Centers for Medicare & Medicaid Services

This is an ACO-level measure of days at home or in community settings (that is, not in acute care such as inpatient hospital or emergent care settings or post-acute skilled nursing) among adult Medicare Fee-for-Service (FFS) beneficiaries with complex, chronic conditions who are attributed to ACOs participating in the ACO REACH model. The measure includes risk adjustment for differences in patient mix across ACOs, with an additional adjustment based on patients’ risk of death.

The Delay in Progression of CKD Measure is an outcome measure to assess how well providers delay progression from Stage 4 CKD to end-stage renal disease (ESRD) requiring chronic dialysis.

Percentage of all patient months for adult patients (> = 18years old) whose delivered dose of hemodialysis (calculated from the last measurement of the month using the UKM or Daugirdas II formula) was spKt/V >= 1.2.

Percentage of all patient months for adult patients (>= 18 years old) whose delivered peritoneal dialysis dose was a weekly Kt/V urea >= 1.7 (dialytic + residual). 

Percent of patients who were screened for depression (using a standardized depression screening tool) at start or resumption of home health care

Medication Possession Ratio (MPR) for statin therapy in diabetic individuals over 18 years of age

The percentage of home health episodes of care in which diabetic foot care and patient/caregiver education were included in the physician-ordered plan of care and implemented for diabetic patients since the previous OASIS assessment.

The Discharge to Community-Post Acute Care Measure for Home Health Agencies (DTC-PAC HHA) measure was developed to address the resource use and other measures domain of Discharge to the Community, a domain mandated by the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). The measure was developed using calendar year 2012-2013 data.

The Discharge to Community-Post Acute Care Measure for Inpatient Rehabilitation Facilities (DTC-PAC IRF) was developed to address the resource use and other measures domain of Discharge to the Community mandated by the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). This outcome measure assesses successful discharge to community from an IRF, with successful discharge to community including no unplanned rehospitalizations and no death in the 31 days following IRF discharge.

The Discharge to Community-Post Acute Care Measure for Long-Term Care Hospitals (DTC-PAC LTCH) was developed to address the resource use and other measures domain of Discharge to the Community mandated by the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). This outcome measure assesses successful discharge to community from an LTCH, with successful discharge to community including no unplanned rehospitalizations and no death in the 31 days following LTCH discharge.