Quality Improvement with Benchmarking (external benchmarking to multiple organizations)

The Medical Home System Survey (MHSS) assesses the degree to which an individual primary-care practice or provider has in place the structures and processes of an evidence-based Patient Centered Medical Home. The survey is composed of six composites. Each measure is used to assess a particular domain of the patient-centered medical home.

Composite 1: Patient-Centered Access
Composite 2: Team-Based Care
Composite 3: Population Health Management
Composite 4: Care Management and Support
Composite 5: Care Coordination and Care Transitions

The percentage of patients 5-64 years of age during the measurement year who were identified as having persistent asthma and were dispensed appropriate medications that they remained on during the treatment period. Two rates are reported.
1. The percentage of patients who remained on an asthma controller medication for at least 50% of their treatment period.
2. The percentage of patients who remained on an asthma controller medication for at least 75% of their treatment period.

Percentage of patient-months for which medication reconciliation* was performed and documented by an eligible professional.**

The percentage of discharges from January 1–December 1 of the measurement year for patients 18 years of age and older for whom medications were reconciled the date of discharge through 30 days after discharge (31 days total).

The percentage of discharges during the first 11 months of the measurement year (e.g., January 1–December 1) for patients 66 years of age and older for whom medications were reconciled on or within 30 days of discharge.

The percentage of children and adolescents 1-17 years of age who had two or more antipsychotic prescriptions and had metabolic testing.

Percentage of pediatric (less than 18 years old) in-center hemodialysis patients (irrespective of frequency of dialysis) for whom delivered HD dose was measured by spKt/V as calculated using UKM or Daugirdas II during the reporting period.

The proportion of admissions to an institutional facility (e.g., nursing facility, intermediate care facility for individuals with intellectual disabilities [ICF/IID]) for managed long-term services and support (MLTSS) plan enrollees that result in successful discharge to the community (community residence for 60 or more days) within 100 days of admission. This measure is reported as an observed rate and a risk-adjusted rate.

Percentage of all adult (>=18 years old) hemodialysis patients, peritoneal dialysis, and home hemodialysis patients with ESRD >=3 months and who had Hb values reported for at least 2 of the 3 study months, who have a mean Hb <10.0 g/dL for a 3 month study period, irrespective of ESA use.

This measure evaluates the percentage of magnetic resonance imaging (MRI) of the lumbar spine studies for low back pain performed in the outpatient setting where conservative therapy was not attempted prior to the MRI. Antecedent conservative therapy may include claim(s) for physical therapy in the 60 days preceding the lumbar spine MRI, claim(s) for chiropractic evaluation and manipulative treatment in the 60 days preceding the lumbar spine MRI, or claim(s) for evaluation and management at least 28 days but no later than 60 days preceding the lumbar spine MRI.