Advanced Illness and Frailty Exclusions 2025

Healthcare Effectiveness Data Information Set^® (HEDIS) is a widely used set of performance measures developed and maintained by NCQA. These are used to drive improvement efforts surrounding best practices.

Definitions:

• Advanced illness: severe chronic conditions that cause general health and function decline
• Frailty: limited mobility or physical functional impairment that may require the use of durable medical equipment

Important notes:

• The following section from HEDIS 2025 targets optimizing care for advanced illness and frailty patients.
• Frailty and advanced illness measures apply to various medical realms from cancer to diabetes.
• This reference notes exclusions or adjustments made to enhance care, ensuring it aligns more closely with the patient's health status.

Purpose

For those with limited life expectancy or advanced illness, the services identified in some measures may not be relevant or in line with the patient’s goals of care. By implementing these exclusions, this population can focus on care that is more appropriate for their conditions and health status (for example, improving care transitions, getting follow‑up after acute care episodes, or avoiding preventable hospitalizations). Exclusions also aim to ensure that frail older adults are not burdened with unnecessary tests or treatments that would benefit them little and may even pose harm.

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