Patient Reported Falls and Plan of Care

Identifying Attributes

Care Settings
Dementia Care
Country
United States of America
Publishing Organisation
Centers for Medicare & Medicaid Services (CMS): Merit-based Incentive Payment System (MIPS) Value Pathways (MVPs)
Type of Quality Indicator
Outcome
IOM Quality Dimension
Safety
Domain
Managing Other Long-Term Conditions

Defining Attributes

Definition

Percentage of patients (or caregivers as appropriate) with an active diagnosis of a movement disorder, multiple sclerosis, a neuromuscular disorder, dementia, or stroke who reported a fall occurred and those that fell had a plan of care for falls documented at every visit

Numerator

A. Patients (or caregivers as appropriate) that reported a fall* occurred since the last visit B. and those that fell had a plan of care^ for falls documented at every visit

*Fall: A sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground, other than as a consequence of a sudden onset of paralysis, epileptic seizure, overwhelming external force, or overwhelming environmental hazards

^Plan of care must include: Balance, strength, or gait training OR Referral to physical or occupational therapy OR Home safety evaluation

Denominator

Patients with an active diagnosis of a movement disorder, multiple sclerosis, a neuromuscular disorder, dementia, or stroke

Exclusions

Patients diagnosed with any of the following disorders: • Syncope • Vertigo and related disorders • Restless leg syndrome • Tourette syndrome/tic disorder • Back pain • Concussion/mTBI • Cervical dystonia • Epilepsy

Use of Risk Adjustment
No
Risk Adjustments
Stratifications

Collection and Reporting Attributes

Type of Data Collection
Standardised clinical data
Data Collection Methods

Qualified Clinical Data Registry (QCDR), which is a Centers for Medicare & Medicaid Services (CMS) approved vendor for the Merit-Based Incentive Payment System (MIPS). QCDR collects clinical data from clinicians and reports this data to CMS on their behalf for purposes of MIPS.

Frequency of Data Collection
Per performance period
Frequency of Data Collection in Days
Reporting Methods

Data not public available

Reporting Frequency
Reporting Frequency in Days
Indicator Has Recommended Targets
No

Source and Reference Attributes

Technical Specifications
Link to Measurement Tools
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)
No
Australian Consortium for Aged Care Endorsed
No
Identified by PHARMA-Care Project
No
Upload Date
02 December 2025