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Endorsed with Conditions

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

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 Visits after Orthopedic Ambulatory Surgical Center Procedures

This measure was developed to improve the quality of care delivered to patients undergoing orthopedic procedures in an ambulatory surgical center (ASC). To assess quality, the measure calculates the risk-standardized rate of acute, unplanned hospital visits within seven days of qualified orthopedic surgeries or procedures performed at an ASC among Medicare fee-for-service (FFS) patients aged 65 years and older. An unplanned hospital visit is defined as an emergency department (ED) visit, observation stay, or unplanned inpatient admission.

CBE ID
3470

Hospital Visits After Urology Ambulatory Surgical Center Procedures

This measure was developed to improve the quality of care delivered to patients undergoing urology procedures in an ambulatory surgical center (ASC). The measure estimates a facility-level rate of risk-standardized, all-cause, unplanned hospital visits within seven days of a urology surgery at an ASC among Medicare fee-for-service (FFS) patients aged 65 years and older. An unplanned hospital visit is defined as an emergency department (ED) visit, observation stay, or unplanned inpatient admission. 

CBE ID
3366

Hospital-Level, Risk-Standardized Complication Rate (RSCR) Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA)

The measure estimates a hospital-level risk-standardized complication rate (RSCR) associated with elective primary THA and/or TKA procedures for Medicare patients (Fee-for-Service [FFS] and Medicare Advantage [MA]) aged 65 and older. The outcome (complication) is defined as any one of the specified complications occurring from the date of index admission to up to 90 days after the index admission. Complications are counted in the measure only if they occur during the index hospital admission or during a readmission.

CBE ID
1550

Hospital-Wide 30-Day, All-Cause, Unplanned Readmission Rate (HWR) for the Merit-Based Incentive Payment System (MIPS) Eligible Clinician Groups

The 30-day Hospital-Wide, All-Cause Unplanned Readmission (HWR) Rate for the Merit-based Incentive Payment System (MIPS) Groups measure is a risk-standardized readmission rate for beneficiaries age 65 or older who were hospitalized and experienced an unplanned readmission for any cause to a short-stay acute-care hospital within 30 days of discharge. The measure attributes readmissions to up to three MIPS participating clinician groups, as identified by their Medicare Taxpayer Identification Number (TIN), and assesses each group’s readmission rate.

CBE ID
3495

Hospitalizations for Ambulatory Care Sensitive Conditions among Home and Community Based Service (HCBS) Participants

The Hospitalizations for Ambulatory Care Sensitive Conditions among Home and Community Based Participants measure is a risk-adjusted, state-level measure that assesses rates of hospital admissions for ambulatory care sensitive conditions per 1,000 Medicaid HCBS participants aged 18 years and older. This measure has three rates reported for potentially avoidable inpatient hospital admissions:

  1. Chronic Conditions
  2. Acute Conditions
  3. Chronic and Acute Conditions Composite
CBE ID
4490