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Coordinated and Integrated Care

Preventive Care and Screening: Screening for Depression and Follow-Up Plan

Percentage of patients aged 12 years and older screened for depression on the date of the encounter or 14 days prior to the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the eligible encounter

CBE ID
0418e

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user

Three rates are reported:
a. Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months
b. Percentage of patients aged 18 years and older who were identified as a tobacco user who received tobacco cessation intervention

CBE ID
0028

Rehospitalization During the First 30 Days of Home Health

Percentage of home health stays in which patients who had an acute inpatient hospitalization in the 5 days before the start of their home health stay were admitted to an acute care hospital during the 30 days following the start of the home health stay.

CBE ID
2380

Risk-Adjusted Coronary Artery Bypass Graft (CABG) Readmission Rate

Risk-adjusted percentage of Medicare fee-for-service beneficiaries aged 65 and older who undergo isolated coronary artery bypass grafting (CABG) and are discharged alive but have a subsequent acute care hospital inpatient admission within 30 days of the date of discharge from the CABG hospitalization.

CBE ID
2514

Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM)

The SNFRM estimates the risk-standardized rate of all-cause, unplanned hospital readmissions for Skilled Nursing Facility (SNF) Medicare fee-for-service (FFS) beneficiaries within 30 days of discharge from a prior proximal acute hospitalization. The prior proximal hospitalization is defined as an admission to an IPPS, CAH, psychiatric, or cancer hospital. The measure is risk-adjusted for patient demographics, principal diagnosis from the prior hospitalization, comorbidities, and other health status variables that affect the probability of a hospital readmission.

CBE ID
2510

Standardized Readmission Ratio (SRR) for dialysis facilities

The Standardized Readmission Ratio (SRR) for a dialysis facility is the ratio of the number of observed index discharges from acute care hospitals to that facility that resulted in an unplanned readmission to an acute care hospital within 4-30 days of discharge to the expected number of readmissions given the discharging hospitals and the characteristics of the patients and based on a national norm. Note that the measure is based on Medicare-covered dialysis patients.

CBE ID
2496