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Fall 2021

Hospice and Palliative Care -- Pain Assessment

  • This quality measure is defined as:
    Percentage of hospice or palliative care patients who screened positive for pain and who received a clinical assessment of pain within 24 hours of screening.

    CBE ID
    1637

Hospice Visits in the Last Days of Life

  • The proportion of hospice patients who received hospice visits from a Registered Nurse or Medical Social Worker (non-telephonically) associated with the measured hospice entity during at least two of the final three days of life.

    CBE ID
    3645

Informed Participation

  • Improved measurement of the continuity of insurance coverage in the Medicaid and CHIP population is needed to help maximize insurance continuity and coverage for vulnerable children. To further this goal, the AHRQ-CMS CHIPRA PQMP Center of Excellence at the Children’s Hospital of Philadelphia developed the metric Informed Coverage.

    CBE ID
    3154

Medication Reconciliation on Admission

  • Percentage of patients for whom a designated PTA medication list was generated by referencing one or more external sources of PTA medications and for which all PTA medications have a documented reconciliation action by the end of Day 2 of the hospitalization.

    CBE ID
    3317

Medication Reconciliation Post-Discharge

  • The percentage of discharges from January 1–December 1 of the measurement year for patients 18 years of age and older for whom medications were reconciled the date of discharge through 30 days after discharge (31 days total).

    CBE ID
    0097

Mismatch Repair (MMR) or Microsatellite Instability (MSI) Biomarker Testing Status in Colorectal Carcinoma, Endometrial, Gastroesophageal, or Small Bowel Carcinoma

  • Percentage of surgical pathology reports for primary colorectal, endometrial, gastroesophageal or small bowel carcinoma, biopsy or resection, that contain impression or conclusion of or recommendation for testing of mismatch repair (MMR) by immunohistochemistry (biomarkers MLH1, MSH2, MSH6, and PMS2), or microsatellite instability (MSI) by DNA-based testing status, or both

    CBE ID
    3661

Percent of Residents Who Lose Too Much Weight (Long-Stay)

  • This measure reports the percentage of long-stay nursing home residents with a target Minimum Data Set (MDS) assessment (OBRA, PPS, Discharge) that indicates a weight loss of 5% or more of the baseline weight in the last 30 days or 10% or more of the baseline weight in the last 6 months, which is not a result of a physician-prescribed weight-loss regimen. The baseline weight is the resident’s weight closest to 30 or 180 days before the date of the target assessment. Long-stay residents are identified as residents who have had at least 101 cumulative days of nursing facility care.

    CBE ID
    0689