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Coordinated and Integrated Care

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

Excess days in acute care (EDAC) after hospitalization for heart failure (HF)

The measure assesses days spent in acute care within 30 days of discharge from an inpatient hospitalization for HF to provide a patient-centered assessment of the post-discharge period. This measure is intended to capture the quality of care transitions provided to discharged patients who had a HF hospitalization by collectively measuring a set of adverse acute care outcomes that can occur post-discharge: emergency department (ED) visits, observation stays, and unplanned readmissions at any time during the 30 days post-discharge.

CBE ID
2880

Excess days in acute care (EDAC) after hospitalization for pneumonia

This measure assesses days spent in acute care within 30 days of discharge from an inpatient hospitalization for pneumonia, including aspiration pneumonia or for sepsis (not severe sepsis) with a secondary discharge diagnosis of pneumonia coded in the claim as present on admission (POA) and no secondary diagnosis of severe sepsis coded as POA.

CBE ID
2882

Family Experiences with Coordination of Care (FECC) -3: Care coordinator helped to obtain community services

The Family Experiences with Coordination of Care (FECC) Survey was developed to gather information about the quality of care coordination being received by children with medical complexity (CMC) over the previous 12 months. The FECC Survey is completed by English- and Spanish-speaking caregivers of CMC aged 0-17 years with at least 4 medical visits in the previous year, and it includes all of the information needed to score 20 separate and independent quality measures, a sub-set of 8 of which are included in this submitted measure set.

CBE ID
2843

Family Experiences with Coordination of Care (FECC) -5: Care coordinator asked about concerns and health

The Family Experiences with Coordination of Care (FECC) Survey was developed to gather information about the quality of care coordination being received by children with medical complexity (CMC) over the previous 12 months. The FECC Survey is completed by English- and Spanish-speaking caregivers of CMC aged 0-17 years with at least 4 medical visits in the previous year, and it includes all of the information needed to score 20 separate and independent quality measures, a sub-set of 8 of which are included in this submitted measure set.

CBE ID
2844