Coordinated and Integrated Care
Description
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
Description
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
Description
Proportion of patients who died from cancer not admitted to hospice
Description
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.
Description
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.
Description
Rate of risk-standardized acute, unplanned hospital admissions among Medicare fee-for-service (FFS) beneficiaries 65 years and older with diabetes who are assigned to an Accountable Care Organization (ACO).
Description
Rate of risk-standardized acute, unplanned hospital admissions among Medicare fee-for-service (FFS) beneficiaries 65 years and older with heart failure who are assigned to an Accountable Care Organization (ACO).
Description
Rate of risk-standardized acute, unplanned hospital admissions among Medicare fee-for-service
(FFS) beneficiaries 65 years and older with multiple chronic conditions (MCCs) who are assigned to an Accountable Care Organization (ACO).
Description
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.
Description
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.