This project will be initiated on October 1, 2007. The background and plans for the study are described. ? ? The long term treatment of patients after an acute care hospitalization can occur in a variety of settings including inpatient rehabilitation facilities, skilled nursing facilities, long term care hospitals, outpatient rehabilitation clinics, and home health agencies. Costs for this post-acute care, (PAC) have grown considerably over time and now represent 13% of the entire Medicare budget, or about $42 billion in 2005. PAC treatment regimens and costs vary considerably between sites of service. However, little is know about differences in outcome. This is because the PAC field has been unable to achieve a standardized, patient-centered outcome assessment approach to date, that can provide unified information across different PAC settings. ? ? Most PAC outcome assessments are imprecise which restricts their utility to monitor clinical outcomes for quality improvement, benchmarking, and research. It is difficult for one instrument to include the number of items necessary to precisely measure the wide range of ability levels of individuals across care settings. The resulting length and complexity of many fixed-form outcome batteries is problematic and raises concerns over respondent burden and administration costs. The field has responded to this legitimate concern by shifting to shorter fixed-form versions of outcome instruments. The widespread adoption of short forms in PAC services underscores the importance of practical considerations in determining whether outcome instruments can be used effectively to monitor relevant outcomes. Unfortunately, the very features underlying the popularity of short forms render them less precise. ? ? We believe that a method developed at Boston University will achieve precise measurement of outcomes across a continuum of functioning through the use Computer Adaptive Testing (CAT) coupled with Item Response Theory (IRT). CAT represents a simple form of artificial intelligence software that selects test items tailored to an individual patient, shortens or lengthens the test to achieve the desired precision of measurement, scores every patient on the same underlying outcome continuum so that results can be compared across the continuum of that outcome, and displays the results instantly for immediate interpretation and use. IRT methods serve as the psychometric foundation underlying CAT. ? ? Using IRT and CAT methodologies, the research group at Boston University has begun developing functional outcome measures designed for use across the full spectrum of PAC settings. Their main instrument is the Activity Measure for Post-Acute Care (AM-PAC). A prototype version of the AM-PAC CAT has been developed and will be used in the OMS that we propose to implement with the Kaiser Permanente of Northern California Health System. This site was chosen because this organization already has some familiarity with the OMS and as a fully integrated managed care system where almost all stroke patients receive their acute and post-acute care within the system, the organization has the ability to enact this protocol and make changes based on the results. ? ? This study will test the feasibility of implementing an Outcomes Monitoring System (OMS), designed for use across all post-acute care settings, among a cohort of 200 stroke patients. Patients will be enrolled at one of two acute care hospitals in the Kaiser Permanente of Northern California Health System during their hospitalization for an acute stroke and will be followed over time. The OMS will be administered at several points to characterize a patients functional status after utilizing different PAC settings. A secondary objective will be to examine the outcomes of stroke patients based on their sites of care.
