Clinical Quality Measures - Colorado SIM, TCPI

Transcription

1 Clinical Quality s - Colorado SIM, TCPI Aniety AOD Aniety Initiation and Engagement of Alcohol and Other Drug Dependence Treatment Not yet endorsed by 0004 e v4 305 General Aniety Disorder GAD-7 or equivalent to show change. A) Percentage of patients aged 12 and up screened annually for general aniety Patient s screening for aniety using GADdisorder using the GAD-7 or equivalent, AND B) of those patients with GAD screen, percentage of patients with a follow-up plan documented 7 tool AND follow-up plan is documented All patients aged 12 years and older Percentage of patients 13 years of age and older with a new episode of alcohol and other drug (AOD) dependence who received the following. Two rates are reported: Percentage of patients who initiated treatment within 14 days of the diagnosis Percentage of patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit Numerator 1: patients who initiated treatment within 14 days of the diagnosis Numerator 2: patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit Patients age 13 years of age and older who were diagnosed with a new episode of alcohol or drug dependency during a visit in the first 11 months of the measurement Asthma Use of Appropriate Medications for Asthma v4 311 Percentage of patients 5-64 years of age who were identified as having persistent asthma and were appropriately prescribed medication during the Patients who were dispensed at least one prescription for a preferred therapy during the Patients 5-64 years of age with persistent asthma and a visit during the Breast Cancer Breast Cancer v5 112 Percentage of women years of age who had a mammogram to screen for breast cancer Women with one or more mammograms during the measurement or the 15 months prior to the measurement Women years of age with a visit during the measurement (note: this denominator statement captures women age years). APCD Colorectal Cancer Colorectal Cancer v4 113 Percentage of adults years of age who had appropriate screening for colorectal cancer. Patients with one or more screenings for colorectal cancer. Appropriate screenings are defined by any one of the following criteria below: Fecal occult blood test (FOBT) during the measurement Fleible sigmoidoscopy during the measurement or the four years prior to the measurement Colonoscopy during the measurement or the nine years prior to the measurement Patients years of age with a visit during the APCD

2 Clinical Quality s - Colorado SIM, TCPI and : for Clinical and Follow-up Plan v5 134 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. Patients 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. All patients aged 12 years and older before the beginning of the measurement with at least one eligible encounter during the assessment e- Development Developmental in the First Three Years of Life 1448 new spec under m ent - OHSU The percentage of children screened for risk of mental, behavioral and social delays using a standardized screening tool in the first three years of life. Numerator 1: Children in Denominator 1 who had screening for risk of mental, behavioral and social delays using a standardized screening tool that was documented by their first birthday Numerator 2:...that was documented by their second birthday Numerator 3:... that was documented by their third birthday Numerator 4:... that was documented by their first, second, or third birthday Children who meet the following eligibility requirement: Age: Children who turn 1, 2, or 3 years of age between January 1 and December 31 of the measurement year. Diabetes: Hemoglobin A1c Hemoglobin A1c Poor Control v4 001 Percentage of patients years of age with diabetes who had hemoglobin A1c>9.0% during the measurement Patients whose most recent HbA1c level (performed during the measurement ) is >9.0% Patients years of age with diabetes with a visit during the measurement Diabetes: Blood Management Diabetes: Blood Management The percentage of patients years of age with diabetes (type 1 and type 2) whose most recent blood pressure level taken during the measurement year is <140/90 mmhg Patients whose most recent blood pressure level was <140/90 mmhg during the measurement year. Patients years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year. Fall Safety Falls: for Future Fall v4 318 Patient Safety Percentage of patients 65 years of age and older who were screened for future fall risk during the Patients who were screened for future fall risk at least once within the Patients aged 65 years and older with a visit during the Influenza and : Influenza Immunization v5 110 Percentage of patients aged 6 months and older seen for a visit between Patients who received an influenza October 1 and March 31 who received immunization OR who reported previous an influenza immunization OR who receipt of an influenza immunization. reported previous receipt of an influenza immunization. All patients aged 6 months and older seen for at least two visits or at least one preventive visit during the measurement and seen for a visit between October 1 and March 31. HF or LVSD Heart Failure (HF): Beta- Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) v4 008 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 when seen in the outpatient setting OR at each hospital discharge. Patients who were prescribed betablocker therapy either within a 12 month when seen in the outpatient setting OR at each hospital discharge. All patients aged 18 years and older with a diagnosis of heart failure with a current or prior LVEF < 40% Page 2 of 5

3 Clinical Quality s - Colorado SIM, TCPI Hypertension Controlling High Blood v4 236 Percentage of patients years of age with a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the Patients whose blood pressure at the most recent visit is adequately controlled (systolic blood pressure < 140 mmhg and diastolic blood pressure < 90 mmhg) during the Patients years of age who had a diagnosis of essential hypertension within the first si months of the measurement or any time prior to the Page 3 of 5

4 Clinical Quality s - Colorado SIM, TCPI e- Imaging Use of Imaging Studies for Low Back Pain v5 312 Efficiency and Cost Reduction Percentage of patients years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis. Patients without an imaging study conducted on the date of the outpatient OR emergency department visit OR in the 28 days following the outpatient or emergency department visit. Patients years of age with a diagnosis of low back pain during an outpatient or emergency department visit. Maternal Maternal v3 372 The percentage of children who turned 6 months of age during the measurement year, who had a face-to-face visit between the clinician and the child during child's first 6 months, and who had a maternal depression screening for the mother at least once between 0 and 6 months of life. Children with documentation of maternal screening or treatment for postpartum depression for the mother. Children with a visit who turned 6 months of age in the MDD Child and Adolescent Major Depressive Disorder (MDD): Suicide v4 382 Patient Safety Percentage of patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder with an assessment for suicide risk. Patient visits with an assessment for suicide risk. All patient visits for those patients aged 6 through 17 years with a diagnosis of major depressive disorder. MDD Adult Major Depressive Disorder (MDD): Suicide v4 107 and older with a diagnosis of major depressive disorder (MDD) with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified. Patients with a suicide risk assessment completed during the visit in which a new diagnosis or recurrent episode was identified. All patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) Obesity: Adolescent Weight and Counseling for Nutrition and Physical Activity for Children and Adolescents v4 239 Percentage of patients 3-17 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of the following during the measurement Three rates are reported: Percentage of patients with height, weight, and BMI percentile documentation Percentage of patients with counseling for nutrition Percentage of patients with counseling for physical activity Numerator 1: Patients who had a height, weight and BMI percentile recorded during the measurement Numerator 2: Patients who had counseling for nutrition during a visit that occurs during the measurement Numerator 3: Patients who had counseling for physical activity during a visit that occurs during the measurement Patients 3-17 years of age with at least one outpatient visit with a primary care physician (PCP) or OB-GYN during the measurement year. Page 4 of 5

5 Clinical Quality s - Colorado SIM, TCPI e- Obesity: Adult and : Body Mass Inde (BMI) and Follow-up Plan v4 128 and older with a BMI documented during the current encounter or during the previous si months AND with a BMI outside of normal parameters, a followup plan is documented during the encounter or during the previous si months of the current encounter. Normal parameters: Age 65 years and older BMI =>23 and <30 kg/m2 Age years BMI=>18.5 and < 25 kg/m2 Patients with a documented BMI during the encounter or during the previous si months, AND when the BMI is outside of normal parameters, a follow-up plan is documented during the encounter or during the previous si months of the current encounter. Initial Patient 1: all patients 18 through 64 years on the date of the encounter with at least one eligible encounter during the measurement Initial Patient 2: all patients 65 years of age and older on the date of the encounter with at least one eligible encounter during the measurement Smoking and : Tobacco Use: and Cessation Intervention v4 226 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. Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation intervention if identified as a tobacco user. All patients aged 18 years and older seen for at least two visits or at least one preventive visit during the measurement Substance Use Disorder Substance Use Composite 2597 in testing phase - American Society of Addiction Medicine and older who were screened at least once within the last 24 months for tobacco use, unhealthy alcohol use, nonmedical prescription drug use, and illicit drug use AND who received an intervention for all positive screening results. Numerator 1: Tobacco use Patients screened for tobacco use at least once within the last 24 months AND who received tobacco cessation, if identified as a tobacco user Numerator 2: Unhealthy alcohol use Patients screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling, if identified as an unhealthy alcohol user Numerator 3: Drug use (nonmedical prescription drug use and illicit drug use) Patients screened for nonmedical prescription drug use and illicit drug use at least once within the last 24 months using a systematic screening method AND who received brief counseling, if identified as a nonmedical prescription drug user or illicit drug user All patients aged 18 years and older who were seen twice for any visits or who had at least one preventive care visit during the 12 month pending finalization of CCBHC measures Page 5 of 5