Assessments of a health-related matter of interest, importance, or worry to a patient, patient’s family, or patient’s healthcare provider that could identify a need, problem, or condition.

Data Element

Self-care
Description

This data element carries information on Self-care that is exchanged as observations. (Observations are characteristics that can be tested, measured, or observed and are communicated with a name-value pair structure). Self-care is a broad domain. Using the conceptual framework of the the International Classification of Function (ICF), it includes aspects such as eating, caring for teeth, putting clothes on, etc. Notes: • This data element is constrained to health data represented in data structures for observations. Observations should be represented using terminologies supporting this conceptual model, such as LOINC, which is designed for this purpose. Representing problems, goals, and other types of information related to functioning should use other data class structures as appropriate. • Examples of Self-care concepts can be found in the ICF browser at: https://apps.who.int/classifications/icfbrowser • Examples of demonstrated use of Self-care data can be found in the PACIO FHIR Functional Status Implementation Guide which supports exchange of observation data such as eating, oral hygiene, upper body dressing using assessments coded with LOINC.

Comment

CMS-CCSQ Recommends the advancement of Self-care to Level 2

Recommendation: CMS CCSQ recommends the Self-care element be advanced to Level 2.

Rationale: Including the Self-care data element at Level 2 is crucial for improving patient care and outcomes in the LTPAC setting. Self-care is a broad domain encompassing activities like eating, dressing, and personal hygiene, which are essential aspects of a patient’s functional status. By tracking self-care abilities, healthcare providers gain valuable insights into a patient’s progress, identifying any barriers to independence and enabling tailored interventions that promote recovery and independence. This data directly impacts the management of chronic conditions and recovery after illness or surgery. Self-care data is already captured and exchanged in standardized functional assessments, such as Section GG in the IRF-PAI, LCDS, MDS, and Outcome and Assessment Information Set (OASIS), and supports tracking functional outcomes over time. It is also aligned with national healthcare initiatives, including CMS Quality Reporting Programs (QRPs), improving the accuracy of reporting for quality measurement and reimbursement purposes. Given its direct relevance to patient care and healthcare quality metrics, advancing Self-care to Level 2 will signal the importance of capturing this data element in healthcare IT systems to vendors which may increase its adoption and facilitate better care coordination, improve patient outcomes, and enhance interoperability across healthcare systems. The inclusion of Self-care in Level 2 would support standardized observation data exchange, as demonstrated in PACIO projects like the Personal Functioning and Engagement (PFE) Implementation Guide (IG) and Cognitive Status IG, further enhancing its utility across diverse care settings.

Advance Self-care to USCDI Level 2

The data element "Self-care" is an important and consistently documented indicator of how someone takes care of themself.  The details of self-care are documented by healthcare providers at all levels of care.  Important concepts included in this data element are listed below:

  • Washing oneself
  • Caring for body parts
  • Toileting
  • Dressing
  • Eating
  • Drinking
  • Looking after one's health

The use of this data element and its associated concepts are well structured and described in the International Classification of Functioning, Disability and Health (ICF).

Moving selfcare to USCDI Level 2 is an important recognition of widespread use and advancement.

Log in or register to post comments