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Care Coordination

Hospital Wide All Cause Readmission Measure

The measure estimates a hospital-level risk-standardized readmission rate (RSRR) of unplanned, all-cause readmission after admission for any eligible condition within 30 days of hospital discharge. The measure reports a single summary risk-standardized readmission rate (RSRR), derived from the volume-weighted results of five different models, one for each of the following specialty cohorts based on groups of discharge condition categories or procedure categories: surgery/gynecology, general medicine, cardiorespiratory, cardiovascular, and neurology, each of which will be described in greater detail below. The measure also indicates the hospital-level standardized risk ratios (SRR) for each of these five specialty cohorts. The outcome is defined as unplanned readmission for any cause within 30 days of the discharge date for the index admission. Admissions for planned procedures that are not accompanied by an acute diagnosis do not count as readmissions in the measure outcome. The target population is patients 18 and over. CMS annually reports the measure for patients who are 65 years or older and are enrolled in fee-for-service (FFS) Medicare and hospitalized in non-federal hospitals.

Date Reviewed: November 7, 2015

Medication Reconciliation Post-Discharge

The percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years and older of age seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record. This measure is reported as three rates stratified by age group:
Reporting Criteria 1: 18-64 years of age
Reporting Criteria 2: 65 years of age
Total Rate: All patients 18 years of age and older

Date Reviewed: November 19, 2017

Closing the Referral Loop: Receipt of the Specialist Report

Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred

Date Reviewed: July 21, 2018

Heart Failure Admission Rate (PQI 8)

Admissions with a principal diagnosis of heart failure per 100,000 populations, ages 18 years and older. Excludes cardiac procedure admissions, obstetric admissions, and transfers from other institutions. NOTE: The software provides the rate per population. However, common practice reports the measure as per 100,000 population. The user must multiply the rate obtained from the software by 100,000 to report admissions per 100,000.

Date Reviewed: November 7, 2015

Post-Discharge Evaluation for Heart Failure Patients

Patients who receive a re-evaluation for symptoms worsening and treatment compliance by a program team member within 72 hours after inpatient discharge.

Date Reviewed: November 7, 2015

Post-Discharge Appointment for Heart Failure Patients

Patients for whom a follow-up appointment for an office or home health visit for management of heart failure was scheduled within 7 days post-discharge and documented including location, date, and time.

Date Reviewed: July 21, 2018

Post-Discharge Appointment for Heart Failure Patients

Percentage of patients, regardless of age, discharged from an inpatient facility to ambulatory care or home health care with a principal discharge diagnosis of heart failure for whom a follow up appointment was scheduled and documented prior to discharge (as specified).

Date Reviewed: July 21, 2018

Documentation of Current Medications in the Medical Record

Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over the counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration.

Date Reviewed: November 19, 2017

Advance Care Plan

Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan.

Date Reviewed: November 19, 2017

30-day, all-cause, risk-standardized mortality rate following Percutaneous Coronary Intervention for patients with ST segment elevation MI or cardiogenic shock

This measure estimates hospital risk-standardized 30-day all-cause mortality rate following percutaneous coronary intervention among patients who are 18 years of age or older with STEMI or cardiogenic shock at the time of procedure. The measure uses clinical data available in the National Cardiovascular Data Registry CathPCI registry for risk adjustment. For the purpose of development, the measure cohort was derived in a Medicare FFS population of patients 65 years of age or older with a PCI. For the purpose of development and testing, the measure used a Medicare FFS population of patients 65 years of age or older with a PCI. However, the measure is designed to be used in the broader population of PCI patients

Date Reviewed: November 7, 2015

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