HEDIS 2024 updates: exclusive insights on advanced illness and frailty exclusions

Description

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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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

Frailty

At least two indications of frailty with different dates of service during 2024

Advanced illness

Any of the following during 2023 and/or 2024 meet criteria:

• At least two outpatient visits, observation visits, emergency department visits, telephone visits, e‑visits, virtual check-ins, or non-acute inpatient discharges (the diagnosis must be on the discharge claim) on different dates of service with an advanced illness diagnosis. Visit type does need not be the same for the two visits.
• At least one acute inpatient encounter with an advanced illness diagnosis on the discharge claim.
• At least one acute inpatient discharge with an advanced illness diagnosis on the discharge claim.
• A dispensed dementia medication:
  • Cholinesterase inhibitors (donepezil, galantamine, rivastigmine)
  • Miscellaneous central nervous system agents (memantine)
  • Dementia combinations (donepezil-memantine)

Note: Exclusions for advanced illness, frailty, and dispensed dementia medications must come from claims.

Breast Cancer Screening (BCS-E)

66 years of age and older* with frailty and advanced illness

Blood Pressure Control for Patients With Diabetes (BPD)

66 years of age and older* with frailty and advanced illness

Colorectal Cancer Screening (COL-E)

66 years of age and older* with frailty and advanced illness

Controlling High Blood Pressure (CBP)

66 to 80 years of age* with frailty and advanced illness or 81 years old and older* with frailty

Cardiac Rehabilitation (CRE)

66 to 80 years of age* with frailty and advanced illness or 81 years old and older* with frailty

Eye Exam for Patients With Diabetes (EED)

66 years of age and older* with frailty and advanced illness

Glycemic Status Assessment for Patients With Diabetes (GSD)

66 years of age and older* with frailty and advanced illness

Kidney Health Evaluation for Patients With Diabetes (KED)

66 to 80 years of age and older* with frailty and advanced illness or 81 years of age and older* with frailty

Use of Imaging Studies for Low Back Pain (LBP)

66 years of age and older* with frailty and advanced illness

Osteoporosis Management In Women Who Had a Fracture (OMW)

67 to 80 years of age* with frailty and advanced illness or 81 years old and older* with frailty

Osteoporosis Screening in Older Women (OSW)

66 years of age and older* with frailty and advanced illness

Persistence of Beta-Blocker Treatment After a Heart Attack (PBH)

66 to 80 years of age* with frailty and advanced illness or 81 years old and older* with frailty

Adherence to Antipsychotic Medications for Individuals With Schizophrenia (SAA)

66 to 80 years of age* with frailty and advanced illness or 81 years old and older* with frailty

Statin Therapy for Patients With Cardiovascular Disease (SPC)

66 years of age and older* with frailty and advanced illness

Statin Therapy for Patients With Diabetes (SPD)

66 years of age and older* with frailty and advanced illness

Examples (lists not inclusive)

Advanced illness:

• Alcoholic fibrosis and cirrhosis of the liver
• Alzheimer’s disease
• Chronic and acute heart failure, various stages
• Chronic renal disease
• Chronic respiratory failure
• Dementia
• Emphysema
• Hepatitis
• Hypertensive heart disease
• Leukemia
• Malignant neoplasms of specific sites
• Parkinson’s disease
• Pulmonary fibrosis
• Rheumatic heart failure

Frailty:

• Ataxic gait
• Cane, walker, wheelchair*
• Commode chair*
• Dependence on enabling machines and devices
• Difficulty in walking
• Falls
• Home ventilator
• Hospital bed*
• Nursing care in home
• Portable and stationary oxygen*
• Pressure ulcer
• Private duty nursing
• Registered nurse (RN) skilled services
• Weight loss or underweight

* Requires a prescription. Medical equipment must be billed during 2024.