Quality Improvement (Internal to the specific organization)

This is a survey-based measure and one of the family of surveys called CAHPS Surveys (Consumer Assessment of Healthcare Providers and Systems)that are focused on patient experience. The questionnaire asks End Stage Renal Disease (ESRD) patients receiving in-center hemodialysis care about the services and quality of care that they experience. Patients assess their dialysis providers, including nephrologists and medical and non-medical staff, the quality of dialysis care they receive, and information sharing about their disease.

The CAHPS Health Plan Survey is a survey that asks health plan enrollees to report about their care and health plan experiences as well as the quality of care received from physicians. HP-CAHPS Version 4.0 was endorsed by NQF in July 2007 (NQF #0006) and Version 5.0 received maintenance endorsement in January 2015. The survey is part of the CAHPS family of patient experience surveys and is available in the public domain at https://www.ahrq.gov/cahps/surveys-guidance/hp/index.html

The following 6 composites and 1 single-item measure are generated from the Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Surgical Care Survey. Each measure is used to assess a particular domain of surgical care quality from the patient’s perspective.

Measure 1: Information to help you prepare for surgery (2 items)
Measure 2: How well surgeon communicates with patients before surgery (4 items)
Measure 3: Surgeon’s attentiveness on day of surgery (2 items)
Measure 4: Information to help you recover from surgery (4 items)

The Continuity of Care After Inpatient or Residential Treatment for Substance Use Disorder measure evaluates the percentage of discharges from inpatient or residential treatment for diagnoses of substance use disorders (SUD) among Medicaid or Medicare-Medicaid beneficiaries, aged 18 years and older, which were followed by a treatment service for SUD.

Percentage of discharges from a medically managed withdrawal episode for adult Medicaid beneficiaries, ages 18–64, that were followed by a treatment service for substance use disorder (including the prescription or receipt of a medication to treat a substance use disorder [pharmacotherapy]) within 7 or 14 days after discharge.

Percentage of Medicaid discharges, ages 18 to 64, being treated for a substance use disorder (SUD) from an inpatient or residential provider that received SUD follow-up treatment within 7 or 30 days after discharge. SUD follow-up treatment includes outpatient, intensive outpatient, or partial hospitalization visits; telehealth encounters; SUD medication fills or administrations; or residential treatment (after an inpatient discharge). Two rates are reported: continuity within 7 and 30 days after discharge.

This measure assesses the percentage of children with medical complexity age 1 to 17 years old who have a Bice-Boxerman continuity of care index (hereafter referred to as Bice-Boxerman COC index) of >=0.5 in the primary care setting over a 12-month period.

Among women ages 15 through 44 who had a live birth, the percentage that is provided:
1) A most effective (i.e., sterilization, implants, intrauterine devices or systems (IUD/IUS)) or moderately (i.e., injectables, oral pills, patch, or ring) effective method of contraception within 3 and 60 days of delivery.

2) A long-acting reversible method of contraception (LARC) within 3 and 60 days of delivery.

The percentage of patients 18-85 years of age with serious mental illness who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled during the measurement year.

The percentage of patients age 18 years or older with poorly controlled COPD, who are taking a long acting bronchodilator.