SOC s Guide to the 2013 CMS New Core Measures for Stroke

Transcription

1 SOC s Guide to the 2013 CMS New Core Measures for Stroke

2 Since 2004, the Centers for Medicare & Medicaid Services (CMS) has collected quality data from acute care hospitals on a voluntary basis under the Hospital Inpatient Quality Reporting (IQR) Program In 2010, CMS added the first stroke-related measure to the IQR Program as a structural measure Participation in a systemic clinical database registry for stroke care.

3 In recognition of the impact of stroke on national healthcare and Medicare beneficiaries in particular, in 2011 CMS announced that as of January 2013 hospitals must start reporting stroke quality measures under the IQR Program, or face a significant financial penalty. These National Quality Forum (NQF) endorsed stroke measures will impact all acute care hospitals participating in Medicare.

4 Although these measures are new to the IQR Program, they are the same quality metrics that have long been used by the Joint Commission and Get With the Guidelines (GWTG)- Stroke. The addition of the stroke measures to the IQR Program is also a result of continued standardization efforts between the NQF, the Joint Commission, and CMS.

5 The following table provides a detailed look at the 8 stroke quality measures that hospitals will need to start reporting to CMS in While all 8 measures are applicable to ischemic stroke, 3 of them (VTE prophylaxis; stroke education; assessment for rehab) are also applicable to hemorrhagic stroke.

6 Stroke Measure Explanation Applies to Ischemic Stroke (/N)? Appliesto Hemorrhagic Stroke (/N)? STK-1:Venous thromboembolism(vte) prophylaxis for patients with ischemic or hemorrhagic stroke % of patients with an ischemic stroke or a hemorrhagic stroke and who are non-ambulatory should start receiving DVT prophylaxis by end of hospital day two STK-2:Ischemic stroke patients discharged on antithrombotic therapy STK-3: Anticoagulation therapy for atrial fibrillation/flutter STK-4:Thrombolytic therapy for acute ischemic stroke patients STK-5:Antithrombotic therapy by the end of hospital day two STK-6: Discharged on statin medication %of patients with an ischemic stroke prescribed antithrombotic therapy at discharge N % of patients with an ischemic stroke with atrialfibrillation discharged on anticoagulation therapy N % of acute ischemic stroke patients who arrive at the hospital within 120 minutes (2 hours) of time last known well and for whom IV t-pa was initiated at this hospital within 180 minutes (3 hours) of time last known well % of patients with ischemic stroke who receive antithrombotic therapy by the end of hospital day two N % of ischemic stroke patients with LDL >/= 100 mg/dl, or LDL not measured, or, who were on cholesterol reducing therapy prior to hospitalization are discharged on a statin medication N N STK-8: Stroke education % of patients with ischemic or hemorrhagic stroke or their caregivers who were given education or educational materials during the hospital stay addressing all of the following: personal risk factors for stroke, warning signs for stroke, activation of emergency STK-10: Assessed for rehabilitation services % of patients with an ischemic stroke or hemorrhagic stroke who were assessed for rehabilitation services

7 For information about how SOC can help your hospital prepare to report on these measures, please contact us.