Centers for Medicare & Medicaid Services

Percentage of home health episodes of care in which the patient was assessed for pain, using a standardized pain assessment tool, at start/resumption of care.

Percentage of short term home health episodes of care during which pain interventions were included in the physician-ordered plan of care and implemented.

Participation in a systematic qualified clinical database registry involves:
a. Physician or other clinician submits standardized data elements to registry
b. Data elements are applicable to consensus endorsed quality measures
c. Registry measures shall include at least two (2) representative NQF consensus endorsed measures for registry's clinical topic(s) and report on all patients eligible for the selected measures.
d. Registry provides calculated measures results, benchmarking, and quality improvement information to individual physicians and clinicians.

This Registry should be capable of
a. generating population based reports relating to published guideline goals or benchmarking data
b. providing comparisons to the practitioner
c. providing feedback that is related to guideline goals
d. capturing data for one or more chronic disease conditions (i.e. diabetes) or preventive care measures (i.e. USPTF recommendations) for all patients eligible for the measures

The PSI 90 composite measure summarizes patient safety across multiple indicators for the CMS Medicare fee-for-service population.

This measure assesses how well facilities provide clear, personalized discharge instructions to patients aged 18 years or older who had a surgery or procedure at an outpatient facility. It uses a 9-item survey to obtain patient’s feedback on 3 domains: applicability; medications; and daily activities. Facility scores are calculated by averaging the individual patient scores for each facility.

Percentage of pediatric (< 18 years old) peritoneal dialysis patient-months whose delivered peritoneal dialysis dose was a weekly Kt/Vurea >= 1.8 (dialytic + residual)

This measure reports the percentage of long-stay, high-risk, residents in a nursing home who have Stage II-IV or unstageable pressure ulcers on a selected target assessment in the target quarter. The long stay nursing home population is defined as residents who have received 101 or more cumulative days of nursing home care by the end of the target assessment period. A nursing home resident is defined as high-risk for pressure ulcer if they meet one or more of the following three criteria:
1. Impaired bed mobility or transfer
2. Comatose

This quality measure reports the percentage of all Long-Term Care Hospital (LTCH) patients with an admission and discharge functional assessment and a care plan that addresses function.

This measure updates CMS’ MDS 2.0 QM on bowel and bladder control. It is based on data from Minimum Data Set (MDS) 3.0 assessments of low risk long-stay nursing facility residents (those whose cumulative days in the facility is greater than 100 days). This measure reports the percent of long-stay residents with a selected target assessment who are frequently or always bladder or bowel incontinent as indicated on the target MDS assessment (OBRA, PPS or discharge) during the selected quarter (3-month period).