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Persistent Indicators of Dementia without a Diagnosis—Short Stay

CBE ID
2092
1.5 Project
Endorsement Status
1.0 New or Maintenance
1.1 Measure Structure
Previous Endorsement Cycle
Is Under Review
No
1.6 Measure Description

Number of adult patients 65 and older who are included in the denominator (i.e., have persistent signs and symptoms of dementia) and who do not have a diagnosis of dementia on any MDS assessment.

    Measure Specs
      General Information
      1.7 Measure Type
      1.3 Electronic Clinical Quality Measure (eCQM)
      1.8 Level of Analysis
      1.9 Care Setting
      1.14 Numerator

      Number of adult patients 65 and older who are included in the denominator (i.e., have persistent signs and symptoms of dementia) and who do not have a diagnosis of dementia on any MDS assessment.

      1.15 Denominator

      The denominator is the total of all short-stay residents in the nursing facility who have at least two MDS PPS assessments (A0310 = 01. 5-day scheduled assessment or 02. 14-day scheduled assessment or 03. 30-day scheduled assessment or 04. 60-day scheduled assessment or 05. 90-day scheduled assessment or 06. Readmission/return assessment), and who do not meet the exclusion criteria.

      The denominator includes (i) residents with Section C Brief Interview for Mental Status (BIMS) score <8 on most recent target assessment and a BIMS < 8 on the prior assessment; or (ii) residents with a staff assessment for cognitive status on both the most recent target assessment and the prior assessment that shows severe cognitive impairment.

      Exclusions

      Residents who are hospice or end of life, or who are comatose or with delirium, manic depressive disease, bipolar disorder or schizophrenia will be excluded from the denominator.

      Most Recent Endorsement Activity
      Measure Retired and Endorsement Removed Neurology Project 2015-2016
      Initial Endorsement
      Last Updated
      Removal Date
      Steward Organization
      American Medical Directors Association
      Steward POC email
      jvance@amda.com
                Public Comments