Skip to main content

Breadcrumb

  1. Home

Accountable Entity-Level (e.g., signal-to-noise analysis)

Valid for Measure Submission

Gains in Patient Activation Measure (PAM) Scores at 12 Months

  • The measure is the percentage of patients who achieve a 3-point increase in their Patient Activation Measure® (PAM®) survey score within 12 months. The outcome measure demonstrates how a clinician group performed in providing best care to its patients by quantifying the proportion of patients who had at least a 3-point score change. 

     

    CBE ID
    2483

Global Malnutrition Composite Score

  • This composite measure assesses the percentage of hospitalizations for adults aged 18 years and older at the start of the inpatient encounter during the measurement period with a length of stay equal to or greater than 24 hours who received optimal malnutrition care during the current inpatient hospitalization where care performed was appropriate to the patient's level of malnutrition risk and severity.

    CBE ID
    3592e

Head CT or MRI Scan Results for Acute Ischemic Stroke or Hemorrhagic Stroke Patients who Received Head CT or MRI Scan Interpretation within 45 minutes of ED Arrival

  • This measure calculates the percentage of acute ischemic stroke or hemorrhagic stroke patients who arrive at the emergency department (ED) within two hours of the onset of symptoms and have a head computed tomography (CT) or magnetic resonance imaging (MRI) scan interpreted within 45 minutes of ED arrival. The measure is calculated using chart abstracted data, on a rolling, quarterly basis and is publicly reported, in aggregate, for one calendar year.

    CBE ID
    0661

Home and Community-Based Services (HCBS) Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Measures

  • The Home and Community-Based Services (HCBS) Consumer Assessment of Healthcare Providers and Systems (CAHPS) Survey consists of 19 measures that assess the experiences of Medicaid participants’ age 18 and older receiving long-term services and supports (LTSS). The measures report a case-mix adjusted top-box score. Measure scores are calculated based on participant responses to a cross-disability survey about their experiences with the LTSS they receive in the community, delivered through a Medicaid-funded HCBS program.

    CBE ID
    2967

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

Hospital 30-Day Risk-Standardized Readmission Rates following Percutaneous Coronary Intervention (PCI)

  • This measure estimates a hospital-level risk-standardized readmission rate (RSRR) following PCI for Medicare Fee-for-Service (FFS) patients who are 65 years of age or older. The outcome is defined as unplanned readmission for any cause within 30 days following hospital stays. The measure includes both patients who are admitted to the hospital (inpatients) for their PCI and patients who undergo PCI without being admitted (outpatient or observation stay). A specified set of planned readmissions do not count as readmissions.

    CBE ID
    0695

Hospital 30-Day, All-Cause, Risk-Standardized Mortality Rate (RSMR) Following Acute Ischemic Stroke Hospitalization with Claims-Based Risk Adjustment for Stroke Severity

  • The measure estimates the hospital-level, risk-standardized mortality rate (RSMR) for Medicare patients (Fee-for-Service [FFS] and Medicare Advantage[MA]) discharged from the hospital with a principal discharge diagnosis of acute ischemic stroke. The outcome is all-cause 30-day mortality, defined as death from any cause within 30 days of the index admission date, including in-hospital death, for stroke patients. The measure includes the National Institutes of Health (NIH) Stroke Scale as an assessment of stroke severity upon admission in the risk-adjustment model.

    CBE ID
    4595

Hospital 30-Day, All-Cause, Risk-Standardized Readmission Rate (RSRR) Following Chronic Obstructive Pulmonary Disease (COPD) Hospitalization

  • The measure estimates a hospital-level 30-day, all-cause, risk-standardized readmission rate (RSRR) for Medicare patients (Fee-For-Service [FFS]and Medicare Advantage [MA]) aged 65 and older discharged from a hospital with either a principal discharge diagnosis of COPD or a principal discharge diagnosis of respiratory failure with a secondary diagnosis of acute exacerbation of COPD. The outcome (readmission) is defined as unplanned readmission for any cause within 30 days of the discharge date for the index admission.

    CBE ID
    1891

Hospital Harm – Falls with Injury

  • This ratio measure assesses the number of inpatient hospitalizations where at least one fall with a major or moderate injury occurs among the total qualifying inpatient hospital days for patients aged 18 years and older.

    CBE ID
    4120e

Hospital Harm – Postoperative Respiratory Failure

  • This electronic clinical quality measure (eCQM) assesses the proportion of elective inpatient hospitalizations for patients aged 18 years and older without an obstetrical condition who have a procedure resulting in postoperative respiratory failure (PRF).

    CBE ID
    4130e