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Prevention and Wellness

Venous Thromboembolism Prophylaxis

This measure assesses the number of patients who received venous thromboembolism (VTE) prophylaxis or have documentation why no VTE prophylaxis was given the day of or the day after hospital admission or surgery end date for surgeries that start the day of or the day after hospital admission. This measure is part of a set of six nationally implemented prevention and treatment measures that address VTE (VTE-2: ICU VTE Prophylaxis, VTE-3: VTE Patients with Anticoagulation Overlap Therapy, VTE-4: VTE Patients Receiving UFH with Dosages/Platelet Count Monitoring, VTE-5: VTE Warfarin Therapy Discharge Instructions and VTE-6: Hospital Acquired Potentially-Preventable VTE) that are used in The Joint Commission’s accreditation process.

Date Reviewed: July 21, 2018

Chlamydia Screening and Follow-up

The percentage of female adolescents 18 years of age who had a chlamydia screening test with proper follow-up

Date Reviewed: November 7, 2015

Pneumococcal Vaccination Status for Older Adults

Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine.

Date Reviewed: November 19, 2017

Chlamydia Screening in Women

The percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year.

Date Reviewed: November 7, 2015

Influenza Immunization

Inpatients age 6 months and older discharged during October, November, December, January, February or March who are screened for influenza vaccine status and vaccinated prior to discharge if indicated.

Date Reviewed: November 19, 2017

Proportion of Patients with a Chronic Condition that have a Potentially Avoidable Complication during a Calendar Year

Percent of adult population aged 18+ years who were identified as having at least one of the following six chronic conditions: Asthma, Chronic Obstructive Pulmonary Disease (COPD), Coronary Artery Disease (CAD), Heart Failure (HF), Hypertension (HTN), or Diabetes Mellitus (DM), were followed for at least one-year, and had one or more potentially avoidable complications (PACs) during the most recent 12 months. Please reference attached document labeled NQF_Chronic_Care_PACs_01_24_17.xls, in the tabs labeled PACs I-9 & I-10 for a list of code definitions of PACs relevant to each of the above chronic conditions.

We define PACs as one of two types:
(1) Type 1 PACs - PACs related to the index condition: Patients are considered to have a PAC, if they receive services during the episode time window for any of the complications directly related to the chronic condition, such as for acute exacerbation of the index condition, respiratory insufficiency in patients with Asthma or COPD, hypotension or fluid and electrolyte disturbances in patients with CAD, HF or diabetes etc.
(2) Type 2 PACs - PACs related to Patient Safety or broader System Failures: Patients are also considered to have a PAC, if they receive services during the episode time window for any of the complications related to patient safety or health system failures such as for sepsis, infections, phlebitis, deep vein thrombosis, pressure sores etc.

Date Reviewed: July 21, 2018

Zoster (Shingles) Vaccination

The percentage of patients 50 years of age and older who have a Varicella Zoster (shingles) vaccination.

Date Reviewed: November 4, 2018

Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up

Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous six months of the current encounter Normal Parameters: Age 18 years and older BMI => 18.5 and < 25 kg/m2

Date Reviewed: November 19, 2017

Flu Vaccinations for Adults Ages 18 and Older

The percentage of adults 18 years of age and older who self-report receiving an influenza vaccine within the measurement period. This measure is collected via the CAHPS 5.0H adults survey for Medicare, Medicaid, and commercial populations. It is reported as two separate rates stratified by age: 18-64 and 65 years of age and older.

Date Reviewed: July 21, 2018

BMI Screening and Follow-up for People with Serious Mental Illness

The percentage of patients 18 years and older with a serious mental illness who received a screening for body mass index and follow-up for those people who were identified as obese (a body mass index greater than or equal to 30 kg/m2).
Note: The proposed health plan measure is adapted from an existing provider-level measure for the general population (Preventive Care & Screening: Body Mass Index: Screening and Follow-Up NQF #0421). It is currently stewarded by CMS and used in the Physician Quality Reporting System.

Date Reviewed: July 21, 2018

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