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Individuals with multiple chronic conditions

3-Item Care Transition Measure (CTM-3)

  • The CTM-3 is a hospital level measure of performance that reports the average patient reported quality of preparation for self-care response among adult patients discharged from general acute care hospitals within the past 30 days.

    CBE ID
    0228

Adolescent Assessment of Preparation for Transition (ADAPT) to Adult-Focused Health Care

  • The Adolescent Assessment of Preparation for Transition (ADAPT) to Adult-Focused Health Care measures the quality of preparation for transition from pediatric-focused to adult-focused health care as reported in a survey completed by youth ages 16-17 years old with a chronic health condition. The ADAPT survey generates measures for each of the 3 domains: 1) Counseling on Transition Self-Management, 2) Counseling on Prescription Medication, and 3) Transfer Planning.

    CBE ID
    2789

All-Cause Unplanned Readmission Measure for 30 Days Post Discharge from Inpatient Rehabilitation Facilities (IRFs)

  • This measure estimates the risk-standardized rate of unplanned, all-cause readmissions for patients (Medicare fee-for-service [FFS] beneficiaries) discharged from an Inpatient Rehabilitation Facility (IRF) who were readmitted to a short-stay acute-care hospital or a Long-Term Care Hospital (LTCH), within 30 days of an IRF discharge. The measure is based on data for 24 months of IRF discharges to non-hospital post-acute levels of care or to the community.

    A risk-adjusted readmission rate for each facility is calculated as follows:

    CBE ID
    2502

All-Cause Unplanned Readmission Measure for 30 Days Post Discharge from Long-Term Care Hospitals (LTCHs)

  • This measure estimates the risk-standardized rate of unplanned, all-cause readmissions for patients (Medicare fee-for-service [FFS] beneficiaries) discharged from a Long-Term Care Hospital (LTCH) who were readmitted to a short-stay acute-care hospital or a Long-Term Care Hospital (LTCH), within 30 days of an LTCH discharge. The measure is based on data for 24 months of LTCH discharges to non-hospital post-acute levels of care or to the community.

    A risk-adjusted readmission rate for each facility is calculated as follows:

    CBE ID
    2512

Asthma Medication Ratio

  • The percentage of patients 5–64 years of age who were identified as having persistent asthma and had a ratio of controller medications to total asthma medications of 0.50 or greater during the measurement year.

    CBE ID
    1800

Asthma: Pharmacologic Therapy for Persistent Asthma

  • Percentage of patients aged 5 years and older with a diagnosis of persistent asthma who were prescribed long-term control medication

    Three rates are reported for this measure:
    1. Patients prescribed inhaled corticosteroids (ICS) as their long term control medication
    2. Patients prescribed other alternative long term control medications (non-ICS)
    3. Total patients prescribed long-term control medication

    CBE ID
    0047

CAHPS® Home Health Care Survey (experience with care)

  • The Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Home Health Care Survey, also referred as the "CAHPS Home Health Care Survey" or "Home Health CAHPS" or “HHCAHPS” is a standardized survey instrument and data collection methodology for measuring home health patients ‘perspectives on their home health care in Medicare-certified home health care agencies. AHRQ and CMS participated in the development of the Home Health CAHPS to measure the experiences of those receiving home health care with these three goals in mind: 

    CBE ID
    0517

Cardiac Rehabilitation Patient Referral From an Inpatient Setting

  • Percentage of patients admitted to a hospital with a primary diagnosis of an acute myocardial infarction or chronic stable angina or who during hospitalization have undergone coronary artery bypass (CABG) surgery, a percutaneous coronary intervention (PCI), cardiac valve surgery (CVS), or cardiac transplantation who are referred to an early outpatient cardiac rehabilitation/secondary prevention program.

    CBE ID
    0642