Advance Care Planning

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.

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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).

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).

Increased score indicates improvement

Reference Type: Citation

Reference Text: 
Aasmul, I., Husebo, B. S., Sampson, E. L., & Flo, E. (2018). Advance care planning in nursing homes - improving the communication among patient, family, and staff: Results from a cluster randomized controlled trial (COSMOS). Frontiers in Psychology, 9, 2284. https://doi.org/10.3389/fpsyg.2018.02284

Reference Type: Citation

Reference Text: 
Doorenbos, A. Z., Levy, W. C., Curtis, J. R., & Dougherty, C. M. (2016). An intervention to enhance goals-of-care communication between heart failure patients and heart failure providers. Journal of Pain and Symptom Management, 52(3), 353–360. https://doi.org/10.1016/j.jpainsymman.2016.03.018

Reference Type: Citation

Reference Text: 
Hammes, B. J., & Rooney, B. L. (1998). Death and end-of-life planning in one midwestern community. Archives of Internal Medicine, 158(4), 383–390. https://doi.org/10.1001/archinte.158.4.383

Reference Type: Citation

Reference Text: 
Martin, R. S., Hayes, B. J., Hutchinson, A., Tacey, M., Yates, P., & Lim, W. K. (2019). Introducing goals of patient care in residential aged care facilities to decrease hospitalization: A cluster randomized controlled trial. Journal of the American Medical Directors Association, 20(10), 1318–1324.e2. https://doi.org/10.1016/j.jamda.2019.06.017

Reference Type: Citation

Reference Text: 
McMahan, R. D., Tellez, I., & Sudore, R. L. (2021). Deconstructing the complexities of advance care planning outcomes: What do we know and where do we go? A scoping review. Journal of the American Geriatrics Society, 69(1), 234–244. https://doi.org/10.1111/jgs.16801

Reference Type: Citation

Reference Text: 
Rosa, W. E., Izumi, S., Sullivan, D. R., Lakin, J., Rosenberg, A. R., Creutzfeldt, C. J., Lafond, D., Tjia, J., Cotter, V., Wallace, C., Sloan, D. E., Cruz-Oliver, D. M., DeSanto-Madeya, S., Bernacki, R., Leblanc, T. W., & Epstein, A. S. (2023). Advance care planning in serious illness: A Narrative Review. Journal of Pain and Symptom Management, 65(1), e63–e78. https://doi.org/10.1016/j.jpainsymman.2022.08.012

Reference Type: Citation

Reference Text: 
Silveira, M. J., Kim, S. Y., & Langa, K. M. (2010). Advance directives and outcomes of surrogate decision making before death. The New England Journal of Medicine, 362(13), 1211–1218. https://doi.org/10.1056/NEJMsa0907901

Reference Type: Citation

Reference Text: 
Tierney, W. M., Dexter, P. R., Gramelspacher, G. P., Perkins, A. J., Zhou, X. H., & Wolinsky, F. D. (2001). The effect of discussions about advance directives on patients' satisfaction with primary care. Journal of General Internal Medicine, 16(1), 32–40. https://doi.org/10.1111/j.1525-1497.2001.00215.x

Reference Type: Citation

Reference Text: 
Yadav, K. N., Gabler, N. B., Cooney, E., Kent, S., Kim, J., Herbst, N., Mante, A., Halpern, S. D., & Courtright, K. R. (2017). Approximately one in three US adults completes any type of advance directive for end-of-life care. Health Affairs (Project Hope), 36(7), 1244–1251. https://doi.org/10.1377/hlthaff.2017.0175

Reference Type: Citation

Reference Text: 
Patient Self-Determination Act of 1990, Pub. L. No. 101–508, 104 Stat. 1388 (1990). https://www.congress.gov/bill/101st-congress/house-bill/4449

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.

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 eCQI resource center (https://ecqi.healthit.gov/qdm) for more information on the QDM.

TBD

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

Equals Initial Population

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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:

 

  
Documentation of an ACP document before end of an inpatient encounter as evidenced by:
  

   

    
Healthcare agent [Health Care Proxy or HCPOA]
   
   

    
AD or living will
   
   

    
Portable Medical Orders [MOLST, POLST, MOST, POST, COLST, TPOPP, DNR Order Form]
   
  
 
 

  
Documentation of DNR order coded during an inpatient encounter, as evidenced by ICD-10-CM code Z66
 
 

  
Documentation that an ACP discussion resulting in a decision occurred during an inpatient encounter, as evidenced by:
  

   

    
ACP discussion with documented ACP (procedure)
   
   

    
Documentation of goals, preferences and priorities
   
   

    
Codes reflecting review of and/or updates to existing ACP documents
   
  
  

 

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For every patient evaluated by this measure also identify payer, race, ethnicity and sex