Safety Concern Screening and Follow-Up for Patients With Dementia

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
Process
IOM Quality Dimension
Effectiveness
Domain
Person-Centred Care

Defining Attributes

Definition

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

Numerator

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

Denominator

All patients with a diagnosis of dementia

Exclusions

Documentation patient unable to communicate and informant not available

Use of Risk Adjustment
No
Risk Adjustments
Stratifications

Collection and Reporting Attributes

Type of Data Collection
Administrative data
Data Collection Methods

Data may be submitted by individual MIPS eligible clinicians, groups, or third party intermediaries

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