Quality Improvement (Internal to the specific organization)

The Discharge to Community-Post Acute Care Measure for Skilled Nursing Facilities (DTC-PAC SNF) was developed to address the resource use and other measures domain of Discharge to the Community mandated by the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). This outcome measure assesses successful discharge to community from a SNF, with successful discharge to community including no unplanned rehospitalizations and no death in the 31 days following SNF discharge.

Percentage of patients 18+ with carpal tunnel syndrome who received surgical carpal tunnel release, and who should not routinely be prescribed postoperative physical and/or occupational therapy within 6 weeks after release.

Time of first contact in the ED to the time when the patient sees qualified medical personnel for patient evaluation and management.

Percent of patients aged 18 years and older undergoing cardiac surgery whose prophylactic antibiotics were ordered to be discontinued OR were discontinued within 48 hours after surgery end time.

This measure identifies patients age 18 or older who started lipid-lowering medication during the measurement year and had a lipid panel checked within 3 months after starting drug therapy.

Of all patient encounters within the past month that used an electronic health record (EHR) with electronic data interchange (EDI) where a prescribing event occurred, how many used EDI for the prescribing event.

Type of score: Proportion
Percentage of patients aged 60 years and older with an emergency department discharge diagnosis of syncope who had an ECG performed

Percentage of all patients transferred from an Emergency Department to another healthcare facility whose medical record documentation indicated that all required information was communicated (sent) to the receiving facility within 60 minutes of transfer For all data elements, the definition of ‘sent’ includes the following:
• Hard copy sent directly with the patient, or 
• Sent via fax or phone within 60 minutes of patient departure, or
• Immediately available via shared Electronic health record (EHR) or Health Information Exchange (HIE) (see definition below)

The percentage of discharges for members 6 years of age and older who were hospitalized for treatment of selected mental illness or intentional self-harm diagnoses and who had at least five follow-up community-based mental health care visits in the 90 days after discharge.

This measure assesses the number of nulliparous women with a term, singleton baby in a vertex position delivered by cesarean birth.