A recent blog suggested that CMS’ efforts to standardize assessment data was based on a goal of “….creating a functional measurement tool that could be used throughout the industry.” In fact, CMS has been working since 2005 to meet the Congressional directive to standardize assessment information at hospital discharge, and post-acute care (PAC) admission and discharge for payment and quality reporting purposes (Deficit Reduction Act of 2005). The CARE tool was developed as part of the national Post-Acute Care Payment Reform Demonstration (PAC PRD). The conceptual domains and items were selected with the input of the wide range of stakeholder communities working with PAC populations. Clinicians from acute hospitals and each of the four PAC settings, including long term care hospitals (LTCHs), inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), and home health agencies (HHAs) identified items to test in four areas: medical status, functional status, cognitive status, and some social support factors. Input was given by physicians, nurses, physical therapists, occupational therapists, speech and language pathologists, social workers and case managers working in each of the different levels of care. Initial item selection was based on a review of existing assessment items, including those in the three Federally-mandated instruments, (the IRF-PAI, MDS 2.0, and OASIS-B which were in effect at this time) and the input of each of the scientific communities working in these areas.

Developers of proprietary systems such as the UDS-MR©, Inter-RAI ©, and AM-PAC ©, as well as public domain items tested in clinical trials such as the PROMIS items, were all reviewed as part of this process. The selected items needed to be in the public domain so the measures could be modified as science advanced practice.

Over 200 providers participated nationwide to submit over 53,000 CARE assessments over the course of the PAC PRD. Participating clinicians also provided feedback during training and exit interviews. In general, positive feedback was provided on most items. Feedback showed that almost all items were commonly collected on existing instruments in hospitals and PAC providers, although some of the information may have been informally noted in charts rather than provided in the structured form of the CARE items.

The items were tested for reliability so they could be applied consistently across populations and settings. Most of the items were previously tested and found reliable in at least one of the five levels of care. Two types of reliability tests were conducted on the final CARE tool item set used in the PAC PRD. The results showed that most items when applied to the other four settings were at least as reliable as the existing Federal assessment items (Kappa scores of 0.6 or better) ensuring their reliable use in future quality measures or payment models would reach consistent results. Complete reports on item reliability and PAC PRD results can be found here.

Data standardization is critical to allow providers to exchange information as they follow the patient. The Deficit Reduction Act of 2005 directed CMS to use standardized assessment items at acute hospital discharge and PAC admission and discharge to allow for empirical comparisons of key questions arising out of changing incentives in the Medicare payment policies. The standardized CARE items are consensus-based versions of the items already collected by clinicians. These and additional items being incorporated into CMS’ assessment item library represent the “best in class.” The team developing the CARE item set represented the leading experts in each of the areas – Dr. Margaret Stineman of the University of Pennsylvania, developer of the function-related groups associated with the proprietary FIM©, Dr. Deborah Saliba, UCLA, lead developer of the MDS 3.0, and Dr. Chris Murtaugh of the Visiting Nurse Service of New York. Team members included Drs. Anne Deutsch and Trudy Mallinson of the Rehabilitation Institute of Chicago. Input was also given by Dr. David Hittle, of the University of Colorado who has worked closely with the OASIS tool, Dr. Samuel Markello, formerly of the UDS-MR©, and Dr. Patrick Murray of Case Western University.

The blog suggested that, “the early reviews of the CARE tool have been poor.” While this clearly is not true, it is worth pointing out that the author owns one of the key proprietary assessment instruments. The CARE items have been evaluated for reliability and they meet the national standards; they allow providers and others the opportunity to download the e-specification of the items without charge and to have the clinicians trained for free under CMS’ regular assessment training initiatives. CMS is currently developing quality measures using the “best in class” assessment items which all meet scientific standards. The quality measure development process already requires CMS to submit measures for endorsement by the National Quality Forum. The “loophole” identified by the UDS-MR© author is non-existent. The Measures Application Partnership is part of the existing NQF process included in the IMPACT legislation. Further, use of uniform data elements across settings, such as those used in the currently collected pressure ulcer measure, allows for exchangeability and improves communication across the system, finally creating a “data follows the person” system.

Event Information

John Quincy Adams famously said that America “goes not abroad in search of monsters to destroy.” A diplomat, secretary of state, as well as the sixth president, Adams is often described as a “realist,” and as the founder of American foreign policy realism. But did his own policy choices square with that doctrine of restraint? Recently, President Obama has described his own views in explicitly realist terms; Hillary Clinton is widely viewed as a more ardent believer in the active use of American power; and the Republican candidates seem more eager to build walls than to engage the outside world.

On April 11, the Brookings Project on International Order and Strategy (IOS) hosted a discussion between Brookings Senior Fellow Robert Kagan and James Traub, columnist and contributor at foreignpolicy.com, lecturer of foreign policy at New York University, and now the author of the new book, “John Quincy Adams: Militant Spirit” (Basic Books, 2016). Kagan and Traub debated whether Adams was a foreign policy realist and whether his approach to foreign policy can still inform the policy choices facing the United States today. Brookings Fellow Thomas Wright, director of IOS, moderated the discussion.

Audio

• Was John Quincy Adams a realist? A debate

Transcript

• Transcript (.pdf)

Event Materials

• 20160411_john_quincy_adams_transcript

There are lots of ways for Syria to go wrong for Russia. Analysts have tended to focus on Moscow’s military shortcomings in that theater, wondering if Syria will become Russia’s Vietnam. They’ve also pointed to Russia’s deep economic troubles—exacerbated, of course, by very low oil prices—which call into question its ability to pay for the military campaign over time.

One of the understudied aspects of Russia’s involvement in the Syrian conflict is the ramifications it could have for the Russian government’s relations with Muslims back at home. Moscow is now home to the largest Muslim community of any city in Europe (with between 1.5 and 2 million Muslims out of a population of around 13 million, although illegal immigration has distorted many of the figures). Russian President Vladimir Putin and other leaders have consciously avoided choosing sides in the Sunni-Shiite divide in the Middle East—recognizing that doing so could provoke a backlash among Russian Muslims.

The rise of an extremist, Salafi- or Wahhabi-inspired, religious state in Syria—an Islamic caliphate established either by the Islamic State or by any religiously-based extremist group in the region—could pose a significant problem for Russia. That’s both because of how it’s likely to behave toward other states in the region (including key Russian partners like Israel, Egypt, and Iran) and because of what it could inspire in Mother Russia, where efforts by militant groups to create their own “caliphate” or “emirate” in the North Caucasus have created headaches for Moscow since the early 2000s. 

Islam and Russia go way back

Russia is a Muslim state. Islam is arguably older than Christianity in traditional Russian territory––with Muslim communities first appearing in southeastern Russia in the 8th century. It is firmly established as the dominant religion among the Tatars of the Volga region and the diverse peoples of the Russian North Caucasus. These indigenous Sunni Muslims have their own unique heritage, history, and religious experience. The Tatars launched a reformist movement in the 19th century that later morphed into ideas of “Euro-Islam,” a progressive credo that could coexist, and even compete, with Russian Orthodoxy and other Christian denominations. Sufi movements, rooted in private forms of belief and practice, similarly prevailed in the Russian North Caucasus after the late 18th century. 

Before the collapse of the Soviet Union in the 1980s, when Central Asia and the South Caucasus were also part of the state, the USSR’s demography was in flux. The “ethnic” Muslim share of the population was rising as a result of high birthrates in Central Asia, while the Slavic, primarily Orthodox, populations of Russia, Belarus, and Ukraine were declining from high mortality and low birthrates. Since the dissolution of the USSR, Russia’s nominal Muslim population has swelled with labor migration from Central Asia and Azerbaijan, which has brought more Shiite Muslims into the mix, in the case of Azeri immigrants. As in other countries, Russia has also had its share of converts to Islam as the population rediscovered religion in the 1990s and 2000s after the enforced atheism of the Soviet period came to an end.

The foreign fighter problem

The Kremlin cannot afford the rise of any group that fuses religion and politics, and has outside allegiances that might encourage opposition to the Russian state among its Muslim populations. The religious wars in the Middle East are not a side show for Russia. Thousands of foreign fighters have flocked to Syria from Russia, as well as from Central Asia and the South Caucasus, all attracted by the extreme messages of ISIS and other groups.

Extremist groups have been active in Russia since the Chechen wars of the 1990s and 2000s. A recent Reuters report reveals how Russia allowed—and even encouraged—militants and radicals from the North Caucasus to go and fight in Syria in 2013, in an effort to divert them away from potential domestic terrorist attacks ahead of the February 2014 Sochi Winter Olympics. The Kremlin now worries that these and other fighters will return from Syria and further radicalize and inflame the situation in the North Caucasus and elsewhere in Russia. Putin intends to eliminate the fighters, in place, before they have an opportunity to come back home.

Putin also knows a thing or two about extremists from his time in the KGB, as well as his reading of Russian history. As a result, he does little to distinguish among them. For Putin, an extremist is an extremist—no matter what name he or she adopts. Indeed, Russian revolutionaries in the 19th and 20th centuries wrote the playbook for fusing ideology with terror and brutality; and Putin has recently become very critical of that revolutionary approach––moving even to criticize Soviet founder and Bolshevik Party leader Vladimir Lenin for destroying the Russian state and empire one hundred years ago in the Russian Revolution of 1917. For Putin, anyone whose views and ideas can become the base for violence in opposition to the legal, legitimate state (and its leader) is an extremist who must be countered. Syria is a crucial front in holding the line.

The long haul

With this in mind, we can be sure that Putin sees Russia in for the long haul in Syria. Recent signs that Russia may be creating a new army base in Palmyra to complement its bases in Latakia and Tarsus, underscore this point. Having watched the United States returning to its old battlegrounds in both Afghanistan and Iraq to head off new extremist threats, Putin will want to prepare contingencies and keep his options open. 

The fight with extremists is only beginning for Russia in Syria, now that Moscow has bolstered the position of Bashar Assad and the secular Alawite regime. For Putin and for Russia, Syria is the focal point of international action, and the current arena for diplomatic as well as military interaction with the United States, but it is also a critical element for Putin in his efforts to maintain control of the homefront.

I this week had the pleasure of doing a podcast debate with my Brookings colleague Jonathan Rauch on the question of whether we need stronger machines and weaker transparency in American government, or the opposite. Guess which side I took! This has been a long-running water cooler and cafeteria discussion between Jon and myself since I arrived at Brookings almost a year ago. While we find some areas of agreement in the podcast (more than you might think),I remain unconvinced by the so-called “political realist” school that Jonathan is a leader of. As I have previously written and blogged (here, here and here), I think the realists are fantasists, disconnected from the actual reality of politics, including its risks. We need more transparency, not less to deal with, for example, things like corruption risk, particularly in the post-Citizens United era. Indeed, that decision itself embraces the value of a vigorous transparency regime when other safeguards are relaxed. My belief is that Washington works both more efficiently and more ethically under the scrutinizing gaze of the American media, ngo's and public. As former White House ethics czar, I often facilitated administration openness efforts, including as a means of accountability, for example helping put the White House visitor logs online.

Jon and my lively debate covers not only issues of transparency itself but also applies them to other current topics—the Affordable Care Act, Trade Promotion Authority, and much more. The debate was silently moderated by our colleague Ben Wittes as part of his “Chess Clock Debates” series. With only ten minutes on the chess clock each to make our points, it was a concise discussion that hit the fundamentals briskly. Thanks to Ben for inviting us and giving us a public forum to discuss this critical policy issue.