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Redwood Community Care Organization Data Capture for ACO Quality Measures

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Essential Resources http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO-NarrativeMeasures- Specs.pdf http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO-NarrativeMeasures- Specs.pdf http://www.rchc.net/download/ecw-aco-quick-reference-setup-guide-november-2013/

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ACO 1-7 CAHPS https://cahps.ahrq.gov/

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ACO 8-11 Claims Data

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ACO 12 Medication Reconciliation Denominator: All ACO patients discharged from inpatient facility within 30 days of the visit Numerator: Medications reconciled Exclusions: psych admits, rehab admits & AMA

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ACO 12 Medication Reconciliation

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ACO 13 Fall Risk Assessment Denominator: All ACO Patients > 65 yoa with an office visit in the reporting year Numerator: Structured data fall screening completed Exclusions: not ambulatory (use CPT code 3288F with 1P)

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Future Integration of fall risk assessment Smartform ($5000) eClincalform ($1500) Structured data (free)

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ACO 14 Influenza Vaccine Denominator: ACO patients > 6 months of age with an office visit between 10/1 3/31 Numerator: Patients who received a flu vaccine (CVX codes must be correct) Exclusions: contraindications (V15.03 or 4037F-2P)

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ACO 15 Pneumonia Vaccine Denominator: All ACO Patients > 65 yoa Numerator: Patients who have ever received a penumococcal vaccine (CVX codes must be correct) Exclusions: Contraindications documented with CPT code 4040F-1P

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ACO 16 BMI Measurement & f/u Denominator: All ACO Patients > 18 yoa Numerator: Patients with a documented BMI and follow-up plan if the BMI is abnormal Exclusions: Palliative care, pregnancy (V66.5 or any pregnancy ICD code) BMI normal? Included in numerator f/u docume nted? Included in numerator Not included in numerator Yes No

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ACO 16 BMI Measurement & f/u

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ACO 17 Tobacco Screening and cessation counseling Denominator: All ACO Patients > 18 yoa Numerator: Patients who have been screened for tobacco use and if they do use tobacco have received cessation counseling or prescription for tobacco cessation medication Exclusions: none Tobacco Use? Included in numerator Documented counseling or med RX? Included in numerator Not included in numerator No Yes No

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ACO 17 Tobacco Screening and cessation counseling

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ACO 18 Depression Screening and follow-up Denominator: All ACO Patients > 18 yoa Numerator: Patients who have been screened for depression and have had follow up documented or medication rx for those who screen positive Exclusions: depression/bipolar codes for those not screened Pos depressi on screen? Included in numerator Documented f/u or med RX? Included in numerator Not included in numerator No Yes No

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ACO 18 Depression Screening and follow-up

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ACO 19 Colon Cancer Screening Denominator: All ACO Patients 50 75 yoa Numerator: Patients who have been screened for colon cancer by colonoscopy, sigmoidoscopy or FOBT test. Exclusions: colectomy (by icd code)

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ACO 19 Colon Cancer Screening

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ACO 20 Breast Cancer Screening Denominator: All ACO female patients 40 69 yoa Numerator: Patients who have been screened for breast cancer with mammography Exclusions: mastectomy (by icd code)

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ACO 21 Blood Pressure Screening and follow-up Denominator: All ACO patients > 18 yoa Numerator: Patients who have been screened for high blood pressure and for those with prehypertension or new hypertension have a documented follow-up plan. Exclusions: diagnosis of hypertension if not screened (by icd code) BP normal? Included in numerator f/u plan or med Rx documente d? Included in numerator Not included in numerator Yes No (prehypertension or HTN values) No

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ACO 21 Blood Pressure Screening and follow-up

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ACO 22 26 Diabetic all or nothing Denominator: All ACO patients 18 75 yoa with a diagnosis of DM that have been seen twice during the reporting year Numerator: A1c

ACO 27 Diabetes Control of A1c Denominator: All ACO patients 18 75 yoa with a diagnosis of DM Numerator: Patients whos last A1c was >9.0% Exclusions: pregnancy, polycystic ovaries, gestational DM, steroid induced DM (by icd code)

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ACO 28 Controlling High Blood Pressure Denominator: All ACO patients 18 84 yoa with a diagnosis of HTN Numerator: Patients whos most recent BP was

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ACO 29 IVD Lipid panel and control Denominator: All ACO patients > 18 yoa, with the diagnosis of ischemic vascular disease, h/o MI, PCI or CABG (by ICD code) Numerator: Patients whos BOTH received a lipid panel (complete panel) in the measurement year and whos most recent LDL was < 100 Exclusions: none *LOINC codes must be correct

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ACO 30 IVD use of aspirin or other antithrombotic Denominator: All ACO patients > 18 yoa, with the diagnosis of ischemic vascular disease, h/o MI, PCI or CABG (by ICD code) Numerator: Patients who are taking aspirin or antithrombotic medication Exclusions: GI bleed, on warfarin Any Antiplatelet Rx meets the requirement for the numerator

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ACO 31 CHF use of beta blocker Denominator: All ACO patients > 18 yoa, with the diagnosis of heart failure (ICD code) or documentation of LVEF

ACO 32 CAD Lipid Control Denominator: All ACO patients > 18 yoa, with the diagnosis of CAD (by ICD code) Numerator: Patients who either have a documented LDL

ACO 33 ACE for CHF or DM/CAD Denominator: All ACO patients > 18 yoa, with the diagnosis of CAD (ICD code) and documentation of LVEF