Care Coordination

Information From 2015 Submission

Optimal End Stage Renal Disease (ESRD) Starts is the percentage of new adult ESRD patients during the measurement period who experience a planned start of renal replacement therapy by receiving a preemptive kidney transplant, by initiating home dialysis (peritoneal dialysis or home hemodialysis), or by initiating outpatient in-center hemodialysis via arteriovenous fistula or arteriovenous graft.

Participation in a multi-center data collection and feedback program that provides benchmarking of the physician’s data relative to national programs and uses structural, process, and outcome measures.

Percentage of vulnerable adults admitted to ICU who survive at least 48 hours who have their care preferences documented within 48 hours OR documentation as to why this was not done.

Adult patients with advanced cancer who are screened for pain with a standardized quantitative tool at each outpatient visit

This quality measure reports the percentage of all Long-Term Care Hospital (LTCH) patients with an admission and discharge functional assessment and a care plan that addresses function.

This measure tracks the percentage of patients in each dialysis practitioner group practice who were on the kidney or kidney-pancreas transplant waitlist. Results are averaged across patients prevalent on the last day of each month during the reporting year.

Please note, this measure is at the dialysis practitioner level (the clinician who receives the Monthly Capitation Payment for overseeing dialysis care).

The proposed measure is a directly standardized percentage, which is adjusted for covariates (e.g. age and risk factors).

0-100 measure of performance evaluation related to patient-centered communication, derived from items on the staff and patient surveys of the Communication Climate Assessment Toolkit

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).

Patients for whom a follow-up appointment for an office or home health visit for management of heart failure was scheduled within 7 days post-discharge and documented including location, date, and time.

Patients who receive a re-evaluation for symptoms worsening and treatment compliance by a program team member within 72 hours after inpatient discharge.