2021 MBHR Measure: Cognitive Assessment with Counseling on Safety and Potential Risk

QCDR Name: MBHR Mental and Behavioral Health Registry

Measure Title Cognitive Assessment with Counseling on Safety and Potential Risk
NQS Domain Effective Clinical Care
Measure ID MBHR11
NQF ID N/A
Measure Type Process
High Priority? No
Description Percentage of patients, regardless of age, referred for evaluation due to concerns for cognitive impairment for whom 1) a standardized valid assessment of cognition was performed and 2) reporting of results included counseling on safety and potential risks. View diagram
Denominator All patients, regardless of age, where there is documentation of concerns regarding cognitive changes or difficulties. Reported concerns may come from: the patient, a treating provider, or a caregiver of the patient

AND
Patient encounter during the performance period (CPT):
96156; 96116; 96121; 96132; 96133; 96146; 96105; 96125; 96110

INCLUDES TELEHEALTH? YES

Denominator Exclusions

and

Exceptions

Exclusions:  Death

Exceptions:  Patients present with an acute condition or crisis who are not administered a standardized cognitive assessment

OR

Patient refuses to participate or is unable to complete the assessment

Numerator Patients for whom a standardized valid assessment of cognition* was performed and reporting of results included counseling on safety and potential risks*. Standardized cognitive assessment – refers to the administration of reliable and research-validated assessment methods or tests that cover one or a combination of the following cognitive domains: memory, language, visual-spatial, executive functioning, academic skills, developmental level, intellectual functioning, attention, and processing speed. Depending on medical needs, referral question, and patient characteristics, cognitive assessment may entail targeted assessment of a particular cognitive domain or a comprehensive assessment battery encompassing multiple domains. Assessment of functional abilities and activities of daily living may also be included in these evaluations. Psychological functioning may also be formally assessed to identify whether emotional or social factors are influencing cognitive functioning. Meeting performance for this measure is not limited to a specific cognitive test as long as it meets the above criteria and is commonly accepted within the medical community. Examples of well validated and commonly accepted cognitive tests can be found in in Strauss, Sherman, & Spreen, A Compendium of Neuropsychological Tests [30].

The following list is illustrative of types of tests and test batteries that would meet this criterion and are not meant to be equal or interchangeable. Clinical judgment, commiserate with education and training, is needed in selecting and interpreting the chosen test(s).
• Montreal Cognitive Assessment (MoCA)
• Mini-Mental Status Examination (MMSE)
• Neuropsychological Assessment Battery (NAB)
• Boston Diagnostic Aphasia Examination (BDAE)
• California Verbal Learning Test-Third Edition (CVLT3)
• Weschler Memory Scale-Fourth Edition (WMS-IV)
• Katz Index of Independence in Activities of Daily Living
• Lawton Instrumental Activities of Daily Living Scale (IADL)

Safety Concerns and Potential Risk – include, but are not limited to, the following areas of concern and potential safety risks identified based on the results of cognitive assessment in one or more of the following areas:
• Fall risk/balance problems
• Medication management
• Financial management
• Home safety risks (e.g., cooking, smoking, etc.)
• Inability to respond rapidly to crisis/household emergencies
• Need for increased supervision due to memory problems, poor judgment, or decreased safety awareness
• Physical aggression posing threat to self, family caregiver, or others
• Possibility of getting lost/Wandering
• Community navigation/driving
• Access to firearms or other weapons
• Access to potentially dangerous materials
• Operation of hazardous equipment
• Vulnerability to undue influence of others who may have mal-intent
• Suicidality
• Abuse or neglect
• Warning signs of disease progression and avoidance of risk for exacerbation of cognitive impairment
• Medical decision-making
• Comprehension of medical plan, treatment recommendations, and prognosis
• Presence of cognitive, psychosocial, or emotional barriers affecting adherence to medical recommendations

Data Source Claims, EHR, Paper medical record, registry
Meaningful Measure Area Prevention, Treatment, and Management of Mental Health
Meaningful Measure Rationale Counseling on safety and potential risk with individuals, who undergo cognitive assessment, will improve the quality of care for functional outcomes and the quality of life for patients by identifying and addressing appropriate safety and other potential risks that can negatively impact patient functioning. This provides a standardized way to document counseling on safety and potential risks for patients receiving a cognitive assessment and will improve quality of treatment, quality of life and efficient use of resources.
Inverse Measure? No
Proportional Measure? Yes
Continuous Variable Measure? No
Ratio Measure No
Number of Performance Rates 1
Risk Adjusted No
Preferred Specialty mental and behavioral health
Applicable Specialties Family Medicine; Geriatrics; Internal Medicine; Mental/Behavioral Health; Neurology; Physical Medicine & Rehabilitation; Psychiatry
Care Settings Ambulatory Care: Hospital; Inpatient; Rehabilitation Facility; Nursing Home; Outpatient Services; Long Term Care

Measure Justification

Numerous organizations and researchers have issued guidelines and statements asserting the importance of detection of cognitive impairment in at-risk individuals as well as the use of cognitive assessment results to address safety risks and health outcomes. Although the majority of guidelines focus on older adults at risk for dementia, there is broad support for the importance of identifying cognitive impairment to improve outcomes across a wide range of medical conditions that occur across the lifespan. See list of examples below:
National Institute on Aging: Cognitive assessment is valuable in identifying emerging cognitive disorders, initiating treatments, and preparing for the future [1].

  • Family Medicine: Cognitive assessment assists with averting or addressing potential safety issues and allows for long term planning and presence of caregiver to help with medical, legal and financial concerns [2].
  • Sports Concussion: Cognitive evaluations allow for safely managing recovery and treatment planning in athletes recovering from concussion by identifying when it is safe to return to physical activities and identifying those at risk for long-term adverse effects [3-5].
  • Traumatic Brain Injury: Position statement supporting the importance of cognitive assessment in military-related traumatic brain injury was approved by the American Academy of Clinical Neuropsychology (AACN), American Psychological Association Division 40 (Neuropsychology), American Psychological Association Division 22 (Rehabilitation Psychology), and the National Academy of Neuropsychology (NAN) [6].
  • Multiple Sclerosis: Researchers have highlighted the importance of neuropsychological evaluations for patients with multiple sclerosis with a proposal of a specific cognitive testing battery [7][8].
  • Epilepsy: Guidelines and consensus statements assert the importance of cognitive and specifically, neuropsychological assessment in the treatment of epilepsy [9, 10].
  • Oncology: Neurocognitive testing is highly valued in treatment planning for patients with brain tumors and is predictive of functional independence [11, 12].

Furthermore, existing Local Coverage Determinations issued by the Centers for Medicare and Medicaid Services provide support that cognitive testing is deemed medically necessary across a broad range of medical diagnoses (for example see ).

  1. Aging, N.I.o. Assessing Cognitive Impairment in Older Patients. 2020 6/14/2020]; Available from: https://www.nia.nih.gov/health/assessing-cognitive-impairment-older-patients.
  2.  Galvin, J.E., C.H. Sadowsky, and NINCDS-ADRDA, Practical guidelines for the recognition and diagnosis of dementia. J Am Board Fam Med, 2012. 25(3): p. 367-82.
  3. Echemendia, R.J., et al., Role of neuropsychologists in the evaluation and management of sport-related concussion: an inter-organization position statement. Arch Clin Neuropsychol, 2012. 27(1): p. 119-22.
  4. McCrory, P., et al., Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport, Zurich, November 2012. J Athl Train, 2013. 48(4): p. 554-75.
  5. Moser, R.S., et al., Neuropsychological evaluation in the diagnosis and management of sports-related concussion. Arch Clin Neuropsychol, 2007. 22(8): p. 909-16.
  6. McCrea, M., et al., Official position of the military TBI task force on the role of neuropsychology and rehabilitation psychology in the evaluation, management, and research of military veterans with traumatic brain injury. Clin Neuropsychol, 2008. 22(1): p. 10-26.
  7. enedict, R.H., et al., Minimal neuropsychological assessment of MS patients: a consensus approach. Clin Neuropsychol, 2002. 16(3): p. 381-97.
  8. Kalb, R., et al., Recommendations for cognitive screening and management in multiple sclerosis care. Mult Scler, 2018. 24(13): p. 1665-1680.
  9. Jones-Gotman, M., et al., The contribution of neuropsychology to diagnostic assessment in epilepsy. Epilepsy Behav, 2010. 18(1-2): p. 3-12.
  10. Labiner, D.M., et al., Essential services, personnel, and facilities in specialized epilepsy centers–revised 2010 guidelines. Epilepsia, 2010. 51(11): p. 2322-33.
  11. Noll, K.R., et al., Neurocognitive functioning is associated with functional independence in newly diagnosed patients with temporal lobe glioma. Neurooncol Pract, 2018. 5(3): p. 184-193.
  12. Noll, K.R., et al., Neuropsychological Practice in the Oncology Setting. Arch Clin Neuropsychol, 2018. 33(3): p. 344-353.

Impact. As with ADHD in children and adolescents there is a robust and extensive literature on the prevalence and impact of ADHD in adults. ADHD is conceptualized as a neurodevelopment disorder in the DSM 5 (APA, 2013) with prevalence estimated to be between 5 and 10% (e.g. Rowland, Skipper, & Umbach, 2015; Thomas, Sanders, Doust, Beller, & Glousiou, 2015). Current estimates are that between 4 and 5% of adults have ADHD (Kessler, et. al 2006) in the United States. ADHD in adults is also related to difficulties in school, occupational functioning, relationships, health, and various adaptive and psychological problems (see Barkley, 2015 as an example). Once thought to be a disorder of childhood, ADHD is now understood to be a disorder that continues well into adulthood including older adulthood.

Assessment and Treatment. Given the now well understood importance of ADHD in adults there are has been significant advancement in identifying how to assess and treat ADHD. The literature is voluminous. As with impact there are now a significant number of reviews of how to screen and diagnosis ADHD in adulthood (see Goodman, 2009; Ramsay, 2017; Ramsay & Rostain, 2016 in addition to the general reviews cited above as well as the CADDRA and NICE Guidelines). Given that attentional issues saturate multiple clinical presentations it is important that clinicians complete a thorough assessment using multiple methods to arrive at a proper diagnosis of ADHD. There are effective medications for ADHD as well as effective psychosocial treatments for this disorder. The issues in the current literature focus on relative efficacy and effectiveness of individual and combined treatments (see Ramsay & Rostain, 2016 as an example).

Underlying Mechanisms and Measuring Outcomes. Even though the word attention is prominent in the very diagnostic label (ADHD), the problems reflected in this diagnosis actually reflect deficits in more central cognitive processes, especially executive functioning (EF or on the deficit side, ED referring to executive dysfunction). Effective EF is needed for success in most tasks of adulthood in this society – planning, organization, execution, prioritizing, social skill, delay of gratification, and impulse control. Individuals with ADHD as defined in the DSM have difficulty with these tasks, and the issue in much of the literature has focused on whether ED is a correlate of ADHD or a criterial feature of ADHD much like the other symptoms in the DSM. There is uniform agreement that individuals with ADHD have difficulty with EF when it is assessed in addition to assessing the diagnostic symptoms of ADHD. Executive Dysfunction (ED) is the mechanism that translates the diagnosis of ADHD in the life difficulties experienced by adults who have this disorder. Therefore, any assessment or formal tracking of treatment outcomes must also address ED.

Specific Rationale for the Proposed Measurement Process. For the purpose of the proposed measure in this document the work of Adler and his colleagues provides the rationale and justification for the selection of the ASRS as the outcome assessment tool. The ASRS developed by the WHO Workgroup on Adult ADHD, is a patient report rating scale based on DSM ADHD symptoms that has been extensively used in clinical work and in research. (Adler, Kessler & Spencer, 2003; Kessler, et. al., 2005). The ASRS is publicly available and is easy to use in clinical settings. Given that ED central to addressing the impact of treatment it needs to be part of the assessment of outcome. In a series of important papers on this topic Adler and his associates have investigated the relation between ADHD/ED relationship and have demonstrated that independent measures of ED are highly correlated with ADHD symptoms in multiple samples (Adler, Faraone, Spencer, Berglund, Alperine, & Kessler, 2017; Silverstein, Faraone, Alperin, Biederman, Spencer, & Adler, 2018; Silverstein, Faraone, Leon, Biederman, Spencer, & Adler, 2018). In Adler et al. (2017), the intercorrelations between symptoms and ED are so substantial that the argument is made that ED is a core feature of ADHD and not simply a correlate of it. For the purpose of the measure proposed in the current document this work means that using the ASRS serves not only as a symptom measure but also serves as a proxy for the measurement of ED. Therefore, there is substantial empirical support for using only a symptom measure to track outcomes of care because this assessment also measures the mechanism that underlies the surface symptoms that are both reported by patients and observed by researchers.

The use of the ASRS in the current project is iterative step in developing a robust set of metrics and measures for assessing and monitoring the process and outcomes of care for adult ADHD. Also related to ADHD in adults are other emotional issues and quality of life difficulties (Agarwal, Goldenberg, Perry, & Ishak, 2012; Barkley, 2015).While these topics are important, and can be addressed either in metric refinement or new measures, they are excluded from this initial measure in this important area. The identification and development of this measure is consistent with the measure development model developed by the American Psychological Association (APA, see Wright, Goodheart, Bard, Bobbitt, Butt, Lysell, McKay, & Stephens, 2019 for overview of the APA project). Also excluded from this metric is proscription about the type of treatment that patients receive. It is expected that clinicians from different professional backgrounds will draw upon the above referenced Guidelines and also on the extant published literature on clinical best practices.