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Care Coordination

Hospital 30-Day, all-cause, risk standardized readmission rate following heart failure hospitalization

The measure estimates a hospital-level risk-standardized readmission rate (RSRR) for patients discharged from the hospital with a principal diagnosis of heart failure (HF). The outcome is defined as unplanned readmission for any cause within 30 days of the discharge date for the index admission. A specified set of planned readmissions do not count as readmissions. The target population is patients 18 and over. CMS annually reports the measure for patients who are 65 years or older and are either enrolled in fee-for-service (FFS) Medicare and hospitalized in non-federal hospitals or are hospitalized in Veterans Health Administration (VA) facilities.

Date Reviewed: November 7, 2015

Hospital 30-day, all-cause, risk-standardized mortality rate following heart failure hospitalization for patients 18 and older

The measure estimates a hospital 30-day risk-standardized mortality rate. Mortality is defined as death for any cause within 30 days after the date of admission of the index admission, for patients 18 and older discharged from the hospital with a principal diagnosis of HF. CMS annually reports the measure for patients who are 65 years or older and are either enrolled in fee-for-service Medicare and hospitalized in non-federal hospitals or are hospitalized in VA facilities.

Date Reviewed: November 7, 2015

Use of High-Risk Medications in the Elderly

Percentage of patients 66 years of age and older who were ordered high-risk medications. Two rates are reported:

a. Percentage of patients who were ordered at least one high-risk medication

b. Percentage of patients who were ordered at least two different high-risk medications.

Date Reviewed: November 19, 2017

Skilled Nursing Facility 30-Day All Cause Readmission

This measure estimates the risk-standardized rate of all-cause, unplanned, hospital readmissions for patients who have been admitted to a Skilled Nursing Facility (SNF) (Medicare fee-for-service [FFS] beneficiaries) within 30 days of discharge from their prior proximal hospitalization. The prior proximal hospitalization is defined as an admission to an IPPS, CAH, or a psychiatric hospital. The measure is based on data for 12 months of SNF admissions.

A risk-adjusted readmission rate for each facility is calculated as follows:

  • Step 1: Calculate the standardized risk ratio of the predicted number of readmissions at the facility divided by the expected number of readmissions for the same patients if treated at the average facility. The magnitude of the risk-standardized ratio is the indicator of a facility's effects on readmission rates.
  • Step 2: The standardized risk ratio is then multiplied by the mean rate of readmission in the population (i.e., all Medicare FFS patients included in the measure) to generate the facility-level standardized readmission rate.

For this measure, readmissions that are usually for planned procedures are excluded. Please refer to the Appendix, Tables 1 - 5 for a list of planned procedures.

The measure specifications are designed to harmonize with CMS' hospital-wide readmission (HWR) measure to the greatest extent possible. The HWR (NQF #1789) estimates the hospital-level, risk-standardize rate of unplanned, all-cause readmissions within 30 days of a hospital discharge and uses the same 30-day risk window as the SNFRM.

Date Reviewed: November 7, 2015

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

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