The Centers for Medicare & Medicaid Services (CMS) finalized adoption of the Advance Care Planning electronic Clinical Quality Measure (eCQM) as a new self-selected electronic quality measure in the FY 2027 finalized Inpatient Prospective Payment System (IPPS) ruling.
This additional quality metric is expected to start voluntarily CY 2028 and will be mandatory in calendar year (CY) 2029 reporting period for the fiscal year (F) 2031 payment determination under both the Hospital Inpatient Quality Reporting (IQR) Program and the Medicare Promoting Interoperability Program.
This measure was very clear on going beyond asking the question, “Do you have an Advance Directive?” Instead, CMS intentionally designed the measure to recognize multiple ways hospitals can demonstrate meaningful advance care planning either by verifying appropriate documents exist in the medical record or clear documentation exists to support this measure.
A patient meets the numerator if any one of the following exists by hospital discharge from an inpatient encounter:
- A documented health care proxy or medical power of attorney
- An advance directive or living will
- A POLST, MOLST, or qualifying DNR order
- Documentation of an advance care planning discussion that resulted in a documented decision in the electronic medical record (EMR)
Importantly, the measure does not require a new document to be completed during every hospitalization. Existing advance care planning documentation already available within the patient’s EMR satisfies the measure, provided it remains accessible during the admission. CMS intentionally declined recommendations to require hospitals to create or revise documentation on every encounter, recognizing that doing so would increase burden without necessarily improving patient care.
Another notable aspect of the final rule is the broad denominator. The measure applies to all inpatient hospitalized adults aged 18 years and older, regardless of diagnosis, severity of illness, or length of stay. CMS specifically rejected recommendations to limit the measure to oncology patients, older adults, ICU patients, or patients with extended hospitalizations.
CMS emphasized in the final rule comments that serious illness, unexpected injury, and loss of decision-making capacity can occur at any age, making advance care planning relevant for every adult patient admitted to an acute care hospital. For hospitals accustomed to focusing advance directive discussions primarily on older adults or palliative care populations, this represents a substantial workflow expansion.
Interestingly enough in the comments there was also discussion from the public raising concern that this measure would inadvertently force uncomfortable end-of-life discussions during acute hospitalizations. I thought that was interesting from a case manager and social work perspective, as we often do encounter providers who are uncomfortable asking these questions to patients and/or their families because of their own moral distress and uncomfortableness with this topic.
What I would expected to see was more comments related to the time it takes for these conversations or that the inpatient setting when crisis occurs is often not the best time to have this discussion, however from the CMS opening statement that the advance care planning incentive in the outpatient setting, is frankly not working.
CMS responded that this is not about end of life, but about documenting patient preferences, identifying surrogate decision-makers, and ensuring clinicians have access to information necessary to provide goal-concordant care across settings. CMS also noted that hospitalization often provides an important opportunity to confirm existing wishes or initiate conversations for patients who may not routinely receive primary care.
Equally important, hospitals are not penalized when patients decline to complete an advance directive or designate a health care proxy. Documentation that an advance care planning conversation occurred, even when the patient chooses not to make decisions or wishes to defer the conversation, will still satisfy the numerator requirements if documented appropriately.
Now is a good time to begin collaborating with quality, nursing, case management/social work, palliative care, medical staff, registration, chaplaincy, and IT teams to assess current compliance and identify opportunities to standardize documentation in discrete medical record fields for data collection.
Establishing baseline data now will help healthcare organizations determine how to operationalize this metric and related processes moving forward.
