| Measure Type | High Priority Measure? | NQS Domain |
|---|---|---|
| Process | Yes | Patient Safety |
| Data Submission Method(s) | ||
| Registry | ||
Measure Description
Percentage of patients with dementia or their caregiver(s) for whom there was a documented safety concerns screening * in two domains of risk: 1) dangerousness to self or others and 2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources or orders for home safety evaluation
Instructions
This measure is to be submitted a minimum of once per performance period for patients with a diagnosis of dementia seen during the performance period. This measure may be submitted by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.
Measure Submission:
The listed denominator criteria is used to identify the intended patient population. The numerator options included in this specification are used to submit the quality actions allowed by the measure. The quality-data codes listed do not need to be submitted for registry submissions; however, these codes may be submitted for those registries that utilize claims data.
Denominator
All patients with a diagnosis of dementia
Denominator Criteria (Eligible Cases):
All patients regardless of age
AND
Diagnosis for dementia (ICD-10-CM): A52.17, A81.00, A81.01, A81.89, B20, F01.50, F01.51, F02, F02.80, F02.81, F03.90, F03.91, F05, F10.27, G20, G30.0, G30.1, G30.8, G30.9, G31.01, G31.09, G31.83, G31.85, G31.89, G94
AND
Patient encounter during the performance period (CPT): 90791, 90792, 90832, 90833, 90834, 90836, 90837, 90838, 96116, 96118, 96119, 96120, 96150, 96151, 96152, 96153, 96154, 96155, 97165, 97166, 97167, 97168, 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215, 99231, 99232, 99233, 99238, 99239, 99281, 99282, 99283, 99284, 99285, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99339, 99340, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350, 99487, 99489, 99490, 99497, 99498
WITHOUT
Telehealth Modifier: GQ, GT, 95, POS 02
Numerator
Patients with dementia or their caregiver(s) for whom there was a documented safety concerns screening * in two domains of risk: 1) dangerousness to self or others and 2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources or orders for home safety evaluation
Numerator Instructions: Mitigation Recommendations should include a discussion with the patient and their caregiver(s) regarding one or more of the following common safety concerns and potential risks to the patient. When appropriate, it should also include a mitigation recommendation or referral or orders for a home safety evaluation.
Note: For nursing home patients, different safety concerns might apply.
A number of organizations have developed educational materials that are recommended to aid implementation of the measure. These materials/tools include:
- Alzheimer’s Association Safety Topics. Available on the Alzheimer’s Association website. Alzheimer’s Disease Education and Referral Center’s Home Safety for the Alzheimer’s Patient Available on the National Institute on Aging website.
Definitions:
Caregiver(s) – Person(s) who provide care to those who need supervision or assistance in illness or disability. They may provide the care in the home, in a hospital, or in an institution. Although caregiver(s) include trained medical, nursing, and other health personnel, the concept also refers to parents, spouses, or other family members, friends, members of the clergy, teachers, social workers, fellow patients.
Safety Concerns – Safety concerns include, but are not limited to:
- Fall risk
- Gait/balance
- Medication management
- Financial management
- Home safety risks that could arise from cooking or smoking
- Physical aggression posing threat to self, family caregiver, or others
- Wandering
- Access to firearms or other weapons
- Access to potentially dangerous materials
- Being left alone in home or locked in room
- Inability to respond rapidly to crisis/household emergencies
- Driving
- Operation of hazardous equipment
- Suicidality
- Abuse or neglect
NUMERATOR NOTE: The 12 month look back period is defined as 12 months from the date of the denominator eligible encounter. Denominator Exception(s) are determined on the date of the denominator eligible encounter.
Numerator Options:
Performance Met:
Safety concerns screen provided and if positive then documented mitigation recommendations (G9922)
OR
Performance Met:
Safety concerns screen provided and negative (G9923)
OR
Denominator Exception:
Documentation of medical reason(s) for not providing safety concerns screen OR for not providing recommendations, orders or referrals for positive screen (e.g., patient in palliative care, other medical reason) (G9924)
OR
Performance Not Met:
Safety concerns screening not provided, reason not otherwise specified (G9925)
OR
Performance Not Met:
Safety concerns screening positive screen is without provision of mitigation recommendations, including but not limited to referral to other resources. (G9926)
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