Advance Care Planning

Identifying Attributes

Care Settings
Care Transitions
Country
United States of America
Publishing Organisation
American Case Management Association: Transitions of Care project
Type of Quality Indicator
Process
IOM Quality Dimension
Effectiveness
Setting-Specific Domain
Appropriate Care

Defining Attributes

Definition

The percentage of adults aged 65 years and older who have an advanced care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advanced 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.

Numerator

Adults aged 65 years and older who have an advanced care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advanced 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.

Denominator

Adults aged 65 years and older with an eligible encounter during the measurement period (inferred).

Exclusions
Use of Risk Adjustment
No
Risk Adjustments
Stratifications

Collection and Reporting Attributes

Type of Data Collection
Data Collection Methods
Frequency of Data Collection
Frequency of Data Collection in Days
Reporting Methods

CMS Inpatient and Outpatient Quality Reporting programs

Reporting Frequency
Reporting Frequency in Days
Indicator Has Recommended Targets
No

Source and Reference Attributes

Technical Specifications
Link to Measurement Tools
Domain
Not Assigned
Quality Indicator Confirmed to be Part of a Program Used to Monitor Quality and Safety of Care Among Older People at a Population-Level between 2012-2022
No
Assessed by the Australian Consortium for Aged Care Collaborators as Generally Containing Good Properties (Importance and Scientific Acceptability)
Yes
Australian Consortium for Aged Care Endorsed
Yes
Can the Quality Indicator be Readily Implemented at a Population Level in Australia Given its Current Data Landscape?
No. Data exists but not formatted in a useable manner.
Identified by PHARMA-Care Project
No
Upload Date
23 July 2025