The table below includes the quality measures an ACO is required to submit to CMS as a participant in an MSSP Track 3 ACO ACO-1 ACO-2 Getting Timely Care, Appointments, and Information How Well Your Providers Communicate CAHPS CAHPS ACO-3 Patients Rating of Provider CAHPS ACO-4 Access to Specialists CAHPS ACO-5 Health Promotion and Education CAHPS Getting an urgent care appointment as soon as needed Getting answers to medical questions on the same day when calling during regular office hours Seeing a clinician within 15 minutes of the schedule appointment time Explaining things in a way that is easy to understand Listening carefully Showing respect for what patients had to say Spending enough time with patients Knew important information about your medical history To give an ACO a score, Medicare looks at the percentage of patients who give their clinicians a rating of 9 or 10 on a scale of 0 (lowest) to 10 (highest) Ease of making appointments with specialists Specialist you saw most often knew the important information about your medical history Number of specialists seen To give an ACO a score, Medicare looked at the percentage of patients that said their care team talked with them about what they can do to stay healthy Talk about reasons you may or may not want to take a prescription medication, provider asks what is best for you when starting or stopping prescription ACO-6 Shared Decision Making CAHPS Talk about reasons you may or may not want a surgery or procedure, provider asks what is best for you Talk about including family/friends in making health decisions and respects your wishes about sharing information with these individuals Overall rating of your health, mental/emotional health Having 3 or more visits for the same health condition or problem ACO-7 Health Status / Functional Status CAHPS Prescription medicine for a condition has lasted 3 months or longer Extent to which physical health interferes with normal social activities, social activities, and activities of daily living 1
ACO-34 Stewardship of Patient Resources CAHPS ACO-8 ACO-35 ACO-36 ACO-37 ACO-38 ACO-43 ACO-11 ACO-12 Risk-Standardized, All Condition Readmission Skilled Nursing Facility 30-Day All Cause Readmission All-Cause Unplanned Admissions for Patients with Diabetes All-Caused Unplanned Admissions for Patients with Hearth Failure All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions Ambulatory Sensitive Condition Acute Composite (AHRQ Prevention Quality Indicator (PQI) #91) Percent of PCPs who Successfully Meet Meaningful Use Requirements Medication Reconciliation Post- Discharge Quality Payment Program Data Percentage of patients that said their care team talked with them about the cost of their prescription medicine Risk-adjusted percentage of ACO assigned beneficiaries who were hospitalized and readmitted to a hospital within 30 days following discharge from the hospital for the index admission Risk-adjusted rate of all-cause, unplanned hospital readmissions within 30 days for ACO-assigned beneficiaries who had been admitted to a skilled nursing facility after discharge from their prior proximal hospital 65 years and older with diabetes who are assigned or aligned to the ACO 65 years and older with heart failure who are assigned or aligned to the ACO and have heart failure 65 years and older with multiple chronic conditions who are assigned or aligned to the ACO Risk-adjusted rate of admissions for acute Prevention Quality Indicator (PQI) conditions: dehydration, bacterial pneumonia, or urinary tract infection Percentage of eligible clinicians participating in the ACO who successfully meet the Advancing Care Information Base Score The percentage of discharges from any inpatient facility for patients 18 years and older seen within 30 days following discharge in the office whose medication list was reconciled with the current medication list in the outpatient medical record Medication Reconciliation can be done by the: o Physician 2
ACO-13 ACO-44 ACO-14 Falls: Screening for Future Fall Risk Use of Imaging Studies for Low Back Pain Influenza Immunization o Prescribing practitioner o Registered nurse o Clinical pharmacist Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period Screening for future fall risk: assessment of whether an individual has experienced a fall or problems with gait or balance A specific screening tool is not required for this measure, however potential screening tools include: (1) Morse Fall Scale, and (2) The Timed Get-Up-And-Go test The proportion of ACO assigned beneficiaries with a primary diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, or CT scan) within 28 days of diagnosis; All patients 18-50 with diagnosis of low back pain who did not have an imaging study within 28 days of diagnosis Percentage of patients aged 6 months are older seen for a visit between October 1 and March 31 who received an influenza immunization, OR; Patients who reported previous receipt of an influenza immunization ACO-15 Pneumonia Vaccination Status for Older Adults Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine ACO-16 ACO-17 Body Mass Index (BMI) Screening and Follow Up Tobacco Use: Screening and Cessation Intervention Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous six months AND with a BMI outside of normal parameters Follow-up plan is documented during the encounter or during the previous 6 months of the encounter Normal parameters: Age 18 and older with a BMI => 18.5 and <25 kg/m2 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 3
ACO-18 Screening for Clinical Depression and Follow-Up Plan Percentage of patient aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool If screening is positive, a follow-up plan is documented on the date of the positive screen ACO-19 Colorectal Cancer Screening Percentage of adults 50 to 75 years of age who had appropriate screening for colorectal cancer ACO-20 Breast Cancer Screening Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer ACO-42 ACO-40 ACO-27 & 41 Statin Therapy for Prevention and Treatment of Cardiovascular Disease Depression Remission at Twelve Months ACO-27: Diabetes Mellitus: Hemoglobin A1c Poor Control ACO-41: Diabetes: Eye Exam Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the measurement period: 1. Criteria 1: Patients 21 with diagnosis of ASCVD; 2. Criteria 2: Patients 21 with a fasting or LDL-C level 190; 3. Criteria 3: Patients 40-75 with diagnosis of diabetes w/ a fasting or direct LDL-C level 70-189. Must be prescribed or on a statin therapy All patients 18 and over with major depression or dysthymia with an initial PHQ-9 score >9 who demonstrate remission at twelve months (+/- 30 days after an index visit) defined as a PHQ-9 score less than five This measure applies to both patients with newly diagnosed and existing depression whose current PHQ-9 score indicates a need for treatment All patients 18-75 with diabetes and a HbgA1c >9% Eye Exam: all patients 18-75 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 or dilated eye exam (no evidence of retinopathy) in the 12 months prior to the measurement period ACO-28 Hypertension (HTN): Controlling High Blood Pressure All patients 18-85 with diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90 mmhg) during the measurement period 4
ACO-30 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic Percentage of patients 18 years of age and older who were diagnosed with acute myocardial infection (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, OR An active diagnosis of ischemic vascular disease (IVD) during the measurement period, who had documentation and use of aspirin or another antiplatelet during the measurement period 5