Performance Measures

Controlling High Blood Pressure

The percentage of adults 18-85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure was adequately controlled (<140/90 mm Hg) during the measurement year.

Date Reviewed: July 1, 2021

Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System Groups

The 30-day Hospital-Wide, All-Cause Unplanned Readmission (HWR) Rate for the Merit-Based Incentive Payment System (MIPS) Groups measure is a risk-standardized readmission rate for beneficiaries age 65 or older who were hospitalized and experienced an unplanned readmission for any cause to a short-stay acute-care hospital within 30 days of discharge. The measure attributes readmissions to up to three MIPS participating clinician groups, as identified by their Medicare Taxpayer Identification Number (TIN) and assesses each group’s readmission rate. This clinician group-level, risk-standardized, all-cause unplanned readmission measure is a re-specified version of the hospital-level measure, “Hospital-wide Allcause Unplanned Readmission Measure” (NQF 1789), which is currently reported within the Inpatient Quality Reporting (IQR) program. This measure will replace the existing All-Cause Readmission (ACR) measure currently in use in QPP.

Date Reviewed: April 1, 2021

Plan All-Cause Readmissions (PCR)

For patients 18 years of age and older, the number of acute inpatient stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission. Data are reported in the following categories:
1. Count of Index Hospital Stays* (denominator)
2. Count of 30-Day Readmissions (numerator)
3. Average Adjusted Probability of Readmission
*An acute inpatient stay with a discharge during the first 11 months of the measurement year (e.g., on or between January 1 and December 1).

Date Reviewed: April 1, 2021

Follow-Up After Hospitalization for Mental Illness (FUH)

The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had a follow-up visit with a mental health practitioner. Two rates are submitted:
• The percentage of discharges for which the patient received follow-up within 30 days after discharge.
• The percentage of discharges for which the patient received follow-up within 7 days after discharge.

Date Reviewed: April 1, 2021

Gains in Patient Activation (PAM) Scores at 12 Months

The Patient Activation Measure® (PAM®) is a 10 or 13 item questionnaire that assesses an individual´s knowledge, skill and confidence for managing their health and health care. The measure assesses individuals on a 0-100 scale. There are 4 levels of activation, from low (1) to high (4). The measure is not disease specific, but has been successfully used with a wide variety of chronic conditions, as well as with people with no conditions. The performance score would be the change in score from the baseline measurement to follow-up measurement, or the change in activation score over time for the eligible patients associated with the accountable unit. The outcome of interest is the patient’s ability to self-manage. High quality care should result in gains in ability to selfmanage for most chronic disease patients. The outcome measured is a change in activation over time. The change score would indicate a change in the patient´s knowledge, skills, and confidence for selfmanagement. A positive change would mean the patient is gaining in their ability to manage their health.

A “passing” score for eligible patients would be to show an average net 3-point PAM score increase in a 6-12 month period. An “excellent” score for eligible patients would be to show an average net 6-point PAM score increase in a 6-12 month period. An “excellent” score would be for eligible patients to show an average of a 6-point PAM score increase in a 6-12 month period.

Date Reviewed: April 1, 2021

CollaboRATE Shared Decision Making Score

CollaboRATE is a patient-reported measure of shared decision making which contains three brief questions that patients, their parents, or their representatives complete following a clinical encounter. The CollaboRATE measure provides a performance score representing the percentage of adults 18 and older who experience a high level of shared decision making.

Date Reviewed: April 1, 2021

Person-Centered Primary Care Measure PRO-PM (PCPCM PRO-PM)

The Person-Centered Primary Care Measure Patient Reported Outcome Performance Measure (PCPCM PRO-PM) uses the PCPCM PROM (a comprehensive and parsimonious set of 11 patient-reported items) to assess the broad scope of primary care. Unlike other primary care measures, the PCPCM PRO-PM measures the high value aspects of primary care based on a patient’s relationship with the provider or practice. Patients identify the PCPCM PROM as meaningful and able to communicate the quality of their care to their clinicians and/or care team. The items within the PCPCM PROM are based on extensive stakeholder engagement and comprehensive reviews of the literature.

Date Reviewed: April 1, 2021