The Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT) amends Title XVIII of the Social Security Act by adding a new section – Standardized Post-Acute Care (PAC) Assessment Data for Quality, Payment, and Discharge Planning. The goal of the IMPACT Act is to reform PAC payments and reimbursement while ensuring continued beneficiary access to the most appropriate setting of care. The act requires the submission of standardized and interoperable PAC assessment and quality measurement data by Long-Term Care Hospitals (LTCH), Skilled Nursing Facilities (SNF), Home Health Agencies (HHA) and Inpatient Rehabilitation Facilities (IRF).

Post-Acute Care Assessment Data and Beneficiary Access

Standardized PAC assessment data will allow continued beneficiary access to the most appropriate setting; CMS can compare quality across PAC settings; allows improvements in hospital and PAC discharge planning and transfer of health information across the care continuum; and supports service and delivery reform. The Advancing Excellence in America’s Nursing Homes Campaign reported that it can cost $19,000 to treat a single Stage 4 pressure ulcer and considering data from 2009 and 2010, severe (Stage 3 and Stage 4) pressure ulcers acquired during a hospital stay were estimated to have increased CMS payments across 90-day episodes of care by at least $18.8 million annually.

October 2016 is the target date for LTCHs, IRFs, and SNFs to report standardized assessment data for the skin integrity and changes in skin integrity Quality Measure Domain. The quality measure addressing skin integrity is an Application of the National Quality Forum (NQF) endorsed Percent of Residents or Patients with Pressure Ulcers That Are New or Worsened (NQF #0678, Measure Steward: CMS). This quality measure reports the percent of patients/short-stay residents with Stage 2-4 pressure ulcers that are new or worsened since admission. The measure for SNF residents is restricted to the short-stay population (100 or fewer days in the SNF at the end of the measure time window). For SNFs, the measure is calculated by examining all assessments during an episode of care for reports of Stage 2-4 pressure ulcers that were not present or were at a lesser stage since admission. For LTCHs and IRFs, this measure reports the percent of patient stays with reports of Stage 2-4 pressure ulcers that were not present or were at a lesser stage on admission for all patients in LTCHs and is limited to Medicare (Part A and Part C) for IRF patients.

Quality of Care and Pressure Ulcer Prevention

The IMPACT Act's skin integrity quality measure reporting requires a team effort to prevent and heal pressure injuries (pressure ulcers). Registered dietitian nutritionists (RDN) should be a member of your wound care team or available to interact with the interdisciplinary team when an individual is screened to be at nutritional risk. Standardized, validated nutrition screening and assessment tools should be implemented so all patients/residents are evaluated using the same criteria.

The Malnutrition Screening Tool (MST) and the Mini-Nutrition Assessment (MNA) have been validated for adults and screen for appetite fluctuations and unintended weight loss. When individuals screened trigger nutritional risk, a referral to the RDN to complete a comprehensive nutrition assessment within 24-72 hours is critical. The nutrition assessment incorporates data and/or consultation from other clinicians on the team. The speech language pathologist is contacted when there are chewing and swallowing problems and the occupational therapist provides strategies to promote independence and proper positioning at meals. Communication with the patient/resident is important in our quest for positive outcomes. The individual and/or family should be consulted about any intervention considered and must understand why nutrition is important. Ordering a high calorie supplement that ends up sitting on the window ledge with the flowers will not promote weight gain or heal a wound.

The care-plan for individuals at risk of or with a pressure injury (pressure ulcers) should be individualized and interventions based on the 2014 NPUAP, EPUAP, and PPPIA nutrition guidelines should be considered. Incorporating evidence-based guidelines ensures that interventions across care settings are consistent. Patient-centered care is key to improving quality of care. Nutrition should be incorporated into the master plan to achieve positive outcomes in the skin integrity quality measure domain.

About The Author
Mary Ellen Posthauer RDN, CD, LD, FAND is an award winning dietitian, consultant for MEP Healthcare Dietary Services, published author, and member of the Purdue University Hall of Fame, Department of Foods and Nutrition, having held positions on numerous boards and panels including the National Pressure Ulcer Advisory Panel and the American Dietetic Association's Unintentional Weight Loss work group.