Comprehensive ESRD Care (CEC) Model Proposed Quality Measures for Public Comment. Table of Contents

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1 Comprehensive ESRD Care (CEC) Model Proposed Quality s for Public Comment Table of Contents Page # Introduction 3 Summaries by Domain Technical Expert Panel Recommended CEC Quality s 4 s that were recommended by a majority of TEP members or that align with CMS priorities. Quality of Life 1. Kidney Disease Quality of Life (KDQOL) 4 Chronic Disease Management 2. Diabetes Care: Eye Exam 5 3. Diabetes Care: Foot Exam 6 4. Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes 7 Care 5. Rate of Lower-Extremity Amputation Among Patients with Diabetes 8 6. Coronary Artery Disease (CAD): Beta-Blocker Therapy Prior Myocardial Infarction (MI) 9 or Left Ventricular Systolic Dysfunction (LVEF <40%) 7. Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin 10 Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) Patient Safety 8. Dialysis Facility Risk-Adjusted Standardized Mortality Ratio 11 Preventive Health 9. Influenza Immunization Pneumonia Vaccination Status for Older Adults Screening for Clinical Depression and Follow-Up Plan Tobacco Use: Screening and Cessation Intervention 15 Care Coordination 13. Standardized Readmission Ratio (SRR) for Dialysis Facilities Standardized Hospitalization Ratio for Admissions Advance Care Plan Documentation of Current Medications in the Medical Record 19 IMPAQ International, LLC Page 1

2 s Under Consideration 20 s that received mixed evaluation results from the TEP, but align with CMS priorities. Quality of Life 1. Functional Status Assessment for Complex Chronic Conditions 20 Chronic Disease Management 2. Diabetes: Hemoglobin A1c Poor Control Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) 23 Patient Safety 5. Hospital-Wide All-Cause Unplanned Readmission (HWR) 24 Care Coordination 6. Medication Reconciliation Anemia of Chronic Kidney Disease: Dialysis Facility Standardized Transfusion Ratio 26 CEC Workbook 2 IMPAQ International, LLC

3 Introduction This workbook includes proposed quality measures for the Comprehensive End Stage Renal Disease Care (CEC) Initiative. The quality measures will be part of an overall quality score used to assess the performance of the ESRD seamless care organizations (ESCOs) and determine the shared savings or losses for each year. This initial CEC measure list includes performance measures that are National Quality Forum (NQF) endorsed or currently in use in other CMS programs that were found to be applicable and relevant to the ESRD population. The measures are presented in two groups: 1. CEC Quality s Recommended by the Technical Expert Panel: measures that were recommended by a majority of TEP members or that align with CMS priorities. 2. s Under Consideration: measures that received mixed evaluation results from the TEP, but align with CMS priorities. The workbook includes detailed information about each of the measures including the numerator, denominator, and a link to the measure specification. Information about the measures is drawn from the CMS Clinical Quality s (CQM) Library, or, when not available, the National Quality Forum s Quality Positioning System. Reviewers should note that the specifications do not yet reflect any adaptations for ESCO implementation; this process will occur subsequent to measure selection. CEC Workbook 3 IMPAQ International, LLC

4 Comprehensive ESRD Care (CEC) Model Public Comment Summaries TEP Recommended CEC Quality s Kidney Disease Quality of Life (KDQOL) Administration Survey Tool Kidney Disease Quality of Life (KDQOL) NQF Number: N/A Criteria Overview Self-reported survey that assesses health-related quality of life (physical and mental functioning) of ESRD patients receiving dialysis. The survey population includes patients currently dialyzing in-center and home hemodialysis and peritoneal dialysis patients (aged 18 years and older) minus exclusions. Includes: peritoneal dialysis, in-center hemodialysis, home hemodialysis. Exclusions Under age 18. Unable to complete due to cognitive impairment, dementia or active psychosis. Non-English speaking/reading (no native language translation or interpreter available). Patients under the facility s care for less than 3 months. Patients who refuse to complete the questionnaire. Data Patient Survey Steward RAND Corporation Quality Domain Other Quality Quality of Life Part 494 Conditions for Coverage for End-Stage Renal Disease Facilities: Interpretive Guidance CEC Workbook 4 IMPAQ International, LLC

5 Diabetes Care: Eye Exam Diabetes Care: Eye Exam NQF Number: 0055 Criteria Description Percentage of patients years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the 12 months prior to the measurement period. Numerator Patients with an eye screening for diabetic retinal disease. This includes diabetics who had one of the following: A retinal or dilated eye exam by an eye care professional in the measurement period or a negative retinal exam (no evidence of retinopathy) by an eye care professional in the year prior to the measurement period. Denominator Patients with diabetes with a visit during the measurement period. Exclusions Patients with a diagnosis of gestational diabetes during the measurement period. Data EHR/paper medical record Steward National Committee for Quality Assurance (NCQA) Quality Domain Chronic Disease Management Other Quality Meaningful Use Stage 2, Physician Quality Reporting System CEC Workbook 5 IMPAQ International, LLC

6 Diabetes Care: Foot Exam Diabetes Care: Foot Exam NQF Number: 0056 Criteria Description Percentage of patients aged years of age with diabetes who had a foot exam during the measurement period. Numerator Patients who received visual, pulse and sensory foot examinations during the measurement period. Denominator Patients with diabetes with a visit during the measurement period. Exclusions Patients with a diagnosis of gestational diabetes, or who had a bilateral foot/leg amputation performed during the measurement period. Data EHR/paper medical record Steward National Committee for Quality Assurance (NCQA) Quality Domain Chronic Disease Management Other Quality Meaningful Use Stage 2, Physician Quality Reporting System CEC Workbook 6 IMPAQ International, LLC

7 Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care Diabetic Retinopathy: Communication with the Physician Managing Ongoing Diabetes Care NQF Number: 0089 Criteria Description 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. Numerator Patients with documentation, at least once within 12 months, of the findings of the dilated macular or fundus exam via communication to the physician who manages the patient s diabetic care. Steward Quality Domain Other Quality Denominator Exclusions Data AMA-PCPI Chronic Disease Management All patients aged 18 years and older with a diagnosis of diabetic retinopathy who had a dilated macular or fundus exam performed. None EHR/paper medical record Meaningful Use Stage 2, Physician Quality Reporting System CEC Workbook 7 IMPAQ International, LLC

8 Rate of Lower-Extremity Amputation Among Patients With Diabetes (PQI 16) Rate of Lower-Extremity Amputation Among Patients With Diabetes (PQI 16) NQF Number: 0285 Criteria Description The number of discharges for lower-extremity amputation among patients with diabetes per 100,000 population age 18 years and older in a Metro Area or county in a one year time period. Steward Quality Domain Other Quality Numerator Denominator All discharges of age 18 years and older with an ICD-9-CM procedure code for lower-extremity amputation and diagnosis code of diabetes in any field. Population age 18 years and older in Metro Area or county. Discharges in the numerator are assigned to the denominator based on the Metro Area or county of the patient residence, not the Metro Area or county where the hospital discharge occurred. Exclusions Transfer from a hospital (different facility). Data Claims Transfer from a skilled Nursing Facility (SNF) or Intermediate Care Facility (ICF). Transfer from another health care facility. MDC 14 (pregnancy, childbirth, and puerperium) with any diagnosis of trauma. Agency for Healthcare Research and Quality (AHRQ) Chronic Disease Management None AHRQ Prevention Quality Indicator Set QI%2016%20Lower-Extremity%20Amputation%20Diabetes%20Rate.pdf CEC Workbook 8 IMPAQ International, LLC

9 Coronary Artery Disease: Beta-Blocker Therapy Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%) Coronary Artery Disease: Beta-Blocker Therapy Prior Myocardial Infarction or Left Ventricular Dysfunction NQF Number: 0070 Criteria Description Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease (CAD) seen within a 12 month period who also have a prior myocardial infarction (MI) or a current or prior LVEF <40% who were prescribed beta-blocker therapy. Numerator Patients who were prescribed beta-blocker therapy. Denominator All patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period. Exclusions None Data EHR/paper medical record Steward AMA-PCPI Quality Domain Chronic Disease Management Other Quality Meaningful Use Stage 2, Physician Quality Reporting System CEC Workbook 9 IMPAQ International, LLC

10 Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) NQF Number: 0081 Criteria Description Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge. Numerator Patients who were prescribed ACE inhibitor or ARB therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge. Denominator All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF < 40%. Exclusions None Data EHR/paper medical record Steward AMA-PCPI Quality Domain Other Quality Chronic Disease Management Meaningful Use Stage 2, Physician Quality Reporting System CEC Workbook 10 IMPAQ International, LLC

11 Dialysis Facility Risk-Adjusted Standardized Mortality Ratio Name Dialysis Facility Risk-Adjusted Standardized Mortality Ratio NQF Number: 0369 Criteria Description Risk-adjusted standardized mortality ratio for dialysis facility patients. Numerator Number of deaths among eligible patients at the facility during the time period. Denominator Number of deaths that would be expected among eligible dialysis patients at the facility during the time period, given the mortality rate is at the national average and the patient mix at the facility. Exclusions N/A Data Claims Steward Centers for Medicare and Medicaid Services (CMS) Quality Domain Patient Safety Other Quality None CEC Workbook 11 IMPAQ International, LLC

12 Influenza Immunization Name Influenza Immunization NQF Number: 0041 Criteria Description Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization. Numerator Patients who received an influenza immunization OR who Steward Quality Domain Other Quality Denominator reported previous receipt of an influenza immunization. All patients aged 6 months and older seen for a visit between October 1 and March 31. Exclusions Documentation of medical reason(s) for not receiving influenza immunization (e.g., patient allergy, other medical reasons). Documentation of patient reason(s) for not receiving influenza immunization (e.g., patient declined, other patient reasons). Documentation of system reason(s) for not receiving influenza immunization (e.g., vaccine not available, other system reasons). Data EHR/paper medical record AMA-PCPI Preventive Health Medicare Shared Savings Program, Meaningful Use Stage 2, Physician Quality Reporting System CEC Workbook 12 IMPAQ International, LLC

13 Pneumonia Vaccination Status for Older Adults Pneumonia Vaccination Status for Older Adults NQF Number: 0043 Criteria Description Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine. Numerator Patients who have ever received a pneumococcal vaccination. Denominator Patients 65 years of age and older with a visit during the measurement period. Exclusions None Data EHR/paper medical record Steward National Committee for Quality Assurance (NCQA) Quality Domain Preventive Health Other Quality Medicare Shared Savings Program, Meaningful Use Stage 2, Physician Quality Reporting System CEC Workbook 13 IMPAQ International, LLC

14 Screening for Clinical Depression and Follow-Up Plan Name Screening for Clinical Depression and Follow-Up Plan NQF Number: 0418 Criteria Description Percentage of patients aged 12 years and older screened for clinical depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen. Numerator Patients who were screened for clinical depression on the date of the encounter using an age appropriate standardized tool and if positive, a follow-up plan is documented on the date of the positive screen. Denominator All patients aged 12 and older at the beginning of the measurement period with at least one eligible encounter during the measurement period. Steward Quality Domain Other Quality Exclusions A patient is not eligible if one or more of the following conditions exist: Patient refuses to participate. Patient is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the patient s health status. Situations where the patient s motivation to improve may impact the accuracy of results of nationally recognized standardized depression assessment tools. For example: certain court appointed cases. Patient was referred with a diagnosis of depression. Patient has been participating in ongoing treatment with screening of clinical depression in a preceding reporting period Severe mental and/or physical incapacity where the person is unable to express himself/herself in a manner understood by others. For example: cases such as delirium or severe cognitive impairment, where depression cannot be accurately assessed through use of nationally recognized standardized depression assessment tools. Data EHR/paper medical record Centers for Medicare and Medicaid Services (CMS) Preventive Health Medicare Shared Savings Program, Meaningful Use Stage 2, Physician Quality Reporting System CEC Workbook 14 IMPAQ International, LLC

15 Tobacco Use: Screening and Cessation Intervention Name Tobacco Use: Screening and Cessation Intervention NQF Number: 0028 Criteria Description Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user. Numerator Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation counseling intervention if identified as a tobacco user. Denominator All patients 18 years and older. Exclusions Documentation of medical reason(s) for not screening for tobacco use (e.g., limited life expectancy) Data EHR/paper medical record Steward AMA-PCPI Quality Domain Other Quality Preventive Health Medicare Shared Savings Program, Meaningful Use Stage 1 & Meaningful Use Stage 2, Physician Quality Reporting System, UDS CEC Workbook 15 IMPAQ International, LLC

16 Standardized Readmission Ratio (SRR) for Dialysis Facilities Standardized Readmission Ratio (SRR) for Dialysis Facilities NQF Number: N/A Criteria Description The ratio of the number of index discharges from acute care hospitals that resulted in an unplanned readmission to an acute care hospital within 30 days of discharge for Medicarecovered dialysis patients treated at a particular dialysis facility to the number of readmissions that would be expected given the discharging hospitals and the characteristics of the patients as well as the national norm for dialysis facilities. Note that in this document, hospital always refers to acute care hospital. Numerator Each facility s observed number of hospital discharges that are followed by an unplanned hospital readmission within 30 days of discharge. Denominator The expected number of unplanned readmissions in each facility, which is derived from a model that accounts for patient characteristics and discharging acute care hospitals. Exclusions Hospital discharges that: End in death. Result in a patient dying within 30 days with no readmission. Are against medical advice. Include a primary diagnosis for cancer, mental health or rehabilitation. Occur after a patient s 12th admission in the calendar year. Are from a PPS-exempt cancer hospital. Result in a transfer to another hospital on the same day. Data Claims Steward Centers for Medicare and Medicaid Services (CMS) Quality Domain Care Coordination Other Quality None CMS Communication/ Information Form CEC Workbook 16 IMPAQ International, LLC

17 Standardized Hospitalization Ratio for Admissions Standardized Hospitalization Ratio for Admissions NQF Number: 1463 Criteria Description Risk-adjusted standardized hospitalization ratio for admissions for dialysis facility patients. Numerator Number of inpatient hospital admissions among eligible patients at the facility during the reporting period. Denominator Number of hospital admissions that would be expected among eligible patients at the facility during the reporting period, given the patient mix at the facility. Exclusions None Data Claims Steward Centers for Medicare and Medicaid Services (CMS) Quality Domain Care Coordination Other Quality None IMPAQ International, LLC Page 17

18 Advance Care Plan Advance Care Plan NQF Number: 0326 Criteria Description Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan. Numerator Patients who have an advance care plan or surrogate decision maker documented in the medical record or documentation in the medical record that an advance care plan was discussed but patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan. Denominator All patients aged 65 years and older. Exclusions None Data Claims, Electronic Clinical Data Steward National Committee for Quality Assurance (NCQA) Quality Domain Other Quality Care Coordination Physician Quality Reporting System S_indclaimsregistry_measurespec_supportingdocs_ zip CEC Workbook 18 IMPAQ International, LLC

19 Documentation of Current Medications in the Medical Record Documentation of Current Medications in the Medical Record NQF Number: 0419 Criteria Description Percentage of visits for patients aged 18 years and older for which the eligible professional attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administration. Numerator Eligible professional attests to documenting a list of current medications to the best of his/her knowledge and ability. This list must include ALL prescriptions, over-the counters, herbals, vitamin/mineral/dietary (nutritional) supplements AND must contain the medications name, dosages, frequency and route. Denominator All visits occurring during the 12 month reporting period for patients aged 18 years and older on the date of the encounter where one or more CPT or HCPCS codes are reported on the claims submission for that encounter. Exclusions Patient is in an urgent or emergent medical situation where time is of the essence and to delay treatment would jeopardize the patient s health status. Data EHR/paper medical record Steward Centers for Medicare and Medicaid Services (CMS) Quality Domain Care Coordination Other Quality Meaningful Use Stage 2, Physician Quality Reporting System CEC Workbook 19 IMPAQ International, LLC

20 Comprehensive ESRD Care (CEC) Model Public Comment Summaries s Under Consideration Functional Status Assessment for Complex Chronic Conditions Functional Status Assessment for Complex Chronic Conditions NQF Number: TBD Criteria Description Percentage of patients aged 65 years and older with heart failure who completed initial and follow-up patient-reported functional status assessments. Numerator Patients with patient reported functional status assessment results (e.g., VR-12, VR-36, MLHF-Q, KCCQ, PROMIS-10 Global Health, PROMIS-29) present in the EHR at least two weeks before or during the initial encounter and the follow-up encounter during the measurement year. Denominator Adults aged 65 years and older who had two outpatient encounters during the measurement year and an active diagnosis of heart failure. Exclusions Patients with severe cognitive impairment or patients with an active diagnosis of cancer. Data EHR/paper medical record Steward CMS Quality Domain Quality of Life Other Quality Meaningful Use Stage 2, Physician Quality Reporting System CEC Workbook 20 IMPAQ International, LLC

21 Diabetes Care: Hemoglobin A1c Poor Control Diabetes Care: Hemoglobin A1c Poor Control NQF Number: 0059 Criteria Description Percentage of patients years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period. Numerator Patients whose most recent HbA1c level (performed during the measurement period) is > 9.0%. Denominator Patients years of age with diabetes with a visit during the measurement period. Exclusions Patients with a diagnosis of gestational diabetes during the measurement period. Data EHR/patient medical record Steward National Committee for Quality Assurance (NCQA) Quality Domain Chronic Disease Management Other Quality Medicare Shared Savings Program, Meaningful Use Stage 2, Physician Quality Reporting System CEC Workbook 21 IMPAQ International, LLC

22 Ischemic Vascular Disease: Use of Aspirin or Another Antithrombotic Ischemic Vascular Disease: Use of Aspirin or Another Antithrombotic NQF Number: 0068 Criteria Description Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had documentation of use of aspirin or another antithrombotic during the measurement period. Numerator Patients who have documentation of use of aspirin or another antithrombotic during the measurement period. Steward Quality Domain Other Quality Denominator Patients 18 years of age and older with a visit during the measurement period, and an active diagnosis of ischemic vascular disease (IVD) or who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period. Exclusions N/A Data EHR/paper medical record National Committee for Quality Assurance (NCQA) Chronic Disease Management Medicare Shared Savings Program, Meaningful Use Stage 2, Physician Quality Reporting System CEC Workbook 22 IMPAQ International, LLC

23 Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) NQF Number: 0083 Criteria Description Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge. Numerator Patients who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge. Denominator All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF < 40%. Exclusions None Data EHR/paper medical record Steward AMA-PCPI Quality Domain Chronic Disease Management Other Quality Medicare Shared Savings Program, Meaningful Use Stage 2, Physician Quality Reporting System CEC Workbook 23 IMPAQ International, LLC

24 Hospital-Wide All-Cause Unplanned Readmission (HWR) Hospital-Wide All-Cause Unplanned Readmission (HWR) NQF Number: 1789 Criteria Description This measure estimates the hospital-level, risk-standardized rate of unplanned, all-cause readmission after admission for any eligible condition within 30 days of hospital discharge (RSRR) for patients aged 18 and older. The measure reports a single summary RSRR, derived from the volume-weighted results of five different models, one for each of the following specialty cohorts (groups of discharge condition categories or procedure categories): surgery/gynecology, general medicine, cardiorespiratory, cardiovascular, and neurology, each of which will be described in greater detail below. The measure also indicates the hospital standardized risk ratios (SRR) for each of these five specialty cohorts. We developed the measure for patients 65 years and older using Medicare fee-for-service (FFS) claims and subsequently tested and specified the measure for patients aged 18 years and older using all-payer data. We used the California Patient Discharge Data (CPDD), a large database of patient hospital admissions, for our all-payer data. Numerator The outcome for this measure is unplanned all-cause 30-day readmission. We defined a readmission as an inpatient admission to any acute care facility which occurs within 30 days of the discharge date of an eligible index admission. All readmissions are counted as outcomes except those that are considered planned. Denominator This claims-based measure can be used in either of two patient cohorts: (1) admissions to acute care facilities for patients aged 65 years or older or (2) admissions to acute care facilities for patients aged 18 years or older. We have tested the measure in both age groups. Exclusion Admissions for patients without 30 days of post-discharge data. Admissions for patients lacking a complete enrollment history for the 12 months prior to admission. Admissions for patients discharged against medical advice (AMA). Admissions for patients to a PPS-exempt cancer hospital. Admissions for patients with medical treatment of cancer. Admissions for primary psychiatric disease. Admissions for rehabilitation care; fitting of prostheses and adjustment devices. Additionally, in the all-payer testing, excluded obstetric admissions because the measure was developed among patients aged 65 years or older (approximately 500,000). Data Claims Steward Centers for Medicare & Medicaid Services (CMS) Quality Domain Patient Safety Other Quality Medicare Shared Savings Program, Hospital Inpatient Quality Reporting National Quality Forum, Quality Positioning System CEC Workbook 24 IMPAQ International, LLC

25 Medication Reconciliation Medication Reconciliation NQF Number: 0097 Criteria Description Percentage of patients aged 18 years and older discharged from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) and seen within 30 days of discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist who had reconciliation of the discharge medications with the current medication list in the outpatient medical record documented. This measure is reported as two rates stratified by age group: and 65+. Numerator Patients who had a reconciliation of the discharge medications with the current medication list in the outpatient medical record documented.* *The medical record must indicate that the physician, prescribing practitioner, registered nurse, or clinical pharmacist is aware of the inpatient facility discharge medications and will reconcile the list with the current medications list in the medical record. Denominator All patients aged 18 years and older discharged from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) and seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care. This measure is reported as two rates with agespecific denominators: and 65+. Exclusions N/A Data Claims, Medical Record Steward National Committee for Quality Assurance (NCQA) Quality Domain Other Quality Care Coordination Medicare Shared Savings Program, Physician Quality Reporting System National Quality Forum, Quality Positioning System; Payment/sharedsavingsprogram/Downloads/ACO-Narratives-Specs.pdf CEC Workbook 25 IMPAQ International, LLC

26 Anemia of Chronic Kidney Disease: Dialysis Facility Standardized Transfusion Ratio Anemia of Chronic Kidney Disease: Dialysis Facility Standardized Transfusion Ratio NQF Number: N/A Criteria Description Dialysis Facility Standardized Transfusion Ratio: Description: Risk adjusted facility level transfusion ratio (STrR) for all adult dialysis patients. STrR is a ratio of number of observed eligible red blood cell transfusion events occurring in patients dialyzing at a facility to the number of eligible transfusions that would be expected from a predictive model that accounts for patient characteristics within each facility. Eligible transfusions are those that do not have any claims pertaining to the comorbidities identified for exclusion, in the one year look back period prior to each observation window. Numerator Number of observed red blood cell transfusion events (defined as transfer of one or more units of blood or blood products as described in the following code set into recipient s blood stream) among patients dialyzing at the facility during the inclusion episodes of the reporting period. Denominator Number of eligible red blood cell transfusion events that would be expected among patients at a facility during the inclusion episodes of the reporting period, given the patient mix at the facility. Exclusions All transfusions associated with transplant hospitalization are excluded. Patients are excluded if they have a Medicare claim for hemolytic and aplastic anemia, solid organ cancer (breast, prostate, lung, digestive tract and others), lymphoma, carcinoma in situ, coagulation disorders, multiple myeloma, myelodysplastic syndrome and myelofibrosis, leukemia, head and neck cancer, other cancers (connective tissue, skin, and others), metastatic cancer, sickle cell anemia within one year of their patient at risk time. Data Claims Steward Centers for Medicare and Medicaid Services (CMS) Quality Domain Care Coordination Other Quality None CMS Communication/ Information Form CEC Workbook 26 IMPAQ International, LLC