HCH Care Coordination Measures:
Advance Care Planning
Description
Percentage of patients age 65 or greater at the start of the measurement year who have evidence
(documentation) of advance care planning in their medical record at their health care home clinic.
Methodology
Population identification is accomplished via a query of a practice management system or Electronic
Medical Record (EMR) to identify the population of eligible patients (denominator). Data elements are
either extracted from an EMR system or abstracted through medical record review.
Rationale
In its influential report Crossing the Quality Chasm, the Institute of Medicine (2001) called for ‘patientcentered care’ that explicitly considers the preferences and desires of the patients. Bioethicists concur
that physicians should share, and in some cases delegate, medical decision-making control to dying
patients and their families (President’s Council on Bioethics, 2005). In practice, however, many dying
persons are unable to convey their preferences for medical treatments because they are incapacitated
when the decision is required (Field and Cassel, 1997). As such, difficult decisions about stopping or
continuing treatment often fall to family members, who may be distressed and may disagree among
themselves about appropriate care (Kramer et al., 2006). When families and health-care providers
cannot agree on a course of action, the default decision typically is to continue treatments, which may be
financially and emotionally draining for family members, and physically distressing to the patient (Field
and Cassel, 1997). In an effort to prevent problematic, futile, or contested end-of-life, practitioners
encourage older adults to express and document their treatment preferences when they are still on good
health (American Medical Association, 1996). (NIH Public Access, Social Forum (Randolph NJ). 2009
December1:24 (4): 754-778.)
Minnesota Honoring Choices:
According to a Harvard Medical School study, nearly half of patients with metastasized lung cancer and
their doctors did not discuss hospice care within four to seven months of their diagnosis.
A recent University of Pittsburgh study showed that when people with Medicare were asked about their
treatment preferences if diagnosed with a terminal illness, the majority did not prefer life-prolonging
measures.
However, the study found a correlation between end-of-life care preferences and race. African
Americans and Hispanics were both more likely to opt for intensive end-of-life care. African Americans
were twice as likely as whites to say they would want life-prolonging treatments. Theories for this
difference include: belief that the health care system is racially biased, communication barriers, and lack
of a regular doctor, which makes end-of-life discussions more difficult within the limited patientphysician relationship. The likelihood of a patient-physician discussion about hospice varied with race
and ethnicity, according to a Harvard study. Hispanics (43%) and African Americans (49%) were less likely
to have discussions than whites (53%) and Asians (59%).
Having a standard of care for physicians to offer patients advance care planning, as they would offer a
screening for colorectal cancer, might help decrease disparities in care and increase patient confidence
that their wishes will be adhered to.
Minnesota’s Health Care Home certification requires under Care Planning, Subp. 7A, that a health care
home must include goals and an action plan for end-of-life care and health care directives, when
appropriate. (MDH)
HEDIS initiated a health care directives (also known as ‘advance directive’) measure in 2011, as part of
the Care for Older Adults (COA) measure, and reports the percent of commercial/Medicaid and Medicare
patients with advance care planning that occurred in that measurement year.
Measurement
Period
Measurement period will be a fixed 12 month period: mm/dd/yyyy to mm/dd/yyyy.
Denominator
Established patient who meets each of the following criteria is included in the population:
Eligible Providers,
Specialties, and
Clinics
•
Patient age 65 years or greater at the start of the measurement period (date of birth was on or
between mm/dd/yyyy to mm/dd/yyyy).
•
Patient was seen by an eligible provider in an eligible specialty face-to-face at least two times
during the last two years (mm/dd/yyyy to mm/dd/yyyy) for any reason by a certified health care
home clinic. Use this date of service range when querying the practice management or EMR
system to allow a count of the visits within this time frame.
•
Patient was seen by an eligible provider in an eligible specialty face-to-face at least one time
during the last 12 months (mm/dd/yyyy to mm/dd/yyyy) for any reason by a certified health
care home clinic.
Eligible Clinics: Certified Health Care Home Clinics
Eligible specialties: Family Medicine (Includes General Practice), Internal Medicine, and Geriatric
Medicine, or any other board certified specialty that is health care home certified.
Eligible providers: Medical Doctor (MD), Doctor of Osteopathy (DO), Physician Assistant (PA), Nurse
Practitioner (NP)
Allowable
Exclusions
There are no allowable exclusions for this measure.
Numerator
Percentage of patients age 65 or greater at the start of the measurement year with evidence of advance
care planning in their medical record. Patient has a written advance care plan in the chart with the
following documented:
o
o
Measure
Calculation
The patient’s wishes are outlined
The patient’s decision-maker is defined
Patients age 65 or greater at the start of the measurement year with evidence (documentation) of
advance care planning in their medical record at their health care home clinic
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Established Patients age 65 or greater at the start of the measurement year