certain specific data elements. In essence, we are all agreeing to use this Latin and agreeing on definitions of the Latin words (data elements). This standardized set of data can then be shared more easily and can even be analyzed to improve quality even further, especially during these transitions of care.

The bottom line is that CMS is now looking for your wisdom. They recognize the need for information from you, and this is your chance to make a very positive difference on a very important topic. Write now to This email address is being protected from spambots. You need JavaScript enabled to view it. and make that difference.

About the Author

Robert Latz is the only physical therapist in the United States to complete the requirements to receive the HealthCare CIO certification from CHIME (College of Health Information Management Executives). Dr. Latz received his bachelor’s degree in physical therapy from the University of Montana and his doctorate in physical therapy from Boston University. Dr. Latz is active with the APTA (American Physical Therapy Association) as the chair of the Technology Special Interest Group of the Health Policy and Administration Section. In addition, he is a member of the Orthopedic, Home Health, and Geriatric sections. Within NASL (the National Association for the Support of Long-Term Care), he is the co-chair of the IMPACT Act Implementation Workgroup and an active member of the Information Technology Committee. Currently, Dr. Latz is the chief information officer for Trinity Rehabilitation Services, which improves human function by providing contracted therapy services in post-acute care settings. He is also the CIO for Passage Healthcare, which owns three campuses providing elder care services.

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Last modified on Tuesday, 27 September 2016 05:56