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Coordinated and Integrated Care

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

Statin Use in Persons with Diabetes

  • The percentage of patients ages 40 to 75 years who were dispensed a medication for diabetes that receive a statin medication.

    CBE ID
    2712

Tobacco Use Screening and Follow-up for People with Serious Mental Illness or Alcohol or Other Drug Dependence

  • The percentage of patients 18 years and older with a serious mental illness or alcohol or other drug dependence who received a screening for tobacco use and follow-up for those identified as a current tobacco user. Two rates are reported.

    Rate 1: The percentage of patients 18 years and older with a diagnosis of serious mental illness who received a screening for tobacco use and follow-up for those identified as a current tobacco user.

    CBE ID
    2600

Uncontrolled Diabetes Admission Rate (PQI 14)

  • Admissions for a principal diagnosis of diabetes without mention of short-term (ketoacidosis, hyperosmolarity, or coma) or long-term (renal, eye, neurological, circulatory, or other unspecified) complications per 100,000 population, ages 18 years and older. Excludes obstetric admissions and transfers from other institutions.

    [NOTE: The software provides the rate per population. However, common practice reports the measure as per 100,000 population. The user must multiply the rate obtained from the software by 100,000 to report admissions per 100,000 population.]

    CBE ID
    0638

Urinary Tract Infection Admission Rate (PQI 12)

  • Admissions with a principal diagnosis of urinary tract infection per 100,000 population, ages 18 years and older. Excludes kidney or urinary tract disorder admissions, other indications of immunocompromised state admissions, obstetric admissions, and transfers from other institutions.

    [NOTE: The software provides the rate per population. However, common practice reports the measure as per 100,000 population. The user must multiply the rate obtained from the software by 100,000 to report admissions per 100,000 population.]

    CBE ID
    0281