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Care Coordination

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

Hospital 30-day, all-cause, risk standardized readmission rate following acute MI hospitalization

The measure estimates a hospital-level 30-day risk-standardized readmission rate for patients discharged from the hospital with a principal diagnosis of acute MI. 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 aged 18 years and older. CMS annually reports the measure for individuals who are 65 years and older and are either Medicare FFS beneficiaries hospitalized in non-federal hospitals or patients hospitalized in Department of VA facilities

Date Reviewed: November 7, 2015

Hospital 30-day, all cause, risk-standardized mortality rate following acute MI 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 acute MI. 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

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

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