Advance Care Plan

Identifying Attributes

Care Settings
Primary Care
Country
United States of America
Publishing Organisation
Centers for Medicare & Medicaid Services (CMS): Primary Care First Model
Type of Quality Indicator
Process
IOM Quality Dimension
Effectiveness
Domain
End of Life and Palliative Care

Defining Attributes

Definition

Percentage of 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.

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

Patients who are 65 years of age or older with an eligible encounter during the measurement period.

Exclusions

Patients who received hospice services during the measurement period.

Use of Risk Adjustment
No
Risk Adjustments

None

Stratifications

Collection and Reporting Attributes

Type of Data Collection
Administrative data
Data Collection Methods

Digital-Clinical Registries

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