Focus Care NCQA Comprehensive Patient Assessment Tool

The Focus Care NCQA Comprehensive Patient Assessment Tool for Medicare addresses the topics required by the Affordable Care Act. Recommendations from the Centers for Disease Control and Prevention also guided its development. The questions set is appropriately tailored to the age 65+ Medicare population and was designed to help participants and providers identify chronic disease, injury risk, modifiable risk factors, and urgent health needs.

The Focus Care NCQA Comprehensive Patient Assessment tool evaluates the 37 elements outlined by Centers for Medicare & Medicaid Services in CFR 410.15. “Health risk assessment” is defined as an evaluation tool that meets the following criteria:

  • Collects self-reported information about the beneficiary.
  • Can be administered independently by the beneficiary or administered by a health professional prior to or as part of the AWV encounter.
  • Is appropriately tailored to and takes into account the communication needs of: underserved populations, persons with limited English proficiency, and persons with health literacy needs. (This includes both readability and health literacy.)
  • Takes no more than 30 minutes to complete.
CMS Required Question Set Covered in Patient Assessment Tool


Social Support



ER Visit

Fall Risk

Memory Problems