Advance Care Plan

Identifying Attributes

Care Settings
Primary Care
Country
United States of America
Publishing Organisation
Centers for Medicare & Medicaid Services (CMS): Traditional Merit-based Incentive Payment System (MIPS)
Type of Quality Indicator
Process
IOM Quality Dimension
Effectiveness
Domain
End of Life and Palliative Care

Defining Attributes

Definition

Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision 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

Numerator

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

Denominator

All patients aged 65 years and older.

Exclusions

Hospice services received by patient any time during the measurement period

Use of Risk Adjustment
No
Risk Adjustments
Stratifications

Collection and Reporting Attributes

Type of Data Collection
Administrative data
Data Collection Methods

MIPS Clinical Quality Measures (CQMS)

Frequency of Data Collection
Annually
Frequency of Data Collection in Days
365
Reporting Methods

Traditional MIPS

Reporting Frequency
Annually
Reporting Frequency in Days
365
Indicator Has Recommended Targets
No

Source and Reference Attributes

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
Yes
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
Identified by PHARMA-Care Project
No
Upload Date
02 December 2025