Coordinated and Integrated Care

The percentage of patients 18-75 years of age with a serious mental illness and diabetes (type 1 and type 2) who had hemoglobin A1c (HbA1c) testing during the measurement year.

Note: This measure is adapted from an existing health plan measure used in a variety of reporting programs for the general population (NQF #0057: Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Testing). This measure is endorsed by NQF and is stewarded by NCQA.

The percentage of patients 18-75 years of age with a serious mental illness and diabetes (type 1 and type 2) who received a nephropathy screening test or had evidence of nephropathy during the measurement year.
Note: This measure is adapted from an existing health plan measure used in a variety of reporting programs for the general population (NQF #0062: Comprehensive Diabetes Care: Medical Attention for Nephropathy). It is endorsed by NQF and is stewarded by NCQA.

Admissions for a principal diagnosis of diabetes with long-term complications (renal, eye, neurological, circulatory, or complications not otherwise specified) 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.]

The percentage of patients 18 – 64 years of age with schizophrenia and diabetes who had both an LDL-C test and an HbA1c test during the measurement year.

The percentage of patients 18 – 64 years of age with schizophrenia or bipolar disorder, who were dispensed an antipsychotic medication and had a diabetes screening test during the measurement year.

Admissions for a principal diagnosis of diabetes with short-term complications (ketoacidosis, hyperosmolarity, or coma) 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.]

Percentage of patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed with documented communication to the physician who manages the ongoing care of the patient with diabetes mellitus regarding the findings of the macular or fundus exam at least once within 12 months

Percentage of patients undergoing a screening mammogram whose information is entered into a reminder system with a target due date for the next mammogram

The Discharge to Community-Post Acute Care Measure for Home Health Agencies (DTC-PAC HHA) measure was developed to address the resource use and other measures domain of Discharge to the Community, a domain mandated by the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act). The measure was developed using calendar year 2012-2013 data.

The Discharge to Community-Post Acute Care Measure for Inpatient Rehabilitation Facilities (DTC-PAC IRF) 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 an IRF, with successful discharge to community including no unplanned rehospitalizations and no death in the 31 days following IRF discharge.