Percent of nursing home/skilled nursing facility residents whose pneumococcal polysaccharide vaccine (PPV) status is up to date during the 12-month reporting period.
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1.5 Measure Type1.7 Electronic Clinical Quality Measure (eCQM)1.8 Level Of Analysis1.9 Care Setting1.20 Testing Data Sources
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1.14 Numerator
The number of residents in the denominator who meet any of the following criteria:
(1) have up-to-date PPV status (computed separately); or
(2) were offered and declined the vaccination (computed separately); or
(3) were determined to be ineligible due to medical contraindication(s) (computed separately) (i.e., anaphylactic hypersensitivity to component(s) of the vaccine, bone marrow transplant within past 12 months, or receiving course of chemotherapy or radiation therapy within past two weeks).
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1.15 Denominator
The measure will be stratified by resident population. Rates will be reported separately for the long-stay (chronic care) and short-stay (post-acute care) populations.
Denominator Statement for Chronic (Long-Stay) Residents
All residents in the chronic care pneumococcal vaccination sample with a valid MDS target record (any assessment or discharge tracking form) within the 12-month target period.
Chronic Care Pneumococcal Vaccination Sample Definition
The chronic care pneumococcal vaccination sample includes residents in the facility during the 12-month target period. The sample includes residents who meet any of the following conditions:
(1) resident has a non-PPS assessment during the 12-month target period; or
(2) resident has a discharge tracking form during the 12-month target period and the prior record was a non-PPS assessment within 100 days prior to discharge; or
(3) resident had a stay with days during the 12-month target period and was discharged prior to completion of an initial assessment. Note that the discharge can be after the target period end.
Denominator Statement for Post-Acute Care (Short-Stay) Residents
Residents in the post-acute care pneumococcal vaccination sample with a valid MDS target record (any assessment or discharge tracking form) within the 12-month target period.
Post-Acute Care Pneumococcal Vaccination Sample Definition
The post-acute care pneumococcal vaccination sample includes residents in the facility during the selected 12-month target period. The sample includes residents who meet either of the following conditions:
(1) resident has a PPS assessment with a reference date during the 12-month target period, or
(2) resident has a PPS assessment before the 12-month target period with the next record being a discharge tracking form during the target period
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Exclusions
Resident-Level Exclusions
There are no resident-level exclusions. Note that residents are not excluded if either or both of the pneumococcal vaccine items (W3a and W3b) have dash (-) values indicating inability to determine.
Facility-Level Exclusions
Facilities with small sample sizes are excluded from public reporting of the pneumococcal vaccination measures.
Chronic Care Facility-Level Exclusions
Facilities are excluded if either of the following is true:
(1) the chronic care pneumococcal vaccination sample includes fewer than 30 residents; or
(2) the facility has fewer than 30 non-PPS quarterly assessments (AA8a = 05) for the entire facility for the year ending with the last day of the selected 12-month target period.
Post-Acute Care Facility-Level Exclusions
Facilities are excluded if either of the following is true:
(1) the post-acute care pneumococcal vaccination sample includes fewer than 20 residents; or
(2) the facility is excluded if there are no 5-day PPS assessments (AA8b = 1) for the entire facility for the year ending with the last day of the 12-month target period.
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Most Recent Endorsement ActivityMeasure Retired and Endorsement Removed National Voluntary Consensus Standards for Influenza and Pneumococcal ImmunizationsInitial EndorsementLast UpdatedRemoval Date
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StewardCenters for Medicare & Medicaid ServicesSteward Organization POC Email
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Risk Adjustment
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6.1.2 Current or Planned Use(s)6.1.3 Current Use(s)
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