DATA COLLECTION FOR ADMINISTERING THE MEDICARE CONTINUITY ASSESSMENT RECORD AND EVALUATION (CARE) INSTRUMENT

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form CMS-10243 DATA COLLECTION FOR ADMINISTERING THE MEDICARECONTINUITY ASSESSMENT RECORD AND EVALUATION (CARE) INSTRUMENT (Acute)	Form and Instruction	New	Repair queued
Form CMS-10243 DATA COLLECTION FOR ADMINISTERING THE MEDICARECONTINUITY ASSESSMENT RECORD AND EVALUATION (CARE) INSTRUMENT (HHA)	Form and Instruction	New	Repair queued
Form CMS-10243 DATA COLLECTION FOR ADMINISTERING THE MEDICARE CONTINUITY ASSESSMENT RECORD AND EVALUATION (CARE) INSTRUMENT (IRF)	Form and Instruction	New	Repair queued
Form CMS-10243 DATA COLLECTION FOR ADMINISTERING THE MEDICARECONTINUITY ASSESSMENT RECORD AND EVALUATION (CARE) INSTRUMENT (LTCH)	Form and Instruction	New	Source copy available
Form CMS-10243 DATA COLLECTION FOR ADMINISTERING THE MEDICARECONTINUITY ASSESSMENT RECORD AND EVALUATION (CARE) INSTRUMENT (SNF)	Form and Instruction	New	Repair queued
Form CMS-10243 DATA COLLECTION FOR ADMINISTERING THE MEDICARE CONTINUITY ASSESSMENT RECORD AND EVALUATION (CARE) INSTRUMENT (volunteers)	Form and Instruction	New	Available
CMS-10243.Appendix B MASTER CARE Tool 30 Day Revisions 103107.doc	Supporting Statement B	Uploaded 2007-11-15	Source copy available
CMS-10243.OMB Package Document List.doc	Supplementary Document	Uploaded 2007-11-15	Repair queued
CMS-10243.CARE Tool Explanation of 30 Day Revisions Spreadsheet 103107.pdf	Supplementary Document	Uploaded 2007-11-15	Repair queued
CMS-10243.Provider Profile-10-23-07.doc	Supplementary Document	Uploaded 2007-11-15	Repair queued
Responses to Public Comments-103107.doc	Supplementary Document	Uploaded 2007-11-15	Repair queued
CAREPrototypeScreens20070716.ppt	Supplementary Document	Uploaded 2007-11-15	Repair queued
CAREPrototypeScreens20070716.ppt	Supplementary Document	Uploaded 2007-11-15	Repair queued
CAREPrototypeScreens20070716.ppt	Supplementary Document	Uploaded 2007-11-15	Repair queued
CAREPrototypeScreens20070716.ppt	Supplementary Document	Uploaded 2007-11-15	Repair queued
CAREPrototypeScreens20070716.ppt	Supplementary Document	Uploaded 2007-11-15	Repair queued
CAREPrototypeScreens20070716.ppt	Supplementary Document	Uploaded 2007-11-15	Repair queued
CMS-10243.Appendix A Master CARE Tool Item Matrix 30 Day Revisions_103107.pdf	Supporting Statement A	Uploaded 2007-11-15	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
183091	DATA COLLECTION FOR ADMINISTERING THE MEDICARECONTINUITY ASSESSMENT RECORD AND EVALUATION (CARE) INSTRUMENT (Acute)	Form and Instruction	New
183090	DATA COLLECTION FOR ADMINISTERING THE MEDICARECONTINUITY ASSESSMENT RECORD AND EVALUATION (CARE) INSTRUMENT (HHA)	Form and Instruction	New
183089	DATA COLLECTION FOR ADMINISTERING THE MEDICARE CONTINUITY ASSESSMENT RECORD AND EVALUATION (CARE) INSTRUMENT (IRF)	Form and Instruction	New
183088	DATA COLLECTION FOR ADMINISTERING THE MEDICARECONTINUITY ASSESSMENT RECORD AND EVALUATION (CARE) INSTRUMENT (LTCH)	Form and Instruction	New
183087	DATA COLLECTION FOR ADMINISTERING THE MEDICARECONTINUITY ASSESSMENT RECORD AND EVALUATION (CARE) INSTRUMENT (SNF)	Form and Instruction	New
183086	DATA COLLECTION FOR ADMINISTERING THE MEDICARE CONTINUITY ASSESSMENT RECORD AND EVALUATION (CARE) INSTRUMENT (volunteers)	Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 200712-0938-004
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: HHS/CMS	Agency Tracking No:
Title: DATA COLLECTION FOR ADMINISTERING THE MEDICARE CONTINUITY ASSESSMENT RECORD AND EVALUATION (CARE) INSTRUMENT
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn	Conclusion Date: 03/25/2008
	Date Received in OIRA: 12/17/2007
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The Medicare Continuity Assessment Record and Evaluation (CARE) is a uniform patient assessment instrument designed to measure differences in patient severity, resource utilization, and outcomes for patients in acute and post-acute care settings. This tool will be used to 1) standardize program information on Medicare beneficiaries'acuity at discharge from acute hospitals, 2) document medical severity, functional status and other factors related to outcomes and resource utilization at admission, discharge, and interim times during post acute treatment, and 3) understand the relationship between severity of illness, functional status, social support factors, and resource utilization.

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Authorizing Statute(s): PL: Pub.L. 109 - 171 5008 Name of Law: Deficit Reduction Act of 2005
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 41328	07/27/2007
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 63612	11/09/2007
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
DATA COLLECTION FOR ADMINISTERING THE MEDICARE CONTINUITY ASSESSMENT RECORD AND EVALUATION (CARE) INSTRUMENT (volunteers)	CMS-10243	CARE Tool
DATA COLLECTION FOR ADMINISTERING THE MEDICARECONTINUITY ASSESSMENT RECORD AND EVALUATION (CARE) INSTRUMENT (SNF)	CMS-10243	CARE Tool
DATA COLLECTION FOR ADMINISTERING THE MEDICARECONTINUITY ASSESSMENT RECORD AND EVALUATION (CARE) INSTRUMENT (LTCH)	CMS-10243	CARE Tool
DATA COLLECTION FOR ADMINISTERING THE MEDICARE CONTINUITY ASSESSMENT RECORD AND EVALUATION (CARE) INSTRUMENT (IRF)	CMS-10243	CARE Tool
DATA COLLECTION FOR ADMINISTERING THE MEDICARECONTINUITY ASSESSMENT RECORD AND EVALUATION (CARE) INSTRUMENT (HHA)	CMS-10243	CARE Tool
DATA COLLECTION FOR ADMINISTERING THE MEDICARECONTINUITY ASSESSMENT RECORD AND EVALUATION (CARE) INSTRUMENT (Acute)	CMS-10243	CARE Tool

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Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Changing Regulations

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The CARE instrument will be used in the Post-Acute Care (PAC) Payment Reform Demonstration program mandated by Section 5008 of the Deficit Reduction Act of 2005 to develop payment groups that reflect patient severity and related cost and resource use across post acute settings.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 12/17/2007

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