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Validating and Expanding Claims-Based Algorithms of Frailty and Functional Disability for Value-Based Care and Payment

Validate and Expand Claims-Based Algorithms, Identifying Patients with Frailty and Functional Disabilities across Payer and Patient Populations
  • Office of the Assistant Secretary for Planning and Evaluation (ASPE)
  • Agency for Healthcare Research and Quality (AHRQ)
  • Centers for Disease Control and Prevention (CDC)
  • Centers for Medicare and Medicaid Services (CMS)
Start Date
  • ASPE - 5/10/2019
  • AHRQ - 5/28/2019
  • CDC - 6/18/2019
  • CMS - TBD
  • Use of Clinical Data for Research
  • Linking of Clinical and Other Data for Research
  • Use of Enhanced Publicly-Funded Data Systems for Research


STATUS: Active Project


Patient function - both physical and cognitive - are important outcomes assessed by patient-centered outcomes (PCOR) researchers. Older adults who are frail and persons with functional disabilities (such as, but not limited to, difficulties with mobility, problems seeing, or forgetfulness that result in limitations in a person’s ability to perform activities of daily living) are at increased risk for poor health outcomes. This project focuses on the functional risk factors, identified below, that identify a person’s risk for physical and cognitive decline and impairment. In addition to medical comorbid conditions, functional risk factors play an important role in risk-adjustment of patient-centered outcomes research studies, as well as for evaluating performance and payments in value-based care programs. Improved data on persons with functional disabilities will help with case identification for research studies and public health surveillance, and enable researchers to evaluate clinical and health systems interventions for these vulnerable, high-need patients.

The Office of the Assistant Secretary for Planning and Evaluation (ASPE) has conducted some preliminary research on four categories of functional risk factors: frailty, predictors of functional dependence, mental and behavioral health disorders, and other potentially disabling conditions; the latter are already housed in the Chronic Conditions Warehouse (CCW). ASPE found these factors improve the predictive/explanatory power of risk-adjustment models of Medicare outcomes measures used in value-based payment programs, as well as help explain worse outcomes among Medicare and Medicaid dually-enrolled beneficiaries. Providing publicly available data on functional risk generated from claims-based algorithms will help support patient-centered outcomes research, for case identification or for more robust risk-adjustment, as well as to assess the quality of care in value-based purchasing programs. Validation of these claims-based algorithms to identify functional risk using Medicaid and Medicare claims would ensure broader use and acceptance for use in payment programs and in research studies.


The project objectives of this four-year project are to build data capacity to conduct robust patient-centered outcomes research by developing the following:

  • A set of validated and refined claims-based algorithms using Medicare and/or Medicaid claims that identify patients’ functional risk (all four categories of functional risk factors), to be made available to the public through the Chronic Condition Warehouse.

  • Draft EHR-modified algorithms tested in a health system to be made available to the public, and an EHR guidance report sharing learnings from a EHR Learning Network on collecting and extracting information on patients’ functional status from the EHR.

Project Partners:

ASPE will work with a contractor and will partner with the Centers for Medicare & Medicaid Services (CMS) to validate existing indicators of potentially disabling conditions in the Chronic Condition Warehouse (CCW) and test additional indicators of frailty and functional disabilities for the CCW. The Centers for Disease Control and Prevention (CDC) and the Agency for Healthcare Research and Quality (AHRQ) will also supporting this project by developing and testing electronic health record (EHR)-modified algorithms. These claims/EHR-based algorithms will help researchers to identify patients with frailty and functional disabilities across patient/payer populations (i.e. Medicare, Medicaid, commercial).