Level of completeness of the data elements

The PACIO (Post-Acute Care Interoperability) Project, established February 2019, is a collaborative effort between industry, government, and other stakeholders, with the goal of establishing a framework for the development of FHIR implementation guides to facilitate health information exchange.

Data Class: Goals

• Support inclusion of data elements related to functional status.
• Recommendation: Remove data elements Functional Ability and Goals: Self-care and Functional Ability and Goals: Mobility under the Goals data class and replace them with Self-care Performance and Mobility Performance under the Health Status Assessments data class
  • Rationale: Functional goal observations are more subjective than functional performance observations, and they are less quantifiable in terms of improvement over time for quality purposes. In addition, in SNF, IRF, and LTCH FY24 proposed rules, CMS proposed removing Discharge Goals from Self-Care and Mobility items from the CMS PAC Assessments. CMS proposed to replace the Application of Percent of Long-Term Care Hospital (LTCH) Patients with an Admission and Discharge Functional Assessment and a Care Plan that Addresses Function Discharge Goals measure (calculated using the Discharge Goals from Self-Care and Mobility items) with the performance-based Discharge Function Score measure, which determines how successful each PAC provider is meeting or exceeding an expected level of functional ability for its patients at discharge. Finally, we note that the Functional Ability and Goals: Self-care and Functional Ability and Goals: Mobility data elements proposed for the USCDI+ data element list are not used in Home Health quality measurement, but the proposed Discharge Function Score measure, which Self-care Performance and Mobility Performance data elements would support, could be used for all four PAC settings.