Safety concern screening and follow-up for patients with dementia

Measure Purpose: Identify and address safety concerns

The numerator: patients with dementia or their caregiver(s) for whom there was a documented safety screening in two domains of risk:

(1) dangerousness to self or others and

(2) environmental risks;

and if screening was positive, there was documentation of mitigation recommendations, including, but not limited to referral to other resources

is divided by

the denominator: all patients with dementia (see measure specification for the complete list of qualifying diagnoses.)

Exclusion is removed from the denominator:

• Patient unable to communicate and informant not available.

Key Phrases

Examples of key phrases you could use to meet this measure:

Environmental

• Discuss fences
• Discuss use of locks

Dangerousness to self and other

• Discussed access to firearms
• Discussed trip hazards in the home

Mitigation

• Remove firearms
• Clear walking paths inside home
• Install fence or hedge

Measure Calculation Example

Dr. Johnson sees 100 patients with dementia between January 1 and December 31. This is the denominator. Five patients are unable to communicate and do not have an informant present. These five are removed from the denominator.

Of the remaining 95 patients, Dr. Johnson assesses 50 patients for dangerousness to self and others. Of those 50 patients, 40 were also screened for environmental risk factors. Of these 40 patients screened, 10 had a positive screening warranting mitigation recommendations. Dr. Johnson documents mitigation recommendations for 8 of the 10 patients. The numerator is 38. Thirty patients screened with no mitigation needs plus eight patients who screened positive and had mitigation recommendations documented.

Quality of patient care = (30+8)/(100-5). Dr. Johnson has a score of 40% for this measure.