Reduction in Suicidal Ideation or Behaviour Symptoms

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
Outcome
IOM Quality Dimension
Effectiveness
Domain
Mental Health

Defining Attributes

Definition

The percentage of patients aged 18 years and older with a mental and/or substance use disorder AND suicidal thoughts, behaviours or risk symptoms who demonstrated a reduction in suicidal ideation and/or behaviour symptoms based on results from the Columbia-Suicide Severity Rating Scale 'Screen Version' or 'Since Last Visit' (C-SSRS), within 120 days after an index assessment.

Numerator

Patients who demonstrated a reduction in suicidal ideation and/or behaviour symptoms as demonstrated by results of a follow-up assessment using the C-SSRS within 120 days after the index assessment during the measurement period

Denominator

Patients aged 18 and older with a mental and/or substance use disorder with suicidal ideation and/or behaviour symptoms OR deemed a suicide risk based on their clinician's evaluation at an encounter with an index assessment completed using the C-SSRS during the denominator identification period

Exclusions

Patients whose functional capacity or motivation (or lack thereof) to improve may impact the accuracy of results of validated tools such as delirium, dementia, intellectual disabilities, and pervasive and specific development disorders OR Patients who died 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)
No
Australian Consortium for Aged Care Endorsed
No
Identified by PHARMA-Care Project
No
Upload Date
02 December 2025