Coordinated and Integrated Care
Description
The percentage of patients 18 years of age and older who were diagnosed with rheumatoid arthritis and who were dispensed at least one ambulatory prescription for a disease-modifying anti-rheumatic drug (DMARD).
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 used an emergency department but were not admitted to an acute care hospital during the 30 days following the start of the home health stay.
Description
Percentage of home health stays in which patients used the emergency department but were not admitted to the hospital during the 60 days following the start of the home health stay.
Description
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)
Description
Percentage of actively enrolled home-based primary care and palliative care patients who received an assessment of their cognitive ability.
Description
Percentage of actively enrolled home-based primary care and palliative care patients who receive an ADL and IADL assessment.
*Basic ADLs must include but are not limited to: bathing, transferring, toileting, and feeding; Instrumental ADLs (IADL) must include but are not limited to: telephone use and managing own medications
Description
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.
Description
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.
Description
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.
Description
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.