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Care Coordination

Plan All-Cause Readmissions (PCR)

  • 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).

    CBE ID
    1768

Post-Discharge Appointment for Heart Failure Patients

  • 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.

    CBE ID
    2439

Radical Prostatectomy Pathology Reporting

  • Percentage of radical prostatectomy pathology reports that include the pT category, the pN category, the Gleason score and a statement about margin status.

    CBE ID
    1853

Rehospitalization During the First 30 Days of Home Health

  • Percentage of home health stays in which patients who had an acute inpatient hospitalization in the 5 days before the start of their home health stay were admitted to an acute care hospital during the 30 days following the start of the home health stay.

    CBE ID
    2380

Risk-Adjusted Coronary Artery Bypass Graft (CABG) Readmission Rate

  • Risk-adjusted percentage of Medicare fee-for-service beneficiaries aged 65 and older who undergo isolated coronary artery bypass grafting (CABG) and are discharged alive but have a subsequent acute care hospital inpatient admission within 30 days of the date of discharge from the CABG hospitalization.

    CBE ID
    2514