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Hospitalizations for Ambulatory Care Sensitive Conditions among Home and Community Based Service (HCBS) Participants

CBE ID
4490
Endorsement Status
E&M Committee Rationale/Justification

When the measure returns for maintenance, the committee would like to see: 

  • Recalculate reliability on observed/expected rates,
  • Evaluate face validity (specifically addressing whether the measure distinguishes quality), and
  • Provide a robust logic model at the HCBS plan level to illustrate areas of improvement
1.0 New or Maintenance
Previous Endorsement Cycle
Is Under Review
No
Next Maintenance Cycle
Spring 2029
1.6 Measure Description

The Hospitalizations for Ambulatory Care Sensitive Conditions among Home and Community Based Participants measure is a risk-adjusted, state-level measure that assesses rates of hospital admissions for ambulatory care sensitive conditions per 1,000 Medicaid HCBS participants aged 18 years and older. This measure has three rates reported for potentially avoidable inpatient hospital admissions:

  1. Chronic Conditions
  2. Acute Conditions
  3. Chronic and Acute Conditions Composite
Measure Specs
General Information
1.7 Measure Type
1.7 Composite Measure
No
1.3 Electronic Clinical Quality Measure (eCQM)
1.8 Level of Analysis
1.8a Population or Geographic Area Level of Analysis
State
1.9 Care Setting
1.9b Other Care Setting
Home and community-based services
1.10 Measure Rationale

Evidence indicates that there are approximately 3.5 million potentially avoidable hospital admissions every year, which account for $33.7 billion in aggregate hospital costs (McDermott & Jiang, 2020). The HCBS ACSC measure will help monitor rates of avoidable hospitalizations for ambulatory care sensitive conditions among HCBS participants.

Appropriate primary care may also prevent the development or worsening of various chronic conditions and prevent individuals from returning to emergency or inpatient care settings for treatment. Continuity of care improvement efforts, such as increasing the average primary care visits to an optimal rate (generally three or four visits, annually, depending on health status and condition-specific needs), has been shown to reduce the risk of hospitalizations for ambulatory care sensitive conditions (Kao et al., 2019).

Reduced hospital admissions and effective care coordination have the potential to contribute to healthcare cost savings as well as improve quality of care.

References:

Kao, Y., Lin, W., Chen, W., Wu, S., & Tseng, T. (2019). Continuity of outpatient care and avoidable hospitalizations: A systematic review. American Journal of Managed Care, 25(4), 126-134. http://ajmc.s3.amazonaws.com/_media/_pdf/AJMC_04_2019_Kao_final.pdf

McDermott, K. W., & Jiang, H. J. (2020). Characteristics and costs of potentially preventable inpatient stays, 2017. Healthcare Cost and Utilization Project: Agency for Healthcare Research and Quality. https://www.hcup-us.ahrq.gov/reports/statbriefs/sb259-Potentially-Preventable-Hospitalizations-2017.jsp

1.20 Types of Data Sources
1.25 Data Source Details

The HCBS ACSC measure is claims based, calculated using existing Medicaid claims data. Participant claims contain the available data needed to capture all desired care settings for the HCBS ACSC measure.

For calendar years 2018 and 2019, quantitative data was obtained from Transformed Medicaid Statistical Information System (T-MSIS) Analytical Files (TAF). T-MSIS contains participant, service utilization, administrative claims, and expenditure data for the Medicaid population, including those covered through both fee-for-service (FFS) and managed-care payers.

Due to data quality issues with more current data, data from 2018 and 2019 were used for specification and testing of the HCBS ACSC measure. The measure developer will continue to monitor the availability and quality of key data elements for this measure within the TAF to validate its specifications using newer data (i.e., claims data available after the COVID-19 public health emergency).