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ACP Level of Support - Do Not Support: Uncertain Validity

HIV Infection Screening

Percentage of patients 15-65 years of age who were tested at least once for HIV.

Date Reviewed: November 4, 2018

Age Appropriate Screening Colonoscopy

The percentage of patients greater than 85 years of age who received a screening colonoscopy from January 1 to December 31.

Date Reviewed: November 4, 2018

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

Diabetes Screening for People with Schizophrenia or Bipolar Disorder who are Using Antipsychotic Medications (SSD)

The percentage of patients 18 – 64 years of age with schizophrenia or bipolar disorder, who were dispensed an antipsychotic medication and had a diabetes screening test during the measurement year.

Date Reviewed: July 21, 2018

National Healthcare Safety Network Catheter Associated Urinary Tract Infection (CAUTI)

Standardized Infection Ratio (SIR) of healthcare-associated, catheter-associated urinary tract infections (UTI) will be calculated among patients in bedded inpatient care locations, except level II or level III neonatal intensive care units (NICU). This includes acute care general hospitals, long-term acute care hospitals, rehabilitation hospitals, oncology hospitals, and behavior health hospitals.

Date Reviewed: July 21, 2018

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

The percentage of patients 18 years and older with a serious mental illness, who were screened for unhealthy alcohol use and received brief counseling or other follow-up care if identified as an unhealthy alcohol user.
Note: The proposed health plan measure is adapted from an existing provider-level measure for the general population (NQF #2152: Preventive Care & Screening: Unhealthy Alcohol Use: Screening & Brief Counseling). It was originally endorsed in 2014 and is currently stewarded by the American Medical Association (AMA-PCPI).

Date Reviewed: July 21, 2018

National Healthcare Safety Network Facility-Wide Inpatient Hospital-Onset Clostridium Difficile (CDI) Outcome Measure

Standardized infection ratio (SIR) and Adjusted Ranking Metric (ARM) of hospital-onset CDI Laboratory-identified events (LabID events) among all inpatients in the facility, excluding well-baby nurseries and neonatal intensive care units (NICUs).

Date Reviewed: July 21, 2018

Comprehensive Diabetes Care: Hemoglobin A1c Control (<8%)

The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) whose most recent HbA1c level is <8.0% during the measurement year.

Date Reviewed: July 21, 2018

TOB-2 Tobacco use Treatment provided or Offered and the subset measure TOB-2a: Tobacco Use Treatment

The measure is reported as an overall rate which includes all hospitalized patients 18 years of age and older to whom tobacco use treatment was provided during the hospital stay, or offered and refused, and a second rate, a subset of the first, which includes only those patients who received tobacco use treatment during the hospital stay.

Date Reviewed: July 21, 2018

SUB-2 Alcohol Use Brief Intervention Provided or Offered and SUB 2a Alcohol Use Brief Intervention

The measure is reported as an overall rate which includes all hospitalized patients 18 years of age and older to whom a brief intervention was provided, or offered and refused, and a second rate, a subset of the first, which includes only those patients who received a brief intervention. The Provided or Offered rate (SUB-2), describes patients who screened positive for unhealthy alcohol use who received or refused a brief intervention during the hospital stay. The Alcohol Use Brief Intervention (SUB-2a) rate describes only those who received the brief intervention during the hospital stay. Those who refused are not included.

Date Reviewed: July 21, 2018

SUB-3a Alcohol & Other Drug Use Disorder Treatment Provided or Offered at Discharge and SUB-3a Alcohol & Other Drug Use Disorder

The measure is reported as an overall rate which includes all hospitalized patients 18 years of age and older to whom alcohol or drug use disorder treatment was provided, or offered and refused, at the time of hospital discharge, and a second rate, a subset of the first, which includes only those patients who received alcohol or drug use disorder treatment at discharge. The Provided or Offered rate (SUB-3) describes patients who are identified with alcohol or drug use disorder who receive or refuse at discharge a prescription for FDA-approved medications for alcohol or drug use disorder, OR who receive or refuse a referral for addictions treatment. The Alcohol and Other Drug Disorder Treatment at Discharge (SUB-3a) rate describes only those who receive a prescription for FDA-approved medications for alcohol or drug use disorder OR a referral for addictions treatment. Those who refused are not included.

These measures are intended to be used as part of a set of 4 linked measures addressing Substance Use (SUB-1 Alcohol Use Screening ; SUB-2 Alcohol Use Brief Intervention Provided or Offered; SUB-3 Alcohol and Other Drug Use Disorder Treatment Provided or Offered at Discharge; SUB-4 Alcohol and Drug Use: Assessing Status after Discharge [temporarily suspended]).

Date Reviewed: July 21, 2018

Medical Assistance with Smoking and Tobacco Cessation

he three components of this measure assess different facets of providing medical assistance with smoking and tobacco use cessation:
Advising Smokers and Tobacco Users to Quit: A rolling average represents the percentage of patients 18 years of age and older who are current smokers or tobacco users and who received advice to quit during the measurement year.
Discussing Cessation Medications: A rolling average represents the percentage of patients 18 years of age and older who are current smokers or tobacco users and who discussed or were recommended cessation medications during the measurement year.
Discussing Cessation Strategies: A rolling average represents the percentage of patients 18 years of age and older who are current smokers or tobacco users and who discussed or were provided cessation methods or strategies during the measurement year.

Date Reviewed: July 21, 2018

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

Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other Drug Dependence

The percentage of patients 18 years and older with a serious mental illness or alcohol or other drug dependence who received a screening for tobacco use and follow-up for those identified as a current tobacco user. Two rates are reported.
Rate 1: The percentage of patients 18 years and older with a diagnosis of serious mental illness who received a screening for tobacco use and follow-up for those identified as a current tobacco user.
Rate 2: The percentage of adults 18 years and older with a diagnosis of alcohol or other drug dependence who received a screening for tobacco use and follow-up for those identified as a current tobacco user.
Note: The proposed health plan measure is adapted from an existing provider-level measure for the general population (Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention NQF #0028). This measure is currently stewarded by the AMA-PCPI and used in the Physician Quality Reporting System.

Date Reviewed: July 21, 2018

Bipolar Disorder and Major Depression: Appraisal for Alcohol or Chemical Substance Use

Percentage of patients with depression or bipolar disorder with evidence of an initial assessment that includes an appraisal for alcohol or chemical substance use.

Date Reviewed: November 19, 2017

HIV/AIDS: Sexually Transmitted Diseases - Screening for Chlamydia, Gonorrhea, and Syphilis

Percentage of patients aged 13 years and older with a diagnosis of HIV/AIDS for whom chlamydia, gonorrhea, and syphilis screenings were performed at least once since the diagnosis of HIV infection.

Date Reviewed: November 19, 2017

COPD: Inhaled Bronchodilator Therapy

Percentage of patients aged 18 years and older with a diagnosis of COPD (FEV1/FVC < 70%) and who have an FEV1 less than 60% predicted and have symptoms who were prescribed a long-acting inhaled bronchodilator.

Date Reviewed: November 19, 2017

Dementia: Counseling Regarding Safety Concerns

Percentage of patients, regardless of age, with a diagnosis of dementia or their caregiver(s) who were counseled or referred for counseling regarding safety concerns within in a 12 month period

Date Reviewed: November 19, 2017

CAHPS for MIPS Clinician/Group Survey

Getting timely care, appointments, and information; How well providers communicate; Patient’s rating of provider; Access to specialists; Health promotion & education; Shared decision making; Health status/functional status; Courteous and helpful office staff; Care coordination; Between visit communication; Helping to take medications as directed; and Stewardship of patient resources.

Date Reviewed: November 19, 2017

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

Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan

Percentage of patients aged 12 years and older screened for clinical depression using an age appropriate standardized tool AND follow-up plan documented.

Date Reviewed: November 19, 2017

Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy

All female patients of childbearing potential (12 - 44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a year.

Date Reviewed: November 19, 2017

Depression Utilization of the PHQ-9 Tool

Patients age 18 and older with the diagnosis of major depression or dysthymia who have a Patient Health Questionnaire (PHQ-9) tool administered at least once during a 4-month period in which there was a qualifying visit.

Date Reviewed: November 19, 2017

Comprehensive Diabetes Care: Hemoglobin A1c (HgbA1c)

Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.  

Date Reviewed: November 19, 2017

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

Functional Status Assessment for Patients with Congestive Heart Failure

Percentage of patients 65 years of age and older with congestive heart failure who completed initial and follow-up patient-reported functional status assessments.

Date Reviewed: November 19, 2017

Adult Sinusitis: Appropriate Choice of Antibiotic: Amoxicillin with or without Clavulanate Prescribed for Patients with Acute Bacterial Sinusitis

Percentage of patients aged 18 years and older with a diagnosis of acute bacterial sinusitis that were prescribed amoxicillin, with or without clavulanate, as a first line antibiotic at the time of diagnosis.

Date Reviewed: November 19, 2017

Adult Sinusitis: Appropriate Choice of Antibiotic Prescribed for Acute Sinusitis (Overuse)

Percentage of patients, aged 18 years and older, with a diagnosis of acute sinusitis who were prescribed an antibiotic within 10 days after onset of symptoms.

Date Reviewed: November 19, 2017

Optimal Asthma Control

Composite measure of the percentage of pediatric and adult patients whose asthma is well-controlled as demonstrated by one of three age appropriate patient reported outcome tools and not at risk for exacerbation.

Date Reviewed: November 19, 2017

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

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

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

Opioid Therapy: Follow-up Evaluation

All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record.

Date Reviewed: November 19, 2017

Controlling High Blood Pressure

Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period.

Date Reviewed: November 19, 2017

Pain Brought Under Control Within 48 Hours

Patients aged 18 and older who report being uncomfortable because of pain at the initial assessment (after admission to palliative care services) that report pain was brought to a comfortable level within 48 hours.

Date Reviewed: November 19, 2017

Hypertension Improvement in Blood Pressure

Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period.

Date Reviewed: November 19, 2017

Use of Appropriate Medications for People with Asthma

The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and who were appropriately prescribed medication during the measurement year

Date Reviewed: July 26, 2015

Pharmacologic Therapy for Persistent Asthma

Percentage of patient aged 5 through 64 years with a diagnosis of persistent asthma who were prescribed long-term control medication Three rates are reported for this measure:

  1. Patients prescribed inhaled corticosteroids (ICS) as their long term control medication
  2. Patients prescribed other alternative long term control medications (non-ICS)
  3. Total patients prescribed long-term control medication

Date Reviewed: July 26, 2015

Rheumatoid Arthritis (RA): Disease-Modifying Anti-Rheumatic Drug (DMARD) Therapy

Percentage of patients 18 years and older with a diagnosis of rheumatoid arthritis who are newly prescribed disease modifying anti-rheumatic drug therapy within 12 months.

Date Reviewed: April 27, 2015

Disease-Modifying Anti-Rheumatic Drug (DMARD) Therapy for Rheumatoid Arthritis

The percentage of patients 18 years and older by the end of the measurement period, diagnosed with rheumatoid arthritis and who had at least one ambulatory prescription for a disease-modifying anti-rheumatic drug.

Date Reviewed: April 27, 2015

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