Integrated Delivery System

For patients 18 years of age and older, the number of acute inpatient stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission. Data are reported in the following categories:

1. Count of Index Hospital Stays* (denominator)
2. Count of 30-Day Readmissions (numerator)
3. Average Adjusted Probability of Readmission

*An acute inpatient stay with a discharge during the first 11 months of the measurement year (e.g., on or between January 1 and December 1).

Percentage of patients with pneumonia, age 65 and older, who were screened for pneumococcal vaccine status and were vaccinated prior to discharge, if indicated

Percentage of patients 65 years of age and older who ever received a pneumococcal vaccination.

This measure identifies patients with ST elevation MI (STEMI), or non-ST elevation MI (NSTEMI) plus a history of hypertension, heart failure and/or diabetes prior to the measurement year who are taking an ACEI or an ARB during the measurement year.

Percentage of pre-school aged children who receive vision screening in the medical home

This measure identifies pregnant women who had a HBsAg (hepatitis B) test during their pregnancy.

This measure identifies pregnant women who had an HIV test during their pregnancy.

This measure identifies pregnant women who had a syphilis test during their pregnancy.

The percentage of deliveries of live births between November 6 of the year prior to the measurement year and November 5 of the measurement year. For these women, the measure assesses the following facets of prenatal and postpartum care:
Rate 1: Timeliness of Prenatal Care. The percentage of deliveries that received a prenatal care visit as a member of the organization in the first trimester or within 42 days of enrollment in the organization.
Rate 2: Postpartum Care. The percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery.

Percentage of enrolled children in the age category of 6-9 years at “elevated” risk (i.e., “moderate” or “high”) who received a sealant on a permanent first molar tooth within the reporting year.