Updated Dementia Management Quality Measures

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Updated Dementia Management Quality Measures

Summary of Quality Measurement Set for Clinicians

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What's New?

  • Three measures retired
  • Three measures added
  • Greater specificity in six updated measures, making it easier to understand what you need to do to meet measure requirements

“Dementia” is a term used to describe a group of symptoms related to cognitive and functional decline, usually with a neurodegenerative etiology. For the purposes of this document, the term “dementia” is used as a catchall phrase for the diseases and disorders that cause dementia symptoms. For a complete list of diagnostic codes, please see Appendix A of the measurement specifications.

Disclosure of Dementia Diagnosis (New 2015 Measure)

Measure Description: Percentage of patients with a diagnosis of a qualifying dementing disorder or disease whose diagnosis has been disclosed to them and, if available, their primary caregiver.

Numerator: Patients and patient/caregiver dyads with a diagnosis* of a qualifying dementing disorder or disease who have been told (1) that they have dementia and (2) what disease is most likely responsible.

* “Diagnosis” is defined as the provider’s best current opinion about dementia etiology, which may include a disclosure that diagnosis remains unknown or that a previous diagnosis must be revised.

Denominator: All patients with a diagnosis of a qualifying dementing disorder or disease.

Denominator Exclusions:

  • Diagnosis previously disclosed (i.e., patient or caregiver provides diagnosis to provider, previous disclosure documented in medical record, or patient or caregiver states they were previously informed.)
  • Disclosure offered, but patient declines information on their diagnosis.
  • Patient does not have caregiver.

Education and Support of Caregivers for Patients with Dementia

Measure Description: Percentage of patients with dementia whose caregiver(s)* were provided with education** on dementia disease management and health behavior changes AND were referred to additional resources*** for support in the last 12 months.

Numerator: Patients with dementia whose caregiver(s) were provided with education on dementia disease management and health behavior changes AND were referred to additional resources for support in the last 12 months.

* “Caregiver” is broadly defined and the work group adopted the definition utilized by the National Quality Forum and Feinberg.1 Caregiver refers to any relative, partner, friend, or neighbor who has a significant relationship with, and who provides a broad range of assistance for, an older adult or an adult with chronic or disabling conditions.1

** “Education” requires learning and processing information about disease management and health behavior changes. This should also include advising the caregiver that, as a caregiver, he or she is at “increased risk of serious illness (including circulatory and heart conditions and respiratory disease and hypertension), increased physician visits and use of prescription medications, emotional strain, anxiety, and depression.”2 Providers are encouraged to review state-specific guidelines to ensure education is being provided as required.

*** “Additional Resources” are defined as situation-specific, tailored programs to assist the caregiver; these included national organizations such as the Alzheimer’s Association, but also include local resources, such as community, senior center, and religion-based support groups.

Denominator: All patients with dementia.

Denominator Exclusions:

  • Patient does not have a caregiver.
  • Caregiver is trained and certified in dementia care.
  • Patient/caregiver dyad has been referred to appropriate resources and connection to those resources confirmed.

Functional Status Assessment for Patients with Dementia

Measure Description: Percentage of patients with dementia for whom an assessment of functional status was performed at least once in the last 12 months.

Numerator: Patients with dementia for whom an assessment of functional status* was performed at least once in the last 12 months.

* “Functional status” is assessed by use of a validated tool, direct assessment of the patient, or by querying a knowledgeable informant. A direct assessment of functional status includes an evaluation of the patient’s ability to perform instrumental activities of daily living (IADL) (i.e., money management, medication management, transportation, cleaning, and cooking) and basic activities of daily living (ADL) (i.e., grooming, bathing, dressing, eating, toileting, gait, and transferring). Documentation why an assessment could not be completed due to advanced stage of dementia in combination with a lack of a knowledgeable informant would meet the measure criteria.

Functional status assessment tools suggested for use in this measure include, but are not limited to:

  • Lawton Instrumental Activities of Daily Living Scale
  • Barthel ADL Index
  • Katz Index of Independence in Activities of Daily Living
  • Functional Activities Questionnaire

Denominator: All patients with dementia.

Numerator:Denominator Exclusions: None.

Screening and Management of Behavioral and Psychiatric Symptoms Associated with Dementia

Measure Description: Percentage of patients with dementia for whom there was a documented screening for behavioral and psychiatric symptoms, including depression, and for whom, if screening positive, there was also documentation of recommendations for management in the last 12 months.

Numerator: Patients with dementia for whom there was a documented screening* for behavioral and psychiatric symptoms, including depression in the last 12 months and for whom, if screening was positive, there was also documentation of recommendations for management in the last 12 months.

* “Screening” is defined as using a validated instrument or directly examining the patient or knowledgeable informant to determine the presence or absence of symptoms from three domains: activity disturbances, mood disturbances (including depression), and thought and perceptional disturbances.

The following is a non-exhaustive list of symptoms falling into each of the three domains pertinent to this measure:

Activity disturbances (To meet measure, patient or knowledgeable informant must be screened for at least one symptom from this list):

  • Agitation
  • Wandering
  • Purposeless hyperactivity
  • Verbal or physical aggressiveness
  • Resisting care
  • Apathy
  • Impulsiveness
  • Socially inappropriate behaviors
  • Eating disturbances
  • Sleep problems
  • Diurnal/sleep-wake cycle disturbances
  • Repetitive behavior

Mood disturbances (To meet measure, patient or knowledgeable informant must be screened for depression and at least one more symptom from this list):

  • Anxiety
  • Elation
  • Irritability
  • Mood lability/fluctuations

Thought and perceptual disturbances (To meet measure, patient or knowledgeable informant must be screened for at least one symptom from this list):

  • Having fixed false beliefs (delusions)
  • Hearing or seeing non-present entities (hallucinations)
  • Paranoia

Examples of reliable and valid instruments that are commonly used in research settings and that can be used to assess behavior include, but are not limited to:

Dementia Signs and Symptoms (DSS) Scale or Neuropsychiatric Inventory (NPI). The assessment of behavioral status may include the assessment of Behavioral and Psychological Symptoms of Dementia (BPSD). For patients residing in nursing homes, it may include an assessment of the behavioral symptom items from the Minimum Data Set (MDS).

Denominator: All patients with dementia.

Numerator:Denominator Exclusions: None.

Safety Concern Screening and Follow-up for Patients with Dementia

Measure Description: Percentage of patients with dementia or their caregiver(s) for whom there was a documented safety screening in two domains of risk: (1) dangerousness to self or others and (2) environmental risks, and for whom, if screening positive, there was documentation they were provided with recommendations for their mitigation, which may include referral to other resources, in the last 12 months.

Numerator: Patients with dementia or their caregiver(s) for whom there was a documented safety screening in two domains of risk: (1) dangerousness to self or others and (2) environmental risks; and if screening was positive in the last 12 months, there was documentation of mitigation recommendations, including, but not limited, to referral to other resources.

The following is a non-exhaustive list of safety concerns in the two domains pertinent to this measure. To meet measure requirements, a patient’s medical record must have documentation of being screened on at least one concern from each of the two domains.

Dangerousness to self (patient) or others (caregivers and other individuals)

  • Medication misuse
  • Physical aggressiveness
  • Wandering, including addressing precautions that may include physical measures (e.g., locks, fences or hedges), video surveillance, GPS monitoring and Safe Return programs, personal companions, schedule modifications (e.g., adult day care and day programs), rehabilitative measures, and risk mitigation strategies
  • Inability to respond rapidly to crisis/household emergencies
  • Financial mismanagement, including being involved in “scams”
  • Other concerns raised by patient or their caregiver

Environmental risks

  • Home safety risks that could arise from cooking or smoking
  • Access to firearms or other weapons
  • Access to potentially dangerous chemicals and other materials
  • Access to and operation of tools and equipment
  • Trip hazards in the home increasing the risk of falling
  • Other concerns raised by patient or their caregiver

Denominator: All patients with dementia.

Numerator:Denominator Exclusions: Patient unable to communicate and informant not available.

Driving Screening and Follow-up for Patients with Dementia

Measure Description: Percentage of patients with dementia for whom there was a documented screening for driving risks and for whom, if screening positive, there was also documentation they were informed of alternatives to driving in the last 12 months.

Numerator: Patients with dementia for whom there was a documented screening for driving risks and for whom, if screening positive, there was also documentation they were informed of alternatives to driving in the last 12 months.

Denominator: All patients with dementia.

Numerator:Denominator Exclusions: None (The work group removed the prior exception for those no longer driving based on feedback from those who had implemented the measure in practice. It is not the intent of the work group to require unnecessary screening for individuals who are no longer driving due to advanced dementia and other health co-morbidities (i.e., bed bound) for which screening is completed via a visual review of patient’s physical status and documentation that patient is not driving.)

Advance Care Planning and Palliative Care Counseling for Patients with Dementia

Measure Description: Percentage of patients with dementia who

  1. have an advance care plan or surrogate decisions maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan AND

Patients with dementia or their surrogate decision maker who

  1. received comprehensive counseling regarding ongoing palliation and symptom management, and end of life decisions within two years of initialdiagnosis or assumption of care.

Numerator: Patients with dementia who

  1. have an advance care plan or surrogate decisions maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan AND

Patients with dementia or their surrogate decision maker who

  1. received comprehensive counseling* regarding ongoing palliation and symptom management, and end of life decisions within two years of initial diagnosis or assumption of care.

* Comprehensive counseling regarding end of life decisions (recognition of end-stage dementia, goals of care, comfort care and hospice referral) is defined as a discussion of the risks and benefits of the following medical interventions to address the major clinical issues associated with advanced dementia:

  • Hospitalization
  • Treatment for infections
  • Surgery
  • Artificial nutrition and hydration
  • Cardiopulmonary resuscitation
  • Mechanical ventilation

Denominator: All patients with dementia.

Numerator:Denominator Exclusions: Patients who at time of intake had advanced dementia for whom there was no record of advance care planning or surrogate decision-maker prior to their admission.

Pain Assessment and Follow-up for Patients with Dementia (New 2015 Measure)

Measure Description: Percentage of patients with dementia who underwent documented screening for pain symptoms at every visit and if screening positive also had a documentation of a follow-up plan.

Numerator: Patients with dementia who underwent documented screening* for pain symptoms at every visit and if screening was positive also had documentation of a follow-up plan**.

* “Screening” is defined as use of a validated screening tools approved for use in this measure include, but are not limited to:

  • Pain Assessment in Advanced Dementia (PAINAD) Pain Assessment Checklist for Seniors with Limited Ability to Communicate (PACSLAC or PACSLAC-II)
  • Visual Analog Scale and Verbal Pain Intensity Scale
  • Pain Assessment for the Dementing Elderly (PADE)
  • Likert Pain Scale
  • Minimum data set (MDS)–version 3.0, Section J

OR evaluation of verbal and non-verbal expressions of pain behaviors (i.e., changes in breathing quality, negative types of verbalization separate from breathing, facial expression, body language) medication usage.

** “Follow-up plan” must include documentation and rationale for treatment considerations. Health care providers may consider analgesic, NSAID, long acting agents, liniments, massage, lidocaine patches, physical therapy, or orthopedic evaluation.

Denominator: All patients with dementia.

Numerator:Denominator Exclusions: None.

Pharmacological Treatment of Dementia (New 2015 Measure)

Measure Description: Percentage of patients with dementia or their caregivers with whom available guideline-appropriate pharmacological treatment options and nonpharmacological behavior and lifestyle modifications were discussed at least once in the last 12-month period.

Numerator: Patients with dementia or their caregivers with whom available guideline-appropriate pharmacological treatment options and nonpharmacological behavior and lifestyle modifications were discussed at least once in the last 12-month period

Denominator: All patients with dementia.

Denominator Exclusions: None.

References

  1. National Quality Forum. Priority Setting for Healthcare Performance Measurement: Addressing Performance Measure Gaps for Dementia, including Alzheimer’s Disease. October 2014. 75p.
  2. California Workgroup on Guidelines for Alzheimer’s Disease Management. Guidelines for Alzheimer’s disease management. Los Angeles, CA: Alzheimer’s Disease and Related Disorders Association, Inc., Los Angeles Chapter. 2008.

© 2016 American Academy of Neurology and American Psychiatric Association