Advance Care Planning
Compare Versions of: "Advance Care Planning"
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| Measure Information | 2028 Reporting Period |
|---|---|
| Title | Advance Care Planning |
| CMS eCQM ID | CMS1317v1 |
| CBE ID* | Not Applicable |
| Measure Steward | Centers for Medicare & Medicaid Services (CMS) |
| Description |
Percentage of patients aged 18 and older at the beginning of the measurement period with at least one hospital inpatient discharge during the measurement period, who have either an advance care planning (ACP) document in the medical record before the end of an encounter, a do not resuscitate (DNR) order coded in the medical record during an encounter, or documentation of an ACP discussion resulting in a documented decision in the medical record during an encounter. |
| Measure Scoring | Proportion |
| Measure Type | Process |
| Stratification |
None |
| Risk Adjustment |
None |
| Rationale |
This measure aims to advance person-centered care by ensuring that hospitals provide patients and their caregivers the opportunity to discuss their goals of care and/or capture patients’ existing ACP decisions. ACP is widely recognized as important to patient care by patients, surrogates, and clinicians, and is associated with improvements in numerous outcomes for patients’ and their caregivers’ experiences and satisfaction with end-of-life (EOL) care (McMahan et al., 2021). The 1990 Patient Self Determination Act mandates healthcare facilities to inform patients of their medical decision-making rights and document their ACP decisions in medical records, yet engagement in ACP remains low across United States populations (Yadav et al., 2017). |
| Clinical Recommendation Statement |
There are numerous evidence-based benefits to ACP, including: ensuring that patients receive care that is consistent with their preferences and increasing the likelihood that providers and families understand and comply with a patient’s preferences for medical care when the patient lacks decision-making capacity (Silveira et al., 2010; Hammes & Rooney, 1998). ACP is also associated with improvements in patient self-efficacy and reductions in patient anxiety, caregiver distress, complicated grief, and clinician distress (McMahan et al., 2021; Rosa et al., 2023). Additionally, ACP has been linked to enhanced communication among patients, surrogates, and clinicians, as well as increased satisfaction with clinicians who initiate discussions about EOL care (Aasmul et al., 2018; Doorenbos et al., 2016; Tierney et al., 2001). ACP is also associated with decreased hospital length of stay and is in alignment with patients' preferred place of death (McMahan et al., 2021; Martin et al., 2019). |
| Improvement Notation |
Increased score indicates improvement |
| Definition |
ACP: Based on expert consensus, ACP is defined as "a process that supports adults at any age or stage of health in understanding and sharing their personal values, life goals, and preferences regarding future medical care" (Silveira et al., 2010). ACP is dynamic and shaped by changes in health status. ACP is an iterative process that can and should be updated across the span of a person’s life, particularly if there is evolution in a patient’s goals for medical treatment. The process of ACP involves conversations with patients or their designated caregivers about their goals, wishes, and preferences for medical treatment and documentation of ACP discussions and/or completion of formal documents to ensure patients or their caregivers’ decisions are captured. Advance Directives (AD): Advance directives are legal documents that outline an individual's preferences for medical treatment and/or decision making in the event that they become incapacitated and unable to communicate their wishes. An AD typically consists of a living will and/or a power of attorney for health care. Code Status: Code status refers to a patient's preference regarding life-sustaining measures in the event of cardiac or respiratory arrest. It typically includes decisions about cardiopulmonary resuscitation (CPR). Common code status options include "do not resuscitate" and "do not intubate" (Hammes & Rooney, 1998). Do Not Resuscitate Order (DNR Order): Rosa et al. (2023) define a DNR as a portable medical order that specifies that a patient does not want emergency responders or healthcare providers to perform CPR if they stop breathing or their heart stops. Living Will: A living will is a type of AD that specifies the medical treatments and interventions that a person would or would not want to receive if they become incapacitated due to a terminal illness or permanent unconsciousness. Medical Orders for Life Sustaining Treatment or Physician Orders for Life Sustaining Treatment forms (MOLST/POLST forms): A MOLST/POLST form is a portable medical orders form that allows seriously ill or frail people to communicate their EOL care wishes to healthcare facilities and providers (Aasmul et al., 2018). While it does encompass instructions regarding resuscitation preferences (similar to code status and DNR Order), it also includes directives concerning other specific medical interventions (Hammes & Rooney, 1998). MOLST/POLST programs are implemented at the state level where they are sometimes known by another name, including Clinical Orders for Life-Sustaining Treatment (COLST), Medical Orders for Scope of Treatment (MOST), Physician Orders for Scope of Treatment (POST), and Transportable Physician Orders for Patient Preferences (TPOPP) (https://polst.org/). Health Care Agent: A health care agent is an individual who has been designated by a person to make medical decisions on their behalf in the event the person is not able to make decisions for themselves. Health care agents are assigned through a type of AD called a Power of Attorney for Health Care (HCPOA); an HCPOA may also be called a Health Care Proxy in some states. |
| Guidance |
This eCQM is a patient-based measure. The hospital-level measure result is the proportion of eligible patients who have ACP sufficiently documented in the medical record. The measure is inclusive of any hospitalizations resulting in discharge during the measurement period; for patients with multiple hospitalizations, such documentation in the record of any one eligible hospitalization is sufficient. Similarly, the numerator does not depend on the number of ACP documents or discussions adequately documented in the record, only upon the presence of at least one. In other words, the numerator will be either TRUE or FALSE for each patient in the cohort. The numerator logic looks for evidence of an ACP document recorded in the patient’s medical record prior to the measurement period or during any hospitalization in the measurement period. This allows for the inclusion of legal documents that may have been obtained prior to the measurement period and are still valid. For any patients without an ACP document in the medical record, the numerator logic will then look for evidence of an ACP discussion resulting in a decision having taken place or a DNR order being coded during any hospitalization in the measurement period. (DNR orders, identified by ICD-10-CM code Z66, are generally institution-specific and non-transferable in contrast to other types of ACP documents, and so must be recorded during a hospitalization in the measurement period to count toward the numerator.) The numerator logic will not consider any ACP document or discussion if the date stamp occurs after the last discharge date in the measurement period. This version of the eCQM uses QDM version 5.6. Please refer to the QDM page for more information on the QDM. |
| Initial Population |
Patients 18 years of age and older at the beginning of the measurement period with a discharge from an acute care hospital or critical access hospital inpatient setting during the measurement period |
| Denominator |
Equals Initial Population |
| Denominator Exclusions |
None |
| Numerator |
Patients who have an ACP document and/or documentation of an ACP discussion resulting in a decision in the medical record by the time of hospital discharge during at least one inpatient encounter during the measurement period. The numerator may be satisfied by codes indicating any one of the following:
|
| Numerator Exclusions |
None |
| Denominator Exceptions |
None |
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