RCCO Quality Indicators Crosswalk
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1 Aim: Better Care for Individuals (patient s perspective) RCCO Quality Indicators Crosswalk Quality Number 1. Access: timely care, appointments & info Denominator& Numerator ACO patients 18+ Data collection Plan or Sample Questions Other program measures RCCO will receive narrative report & excel workbooks of scores. Example: 10. In the last 6 months, when you d this provider s office during regular office hours, how often did you get an answer to your medical question that same day? PCMH PHP /QIP 2. Communication with PCP ACO patients 18+ Complete survey available at: In the last 6 months, how often did this provider show respect for what you had to say? PCMH 3. Patients rating of PCP ACO patients Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate this provider? Page 1 of 10
2 RCCO Quality Indicators Crosswalk 4. Access to specialty care ACO patients questions total. 46. In the last 6 months, how often was it easy to get appointments with specialists? ever PCMH PHP/QIP 5. Health promotion & education ACO patients In the last 6 months, did anyone on your health care team talk with you about specific goals for your health? PCMH 6. Shared decision making ACO patients When you and this provider talked about having surgery or a procedure, did this provider ask what you thought was best for you? PCMH Page 2 of 10
3 RCCO Quality Indicators Crosswalk 7. Health /functional status* ACO patients During the last 4 weeks, how much of the time did your physical health interfere with your social activities (like visiting with friends, relatives, etc.)? Aim: Better Care for Individuals (care coordination/patient safety) Quality Number day readmission rates Denominator/ Numerator # Hospitalizations pts >65yo Data collection Plan Other program measures Claims data Care transition service for all hospitalized ACO patients PHP QIP #Readmission excluding planned 9. Admissions COPD/asthma # patients with dx of COPD/asthma >40yo Claims data Complex care services for ACO pts who meet criteria # of those patients discharged from hosp. with that DX Page 3 of 10
4 10. Admissions CHF # patients with dx of CHF >18yo Claims data Complex care services for ACO pts who meet criteria # of those patients discharged from hosp. with that DX 11. EHR usage # Participating providers in ACO MU data Meaningful use requirements Meaningful use 12. Medication reconciliation post discharge # Participating provider in ACO who qualify for MU #Pts >65yo discharged from In-Pt hospital/snf or rehab and seen by PCP within 30 days Hospital F/u procedure PHP QIP #Pts who had medication rec done /corrected meds in list documented at visit with PCP 13. Screening for fall risk All patients > 65 yo. (unless documented medical reason for not completing assessment) # patients screened (must be done annually) EHR & claims data Need to create screening process Page 4 of 10
5 Aim: Better Health for Populations (Preventative Health) Quality Number Denominator& Numerator 14. Influenza Immunization All patients >6 mo. With appts between Oct-Mar # of pts who received flu shot or recorded having one in chart (since Aug 1) 15. Pneumonia Vaccination All patients > 65 yo 16. BMI screening and follow-up 17. Screening tobacco use & cessation intervention # patients who have ever received a pneumococcal vaccine All patients > 17 yo. BMI calculated in the past 6 months with F/U plan documented if BMI outside parameters. All patients > 17 yo. # patients screened 1x in 24 months and who received intervention. Physicians should encourage cessation. Data collection Plan Other program measures EHR Data Offer all pts flu shots Oct-March. Reminder cards mailing. Document declines and medical reasons for not giving flu shot. Send out reminders to patients who do not have up to date immunizations BMIs checked on all patients. Create structured field for f/u addressed Training on documentation in ecw Meaningful use Page 5 of 10
6 18. Screening for clinical depression and followup plan All patients >11 yo # patients screened with age appropriate tool and follow-up plan documented when screening positive. EHR documentation (structured fields), implementation plan, training 19. Colorectal cancer screening All patients 50 thru 75 yo. Use guidelines preset by ACS pilot project # of patients who had at least one screening during or prior to reporting period. 20. Screening mammography All female patients yo. Create implementation plan (PHP plan not very effective) # patients who had a mammogram at least 1 x within 24 months. 21. Screening for High Blood Pressure All pts >17 yo. # patients screened for high PB and follow-up plan is documented for pre/hypertensive pts. Use RHC BP quality program as guide (Vista Pilot) PHP Page 6 of 10
7 Aim: Better Health for Populations (At Risk Populations) RCCO Quality Indicators Crosswalk Quality Number 22. Diabetes: A1c control (<8%) 23. Diabetes: LDL - C control 24. Diabetes: High BP control Denominator/ Numerator Pts 18 to 75 with a DX of diabetes with 2+ visits for diabetes in last 2 years and 1+ visit for any reason in last 12 months. Pts with most recent A1c < 8.0 %. Pt s 18 to 75 with a DX of diabetes with 2+ visits for diabetes in last 2 years and 1+ visit for any reason within measured year. Pts with most recent LDL < 100 mg/dl Pts 18 to 75 with a DX of diabetes with 2+ visits in last 2 years and 1+ visit for any reason within measured year. Pt s with most recent Data collection Plan Other program measures Create implementation plan PHP/ QIP Create implementation plan PHP/ QIP Create implementation plan PHP QIP Page 7 of 10
8 PB< 140/ Diabetes: Tobacco Non-Use Pts 18 to 75 with a DX of diabetes with 2+ visits for diabetes during past 2 years and 1+ visit for any reason within measured year. Create implementation plan with EHR documentation Pts with diabetes DX who were identified as non-users of tobacco 26. Diabetes: daily aspirin use for Dx of DM & IVD Pts 18 to 75 with a DX of diabetes with 2+ visits for diabetes during past 2 years and 1+ visit for any reason within measured year and DX of IVD Create implementation plan with EHR documentation 27. Diabetes: A1c poor control Pts with DM & IVD with documentation of taking daily aspirin or documented contraindication Pts 18 to 75 with DX of DM. Pts with most recent A1c level >9.0% Create implementation plan PHP/ QIP Page 8 of 10
9 28. Controlling High BP Pts 18 thru 85 with DX of HTN Create implementation plan with EHR documentation PHP QIP Pts with most recent blood pressure <140/90mmHg 29. Ischemic Vascular disease (IVD) complete lipid profile and LDL-C control Pts >17 yo with DX of IVD or discharged alive for AMI, CABG (bypass)or PTCA (angioplasty) Create guideline & implementation plan with EHR documentation Pts with complete lipid profile with LDL-C <100 mg/dl 30. IVD and the use of ASA or other antithrombotic Pts >17 yo with DX of IVD or discharged alive for AMI, CABG (bypass)or PTCA (angioplasty) Pts who are using ASA or another antithrombotic Create guideline & implementation plan with EHR documentation of medications 31. Heart failure : beta block therapy for LVSD All pts >17yo with DX of heart failure with current or prior LVEF < 40% or severe LVSD Create guideline & implementation plan with EHR documentation of medications # Pts who were prescribed beta Page 9 of 10
10 blocker therapy either within 12 mo. period or at hosp. discharge 32. Coronary Artery Disease (CAD): Lipid control All pts >17yo with DX of CAD seen within a 12 month period. Create, guideline & implementation plan with EHR documentation of medications PHP QIP Pts who have LDL-C <100 mg/dl OR LCL-C 100 with documented care plan to achieve <100, including at a min. RX of a statin 33. CAD : ACE inhibitor or ARB therapy for pts with CAD and LVEF<40 or DM All pts >17yo with DX of CAD seen within a 12 month period who also have a current or prior LVEF < 40% Create, guideline & implementation plan with EHR documentation of medications OR pts >17yo with DX of CAD and DM seen within a 12 month period. Pts who were RX d ACE or ARB therapy (or RX is already part of med list) Page 10 of 10
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