Centers for Medicare & Medicaid Services

The Discharge to Community-Post Acute Care Measure for Skilled Nursing Facilities (DTC-PAC SNF) 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 a SNF, with successful discharge to community including no unplanned rehospitalizations and no death in the 31 days following SNF discharge.

For both the 2018 claims and registry specifications AND the 2019 performance period eMeasure (v8) the measure description is as follows:

Percentage of short term home health episodes of care during which patient/caregiver was instructed on how to monitor the effectiveness of drug therapy, how to recognize potential adverse effects, and how and when to report problems.

The Elective Primary Hip Arthroplasty episode-based cost measure evaluates a clinician’s risk-adjusted cost to Medicare for patients who receive an elective primary hip arthroplasty during the performance period. The measure score is a clinician’s risk-adjusted cost for the episode group averaged across all episodes attributed to the clinician.

This intermediate outcome eCQM captures the proportion of visits for patients of all ages that experience emergency care access barriers during a one-year performance period.

Percentage of home health stays in which patients who had an acute inpatient hospitalization in the 5 days before the start of their home health stay used an emergency department but were not admitted to an acute care hospital during the 30 days following the start of the home health stay.

Percentage of home health stays in which patients used the emergency department but were not admitted to the hospital during the 60 days following the start of the home health stay.

The PaLS is used to generate a patient-level t-score that reflects patient-reported satisfaction with how well his/her/their facility is doing in discussing life goals with the patient as part of the treatment planning process.

Percentage of all adult (>= 18 years old) patients in the sample for analysis who have been on hemodialysis for 90 days or more and dialyzing thrice weekly, and have a residual renal function (if measured in the last three months) less than 2 ml/min/1.73m2), whose delivered dose of hemodialysis (calculated from the last measurements of the month using the UKM or Daugirdas II formula) was a spKt/V >= 1.2 during the reporting period.

Percentage of heart failure patients with documentation in the hospital record that left ventricular systolic (LVS) function was evaluated before arrival, during hospitalization, or is planned for after discharge.