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Full Year 2015

Prenatal & Postpartum Care (PPC)

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.

CBE ID
1517

Pressure ulcer prevalence (hospital acquired)

The total number of patients that have hospital-acquired (nosocomial) category/stage II or greater pressure ulcers on the day of the prevalence measurement episode.

CBE ID
0201

Pressure Ulcer Prevention and Care

Pressure Ulcer Risk Assessment Conducted: Percentage of home health episodes of care in which the patient was assessed for risk of developing pressure ulcers at start/resumption of care.

Pressure Ulcer Prevention Included in Plan of Care: Percentage of home health episodes of care in which the physician-ordered plan of care included interventions to prevent pressure ulcers.

CBE ID
0538

Proportion of Patients Hospitalized with AMI that have a Potentially Avoidable Complication (during the Index Stay or in the 30-day Post-Discharge Period)

Percent of adult population aged 18 + years who are admitted to a hospital with acute myocardial infarction (AMI), are followed for one-month after discharge, and have one or more potentially avoidable complications (PACs). PACs may occur during the index stay or during the 30-day post discharge period. Please reference attached document labeled NQF_AMI_all_codes_risk_adjustment_06.30.15.xls, in the tabs labeled PACs I-9 and PAC I-10 for a list of code definitions of PACs relevant to AMI.

We define PACs during each time period as one of two types:

CBE ID
0704

Proportion of Patients Hospitalized with Stroke that have a Potentially Avoidable Complication (during the Index Stay or in the 30-day Post-Discharge Period)

Percent of adult population aged 18 – 65 years who were admitted to a hospital with stroke, were followed for one-month after discharge, and had one or more potentially avoidable complications (PACs). PACs may occur during the index stay or during the 30-day post discharge period (Please reference attached document labeled NQF_Stroke_PACs_Risk_Adjustment_2.16.10.xls, tabs labeled CIP_Index PAC_Stays and CIP_PAC_Readmission). We define PACs during each time period as one of three types:

(A) PACs during the Index Stay (Hospitalization):

CBE ID
0705

Proportion of Patients with Pneumonia that have a Potentially Avoidable Complication (during the episode time window)

Brief Description of Measure: Percent of adult population aged 18+ years with Community Acquired Pneumonia who are followed for one-month, and have one or more potentially avoidable complication (PAC) during the episode time window. Please reference the attached document labeled NQF_PNE_all_codes_risk_adjustment_12_14_15.xls, in the tab labeled PACS I-9 & I-10 for a list of code definitions of PACs relevant to pneumonia.

CBE ID
0708