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Regulatory and Accreditation Programs

Valid for Measure Submission
Valid for Initial Endorsement
Valid for Maintenance

Diabetes: Appropriate Treatment of Hypertension

  • The percentage of patients who were dispensed a medication for diabetes and hypertension that are receiving an angiotensin-converting -enzyme-inhibitor (ACEI) or angiotensin receptor blocker (ARB) or direct renin inhibitor (DRI) renin-angiotensin-antagonist medication.

    CBE ID
    0546

Emergency Transfer Communication Measure

  • 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)

    CBE ID
    0291

ePC-02 Cesarean Birth

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

    CBE ID
    0471e

ePC-07 Severe Obstetric Complications

  • Hospital-level measure scores are calculated as a risk-adjusted proportion of the number of delivery hospitalizations for women who experience a severe obstetric complication, as defined by the numerator, by the total number of delivery hospitalizations in the denominator during the measurement period.

    CBE ID
    3687e

Falls with injury

  • All documented patient falls with an injury level of minor or greater on eligible unit types in a calendar quarter. Reported as Injury falls per 1000 Patient Days.

    (Total number of injury falls / Patient days) X 1000

    Measure focus is safety.
    Target population is adult acute care inpatient and adult rehabilitation patients.

    CBE ID
    0202

Flu Shot for Older Adults

  • Percentage of patients age 65 and over who received an influenza vaccination from September through December of the year

    CBE ID
    0040

Flu Vaccinations for Adults Ages 18 and Older

  • The percentage of adults 18 years of age and older who self-report receiving an influenza vaccine within the measurement period. This measure is collected via the CAHPS 5.0H adults survey for Medicare, Medicaid, and commercial populations. It is reported as two separate rates stratified by age: 18-64 and 65 years of age and older.

    CBE ID
    0039

Follow-Up After Emergency Department Visit for Alcohol and Other Drug Abuse or Dependence

  • The percentage of emergency department (ED) visits for members 13 years of age and older with a principal diagnosis of alcohol or other drug (AOD) abuse or dependence, who had a follow up visit for AOD. Two rates are reported:
    - The percentage of ED visits for which the member received follow-up within 30 days of the ED visit (31 total days).
    - The percentage of ED visits for which the member received follow-up within 7 days of the ED visit (8 total days).

    CBE ID
    3488

Follow-Up After Emergency Department Visit for Mental Illness

  • The percentage of emergency department (ED) visits for members 6 years of age and older with a principal diagnosis of mental illness or intentional self-harm, who had a follow-up visit for mental illness. Two rates are reported:
    - The percentage of ED visits for which the member received follow-up within 30 days of the ED visit (31 total days).
    - The percentage of ED visits for which the member received follow-up within 7 days of the ED visit (8 total days).

    CBE ID
    3489

Functional Change: Change in Mobility Score

  • Change in rasch derived values of mobility function from admission to discharge among adults aged 18 and older receiving inpatient medical rehabilitation at a post acute care facility who were discharged alive. The timeframe for the measure is 12 months. The measure includes the following 4 mobility items:1. Transfer Bed/Chair/Wheelchair, 2. Transfer Toilet, 3. Locomotion, 4. Stairs.

    CBE ID
    2321