• Measure 318 (NQF #0101): Falls: Screening for Future Fall Risk


    Updated January 2019.

    Reporting Options: 

    • IRIS Registry for EHR: groups and individuals
    • EHR through your vendor (if offered): groups and individuals

    eMeasure Identifier: CMS139v7

    Measure Type: Process - High Priority

    NQS Domain: Patient Safety

     

    Meaningful Measure Area: Preventable Healthcare Harm

    Instructions: Percentage of patients 65 years of age and older who were screened for future falls risk during the measurement period.

    This measure is to be reported a minimum of once per reporting period for patients who were screened for future fall risk at least once within the measurement period.

    Definition: 

    Future fall risk: Patients are considered at risk for future falls if they have had 2 or more falls in the past year or any fall with injury in the past year.

    Fall: A sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground, other than as a consequence of sudden onset of paralysis, epileptic seizure, or overwhelming external force.

    Initial Patient Population: Patients aged 65 years and older with a visit during the measurement period

    Denominator: Equals initial patient population

    Denominator exceptions: Documentation of medical reason(s) for not screening for fall risk (eg, patient is not ambulatory) 

    Denominator exclusions: Exclude patients whose hospice care overlaps the measurement period, and patients who were non-ambulatory at some point in the measurement period.

    IRIS Registry EHR Reporting

    These are the required elements to be documented at least once a year to meet the measure performance requirements.

    • A falls-risk assessment (involving gait/balance assessment as well as vision, and not using a specific survey)

    How CMS Scores Your Performance

    • If you successfully report a measure for less than 60 percent of your patients, you will earn points based on your practice size:
      • Small practices (≤ 15 clinicians) will receive 3 points,
      • Larger practices (> 15 clinicians) will receive 1 point.
    • If you successfully report a measure for at least 60 percent of your patients, but do not report at least 20 cases, you will receive 3 points.
    • If you report this measure for at least 60 percent of applicable patients and on at least 20 patients during a reporting period, you will earn points based on the decile that corresponds to your performance rate. Not all measures offer points for every decile.

    Benchmarks

    Decile/Points EHR (including EHR–IRIS integration)
    3 7.24  – 20.26
    4 20.27 – 36.40
    5 36.41 – 52.24
    6 52.25 – 66.72
    7 65.73 – 78.59
    8 78.60 – 88.50
    9 88.51 – 96.55
    10 >=96.56