| Valid Data Submission Method(s) | Measure Type | High Priority Measure? | NQS Domain | Specialty Measure Sets |
|---|---|---|---|---|
| Registry | Process | Yes | Patient Safety | Neurology, Mental/Behavioral Health |
Measure Description
Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled or referred for counseling regarding safety concerns within a 12 month period
Instruction
This measure is to be reported a minimum of once per performance period for patients with a diagnosis of dementia seen during the performance period. This measure may be reported by eligible clinicians who perform the quality actions described in the measure based on the services provided and the measure-specific denominator coding.
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, F01.50, F01.51, F02.80, F02.81, F03.90, F03.91, F05, F06.8, G30.0, G30.1, G30.8, G30.9, G31.01, G31.09, G31.83
AND
Patient encounter during the performance period (CPT): 90791, 90792, 90832, 90834, 90837, 96116, 96118, 96119, 96120, 96150, 96151, 96152, 96154, 97165, 97166, 97167, 97168, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99304, 99305, 99306, 99307, 99308, 99309, 99310, 99324, 99325, 99326, 99327, 99328, 99334, 99335, 99336, 99337, 99341, 99342, 99343, 99344, 99345, 99347, 99348, 99349, 99350
WITHOUT
Telehealth Modifier: GQ, GT
Numerator
Patients or their caregiver(s) who were counseled or referred for counseling regarding safety concerns within a 12 month period
Numerator Instructions: Counseling 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 recommendation or referral 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 Options:
Performance Met: Safety counseling for dementia provided (6101F)
OR
Performance Met: Safety counseling for dementia ordered (6102F)
OR
Denominator Exception: Documentation of medical reason(s) for not providing counseling regarding safety concerns (eg, patient in palliative care, other medical reason) (6101F with 1P)
OR
Denominator Exception: Documentation of medical reason(s) for not ordering safety counseling (eg, patient in palliative care, other medical reason) (6102F with 1P)
OR
Performance Not Met: Safety counseling for dementia not provided, reason not otherwise specified (6101F with 8P)
OR
Performance Not Met: Safety counseling for dementia not ordered, reason not otherwise specified (6102F with 8P)