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Mrs. S., 68 years old, suffers from end-stage liver disease. Her husband, Mr. F., cares for her at home; however, it has been increasingly difficult for him as her condition has progressed and she has had to go to the hospital more frequently over the past year. While Mrs. S. has been making her own medical decisions and has stated on numerous occasions that she hates the hospital and prefers to stay at home, there is no advance directive in her medical chart.

Recently, Mrs. S. was admitted to the Intensive Care Unit (ICU) due to confusion, lethargy, and seizures – symptoms of severe hepatic encephalopathy. The ICU hospitalist, Dr. C., informed the family that their loved one was experiencing recurring internal bleeding and no longer had decisional capacity. Dr. C. recommended hospice care, but the family wanted to do everything medically possible to prolong her life. Mrs. S. died in the ICU three days after slipping into a coma.

What kind of end-of-life care and experience would Mrs. S. have wanted? Other than the fact that she hated being in the hospital, no one really knew her wishes because there was no conversation (or documentation) to find out. Sadly, this kind of scenario plays out every day.

Advance care planning (ACP) is an evidence-based process that identifies, documents, plans, and adjusts patients’ medical care to meet their stated goals and wishes. Healthcare systems have the opportunity to improve the end-of-life care experience through ACP; however, recent data indicate that less than 60 percent of older adults have had an ACP discussion and only half of them have completed any legal documentation. A new HEDIS measure aims to avoid cases like Mrs. S. by incentivizing ACP within health plans.

 

What is HEDIS?

The Healthcare Effectiveness Data and Information Set – HEDIS – was developed by the National Committee for Quality Assurance (NCQA) to measure the clinical quality of health plans, including commercial, Medicare, and Medicaid. As one of the most widely used performance improvement tools, HEDIS includes more than 90 measures across six domains of care. The measures cover many aspects of healthcare including preventive care such as screening tests and immunizations, management of physical and mental health conditions, access and availability of care, patient experience, utilization, and relative resource use.

NCQA uses the data to report on and rate the care delivered by health plans and other healthcare organizations. These reports are used by employers and consumers to assess and compare the quality of health plans. Health plans can use HEDIS performance data to identify opportunities for improvement, monitor the success of quality improvement initiatives, and track performance. In a value-based care environment, many payers use HEDIS quality measures to determine reimbursements to providers.

 

What is the New Advance Care Planning HEDIS Measure for 2022?

According to an August 2021 NCQA announcement, HEDIS added a new ACP measure for MY (measurement year) 2022, which includes two components:

• The percentage of Medicare members 65-80 years of age with advanced illness, indication of frailty or receiving palliative care; and
• The percentage of adults 81 years and older who had ACP during the measurement year

To be counted, the ACP discussion or documentation about a patient’s end-of-life care preferences must be documented in the medical record on or before December 31st of the MY.

As part of the update, NCQA is retiring the Advance Care Planning Indicator that falls under Care for Older Adults (COA), as this clinical topic is now addressed with the new measure. Also, this is a first-year measure for HEDIS MY 2022 and is applicable to the Medicare line of business.

 

Why it Matters

The intent of the new ACP measure is as follows:

“Advance care planning is associated with improved quality of life, increased provider trust and decreased hospitalization. This measure will allow plans to understand if advance care planning is provided to beneficiaries who are most likely to benefit from it.”   

According to the Urban Institute, the number of adults aged 65 years and older will reach 80 million – or one in five Americans – in 2040 and 15 million of those will be age 85 and older, which is more than double the number in 2020.

This rapidly growing population of older adults are considered “high-risk” and “high-cost” when it comes to healthcare. About 85 percent of older adults are living with at least one chronic health condition, while 57 percent of older adults with a serious illness are age 80 or older. Their health status not only puts them at increased risk of higher healthcare utilization, but also significantly lower quality of life.

ACP is a crucial part of optimizing population health and avoiding situations – like the one with Mrs. S. – in which the medical care wishes of patients are unknown and subsequently not carried out.

Is your healthcare organization interested in implementing or improving an ACP initiative? Read this blog article to learn how to increase ACP uptake, check out these real-world case studies to see how other organizations have implemented ACP Decision’s Video Library platform to improve ACP conversations with their patients, or contact us today to learn how to get started!

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