Patient Navigator Program: Focus MI Diplomat Hospital Metrics Goal Statement: To reduce avoidable hospital readmissions for patients discharged with acute myocardial infarction (AMI) by supporting a culture of patient-centered care during the hospital stay and in the weeks following discharge, thereby reducing mortality, and improving quality of life. # Program Metric Metric Description Data Source Outcome Measures 1a 30-day unadjusted readmission rate for AMI. Proportion of patients discharged from your hospital during the quarter with discharge diagnosis of AMI that resulted in a readmission to your hospital within 30 days. 1b 1c In-hospital risk-adjusted mortality rate (including patients with cardiac arrest). In-hospital risk-adjusted mortality rate (excluding patients with cardiac arrest). In-hospital risk-adjusted mortality rate (including patients with cardiac arrest) In-hospital risk-adjusted mortality rate (excluding patients with cardiac arrest) 1d 30-day risk-adjusted mortality rate for AMI Patients 18 years of age and older whose entire Episode of Care* occurred during the reporting timeframe Exclusions: Inconsistent or unreliable data (for example, date of death precedes date of admission); Transferred in from another acute care hospital; Discharged against medical advice (AMA) * For patients with multiple AMI admissions in the reporting period, one admission is randomly selected and the other admissions are excluded from the measure. Linked with the National Death Index (NDI). 9-1 30-day risk-adjusted readmission rate for AMI. Hospital-specific 30-day all-cause risk adjusted readmission rate following hospitalization for AMI among Medicare beneficiaries aged 65 years or older at the time of index hospitalization. ACTION Registry Metric # 43 ACTION Registry Metric #44 ACTION Registry (Other Report tab) CMS Hospital Compare (Collected Annually)
10a 90-day unadjusted readmission rate for AMI. Proportion of patients discharged from your hospital during the quarter with discharge diagnosis of AMI that resulted in a readmission to your hospital within 90 days. 10b 30-day unadjusted mortality rate for AMI. Proportion of patients discharged from your hospital during the quarter with a discharge diagnosis of AMI that resulted in death 30-days post Cost Measures 9-2 30-day risk standardized episode of payment measure for AMI. In-Hospital Patient Satisfaction Measures 2-1 When I left the hospital, I had a good understanding of the things I was responsible for in managing my health. This measure estimates hospital-level, AMI episode of care starting with inpatient admission to a short term acute-care facility and extending 30 days postadmission for Medicare fee-for-service (FFS) patients who are 65 years of age or older with a principal discharge diagnosis of AMI. CMS Hospital Compare (Collected Annually) Collected Quarterly 2-2 When I left the hospital, I clearly understood the purpose for taking each of my medications. 2-3 During this hospital stay, did you get information in writing about what symptoms or health problems to look out for after you left the hospital? Collected Quarterly Collected Quarterly Process Measures Metric Description Data Source 3-1 STEMI Performance Composite Includes all 11 acute and discharge performance measures for STEMI patients. Proportion of performance measure opportunities that were met among eligible opportunities. ACTION Registry Metric #3
3-2 NSTEMI Performance Composite Includes all 8 acute and discharge performance measures for NSTEMI patients. Proportion of performance measure opportunities that were met among eligible opportunities. ACTION Registry Metric #4 3-3 Overall defect free care Proportion of patients that receive "perfect care" based ACTION Registry Metric #2 upon their eligibility for each performance measure. 3-4 Aldosterone inhibitor prescribed at discharge Proportion of AMI patients prescribed an aldosterone ACTION Registry Metric #30 for AMI patients with LV systolic dysfunction (LVEF <40%). blocking agent at 3-5 In Hospital Risk Adjusted Bleeding Rate The model provides accurate estimates of bleeding risk ACTION Registry Metric #45 and is helpful in providing risk adjusted feedback on bleeding complications, informing clinical decisionmaking, and directing the use of bleeding avoidance strategies in AMIs. 3-6 Cardiac Rehabilitation Patient Referral from an Proportion of patients that received a cardiac rehab ACTION Registry Metric #21 Inpatient setting. referral from the inpatient setting. 3-7 Aspirin prescribed at discharge for AMI Proportion of patients prescribed aspirin at ACTION Registry Metric #34 patients. 3-8 AMI revascularized patients discharged on ADP Proportion of AMI revascularized patients prescribed ACTION Registry Metric #35 (P2Y12) receptor inhibitors. 3-9 ADP (P2Y12) receptor inhibitor prescribed at discharge for AMI patients treated with CABG surgery. 3-10 ADP (P2Y12) receptor inhibitor prescribed at discharge for AMI patients treated medically. 3-11 Beta-blocker prescribed at discharge for AMI patients. 3-12 Any statin prescribed at discharge for AMI patients. 3-13 High-intensity statin prescribed at discharge for AMI patients. an ADP (P2Y12) receptor inhibitor at Proportion of AMI patients treated with CABG surgery prescribed an ADP (P2Y12) receptor inhibitor at Proportion of AMI patients treated medically prescribed an ADP (P2Y12) receptor inhibitor at Proportion of patients prescribed a beta blocker at Proportion of AMI patients prescribed any statin at Proportion of AMI patients that received intensive statin therapy at ACTION Registry detail line. ACTION Registry detail line. ACTION Registry Metric #9 ACTION Registry detail line. ACTION Registry Metric #36
3-14 ACE-I/ARB/ARNI prescribed at discharge for AMI patients with LV systolic dysfunction (LVEF <40%). Proportion of AMI patients prescribed an ACE- I/ARB/ARNI for LVSD at 4 AMI patients are identified prior to Number of AMI patients that are identified prior to 5a AMI patients assessed for risk of readmission Number of AMI patients that are assessed for risk of prior to readmission prior to 5b AMI patients who are risk assessed for risk of Number of AMI patients who are risk assessed for risk readmission and have deployed interventions of readmission and have interventions deployed. based on the risk score. 6a Medication reconciliation is performed for every patient and is documented in the medical record on admission. 6b. Medication reconciliation is performed for every patient and is documented in the medical record upon 7 Discharge Summary or Transitions of Care Summary is made available to follow-up clinician within 72 hours. 8a Clinician discusses and provides documentation for specific education on the patient s treatment regimen (self-care plan). Number of AMI patient charts with accurate medication reconciliation documentation on admission. (Accurately means that the medication reconciliation form matches the discharge plans and is updated from admission). Number of AMI patient charts with accurate medication reconciliation documentation upon (Accurately means that the medication reconciliation form matches the discharge plans and is updated from admission). Number of AMI patient discharge summaries or transition of care summaries available to the follow-up clinician within 72 hours of patient s (including summary of hospitalization discharge summary, or transition of care summary, updated medication reconciliation list). Number AMI patients/caregivers that were provided with specific education and documentation on their treatment regimen (self-care plan). (Education completed and documented in the medical record to include when to call their healthcare provider). ACTION Registry Metric #12 8b Clinician discusses and provides documentation Number of AMI patients/caregivers that are provided
8c for: 1. All prescribed medications 2. Changes to their medications 3. Instructions on when and how medications should be taken. Clinician discusses and provides documentation on community resources to high risk patients 30-Day (-7/+14 Days) Discharge Process Measures 11a AMI patients reached 30 days post hospitalization. with documentation and given an explanation on prescribed medications and medication changes. Number of AMI high risk patients/caregivers that are provided with documentation and given an explanation on community resources available. High risk patient criteria for receiving community resources: Requiring nursing home or extended care placement/services; 80+ years old with multiple diagnoses and/or living alone; Status post trauma, new chronic diagnosis with significant lifestyle implications (CVA, CHF, COPD, ESRD); Experiencing difficulty coping or family dysfunction that may hinder post discharge care; Impaired cognitive ability with no identified family/caregiver support; Issues with mental health or chemical dependency; Significant financial hardships ;Admitted from an assisted living/skilled nursing or extended care facility; Receiving home health care services at the time of admission; Terminal illness/chronic or intractable pain/candidate for hospice referral. Number of patients that completed the phone/email interview 30 days post 11b AMI patients on aspirin 30 days post Number of patients that report they are on aspirin 30 days post discharge 11c AMI patients continued on an ADP (P2Y12) Number of AMI patients continued on an ADP (P2Y12) receptor inhibitor at 30 days post receptor inhibitor 30 days post 11d AMI patients changed to a different ADP Number of AMI patients changed to a different ADP (P2Y12) receptor inhibitor 30 days post (P2Y12) receptor inhibitor 30 days post
11e AMI patients changed to Clopidogrel 30 days post 11f AMI patients changed to Prasugrel 30 days post 11g AMI patients changed to Ticagrelor 30 days post 11h AMI patients no longer on an ADP (P2Y12) receptor inhibitor 30 days post 11i AMI patients no longer on an ADP (P2Y12) receptor inhibitor 30 days post discharge because of a bleeding event. 11j AMI patients no longer on an ADP (P2Y12) receptor inhibitor 30 days post discharge because of hypersensitivity or non-bleeding related intolerance. 11k AMI patients on a beta blocker 30 days post 11l AMI patients on a statin (any intensity) 30 days post 11m AMI patients on a high-intensity statin 30 days post 11n AMI patients with LV systolic dysfunction (LV EF <40%) on an ACE-I/ARB/ARNI 30 days post 11o AMI patients with LV systolic dysfunction (LV EF <40%) on an aldosterone inhibitor 30 days post 11p AMI patients attending at least 1 cardiac rehabilitation (phase 2) session 30 days post 90-Day (-7/+14 days) Discharge Process Measures Number of AMI patients changed to Clopidogrel 30 days post Number of AMI patients changed to Prasugrel 30 days post Number of AMI patients changed to Ticagrelor 30 days post Number of patients no longer on an ADP (P2Y12) receptor at 30 days post hospitalization. Number of AMI patients no longer on an ADP (P2Y12) receptor inhibitor 30 days post discharge because of a bleeding event. Number of AMI patients no longer on an ADP (P2Y12) receptor inhibitor 30 days post discharge because of hypersensitivity or non-bleeding related intolerance. Number of AMI patients on a beta blocker 30 days post Number of AMI patients on a statin (any intensity) 30 days post Number of AMI patients on a high-intensity statin 30 days post Number of AMI patients with LV systolic dysfunction (LV EF <40%) on an ACE-I/ARB/ARNI 30 days post Number of AMI patients with LV systolic dysfunction (LV EF <40%) on an aldosterone inhibitor 30 days post Number of AMI patients attending at least 1 cardiac rehabilitation (phase 2).
12a Number of patients that completed the phone/email AMI patients reached 90 days post interview 90 days post 12b AMI patients on aspirin 90 days post Number of patients that report they are on aspirin 90 days post 12c AMI patients continued on an ADP (P2Y12) Number of AMI patients continued on an ADP (P2Y12) receptor inhibitor at 90 days post receptor inhibitor 90 days post 12d AMI patients changed to a different ADP Number of AMI patients changed to a different ADP (P2Y12) receptor inhibitor 90 days post (P2Y12) receptor inhibitor 90 days post 12e AMI patients changed to Clopidogrel 90 days Number of AMI patients changed to Clopidogrel 90 post days post 12f AMI patients changed to Prasugrel 90 days post Number of AMI patients changed to Prasugrel 90 days post 12g AMI patients changed to Ticagrelor 90 days Number of AMI patients changed to Ticagrelor 90 days post post 12h AMI patients no longer on an ADP (P2Y12) Number of patients no longer on an ADP (P2Y12) 12i 12j 12k 12l 12m 12n receptor inhibitor 90 days post AMI patients no longer on an ADP (P2Y12) receptor inhibitor 90 days post discharge because of a bleeding event. AMI patients no longer on an ADP (P2Y12) receptor inhibitor 90 days post discharge because of hypersensitivity or non-bleeding related intolerance. AMI patients on a beta blocker 90 days post AMI patients on a statin (any intensity) 90 days post AMI patients on a high-intensity statin 90 days post AMI patients with LV systolic dysfunction (LV EF <40%) on an ACE-I/ARB/ARNI 90 days post receptor at 90 days post hospitalization. Number of AMI patients no longer on an ADP (P2Y12) receptor inhibitor 90 days post discharge because of a bleeding event. Number of AMI patients no longer on an ADP (P2Y12) receptor inhibitor 90 days post discharge because of hypersensitivity or non-bleeding related intolerance. Number of AMI patients on a beta blocker 90 days post Number of AMI patients on a statin (any intensity) 90 days post Number of AMI patients on a high-intensity statin 90 days post Number of AMI patients with LV systolic dysfunction (LV EF <40%) on an ACE-I/ARB/ARNI 90 days post
12o 12p AMI patients with LV systolic dysfunction (LV EF <40%) on an aldosterone inhibitor 90 days post AMI patients attending at least 12 cardiac rehabilitation (phase 2) sessions 90 days post Number of AMI patients with LV systolic dysfunction (LV EF <40%) on an aldosterone inhibitor 90 days post Number of AMI patients attending at least 12 cardiac rehabilitation (phase 2) sessions 90 days post