See page 331 of HEDIS 2013 Tech Specs Vol 2. HEDIS specs apply to plans. RARE applies to hospitals. Plan All-Cause Readmissions (PCR) *++

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1 Hospitalizations Inpatient Utilization General Hospital/Acute Care (IPU) * This measure summarizes utilization of acute inpatient care and services in the following categories: Total inpatient. Medicine. Surgery. May be disease specific rather than general hospitalizations Claims See page 307 of 2013 Tech Specs V. 2. Product lines include Medicaid and Medicare. The measure does not include services for discharges with a principal diagnosis of mental health or chemical dependency. Could be disease specific reporting rather than general hospitalizations. Plan All-Cause Readmissions (PCR) *++ Ambulatory Care Sensitive Conditions (ACSC) Admission Rates: ++ DB short term complications Perforated Appendix DB Long-Term AHRQ standards For members the number of acute inpatient stays during the measurement years that were followed by an acute readmission for any diagnosis within 30 days and the predicted probability of an acute readmission. Data are reported in the following categories: 1. Count of Index Hospital Stays (IHS) (denominator). 2. Count of 30-Day Readmissions (numerator). 3. Average Adjusted Probability of Readmission. Numerators DB- Short term Complications: All discharges of age 18 years and older for diabetes short-term complications (ketoacidosis, hyperosmolarity, coma. DX are listed in the document. Perforated Appendix: Claims Claims See page 331 of 2013 Tech Specs Vol 2. specs apply to plans. RARE applies to hospitals. AHRQ methodology. Numerator as in AHRQ methodology. Denominators include one recipient per year (last month of eligibility determined age, pay system and MCO assignment) No deviation from the AHRQ methodology to include the calculation of the denominators/rates 1

2 Potential Measures for SNBC Enrollees in Integrated/Coordinated Medicare and Medicaid ICSP Subcontract Arrangement Complications COPD Asthma Hypertension Heart Failure Dehydration Bacterial Pneumonia Urinary Tract Infection (UTI) Angina W/O Procedure Uncontrolled DB Rate of Lower- Extremity Amputation Among Patients with DB All discharges with ICD-9-CM diagnosis code for perforations or abscesses of appendix in any field. DX are listed in the document. DB- Long Term Complications: All discharges age 18 years and older for diabetes long-term complications (renal, eye, neurological, circulatory, or complications not otherwise specified). DX are listed in the document. COPD: All discharges of age 40 years and older for COPD. DX are listed in the document. Asthma: All discharges of age greater than 18 years and older with ICD-9-CM principal diagnosis code for Asthma. DX are listed in the document. Hypertension: All discharges of age 18 years and older for hypertension. DX are listed in the document. Heart Failure: All discharges of age 18 years and older for heart failure. DX are listed in the document. Dehydration: All discharges of age 18 years and older (for example, the denominator for the Perforated Appendix measure is the count of hospitalizations for Appendicitis and NOT enrollees). 2

3 for dehydration. DX are listed in the document. Bacterial Pneumonia: All discharges of age 18 years and older for bacterial pneumonia. DX are listed in the document. Follow Up after Hospitalization for Mental Illness (FUH)*++ UTI: All discharges of age 18 years and older of urinary tract infection. DX are listed in the document. Angina w/o procedure: All discharges of age 18 years and older for angina. DX are listed in the document. Uncontrolled DB All discharges of age 18 years and older for uncontrolled diabetes, without mention of a short-term or long-term complication. Rate of Lower-Extremity Amputation DB All discharges of age 18 years and older with ICD-9-CM procedure code for lower-extremity amputation and diagnosis code of diabetes in any field. The percentage of discharges who were hospitalized for treatment of selected mental health disorders and who had an outpatient visit, an intensive outpatient Claims See page 191 of 2013 Tech Specs Vol 2. Product lines include Medicaid and Medicare. Discussion about what is the standard 3

4 encounter or partial Hospitalization with a mental health practitioner. Two rates are reported: * The percentage of discharges for which the member received follow-up within 30 days of discharge * The percentage discharges for which the member received follow-up within 7 days some say 14 days are as good as 7 days? Care Transition- Transition Record Transmitted to Health care Professional ++ Medication Reconciliation Post- Discharge(MRP) Health Home Core Quality Measures Like of discharge" Care transitions: percentage of patients, regardless of age, discharged from an inpatient facility to home or any other site of care for whom a transition record was transmitted to the facility or primary physician or other health care professional designated for follow-up care within 24 hours of discharge. The percentage of discharges from January 1- December 1 of the measurement year for members 18 years of age and older for who medications were reconciled on or within 30 days of discharge. Numerator Description Patients for whom a transition record was transmitted to the facility or primary physician or other health care professional designated for follow-up care within 24 hours of discharge Denominator Description All patients, regardless of age, discharged from an inpatient facility (e.g., hospital inpatient or observation, skilled nursing facility, or rehabilitation facility) to home/self-care or any other site of care Hybrid. Discharge date found in claims data. Denominator is based episodes, not members. Numerator See page 214 of 2013 Tech Specs Vol 2. Need to have adequate sample size or full population. Age changed from measure of 66 4

5 Ambulatory Care (AMB) and ED Visits * This measure summarizes utilization of ambulatory care in the following categories. Outpatient Visits ED Visits reconciliation administrative data or medical record review on or within 30 days of discharge. Claims years of age to 18 so measure becomes like. See page 303 of 2013 Tech Specs Vol 2. The measure does not include services mental health or chemical dependency services. Report separately for duals and nonduals. Adult Access to Preventive/Ambulatory health Services (AAP)* Pressure Ulcers Anti-Depressant Medication Management (AMM) Braden Scale The percentage of members 18 years and older who had an ambulatory or preventive care visit. The organization reports three separate percentages for each product line. Medicaid and Medicare members who had an ambulatory or preventive care visit during the measurement year. The percentage of participants age 18 years and older with mobility impairments who are assess every 6 months for pressure ulcers using the Braden Scale AND follow up documented. The percentage of members 18 years of age and older with a diagnosis of major depression and were newly treated with antidepressant medication, and who remained on an antidepressant medication treatment. Two rates are reported. Effective Acute Phase Treatment. The percentage of newly diagnosed and treated Claims Chart See page 242 of 2013 Tech Specs Vol 2. Goal to increase access to primary and preventive care See page 182 of 2013 Tech Specs Vol 2 In the education regarding this measure, emphasize when used as treatment for depression. In recent years some of the antidepressants are used in neuromuscular conditions for their anti-fatigue benefits secondary to their multiple sclerosis or 5

6 members who remained on an similar conditions antidepressant medication for at least 84 days (12 weeks). Effective Continuation Phase Treatment. The percentage of newly diagnosed and treated, members and who remained on an antidepressant medication for at least 180 days (6 months). Preventive Screenings Cholesterol Management for Patients with Cardiovascular Conditions (CMC) Colorectal Cancer Screening (COL) The percentage of members years of age who were discharged alive for AMI, coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) from January 1 November 1 of the year prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during the measurement year and the year prior to the measurement year, who had each of the following during the measurement year: LDL-C screening. LDL-C control (<100 mg/dl). The percentage of members years of age who had appropriate screening for colorectal cancer. HYBRID Denominator A systematic sample drawn from the eligible population for each product line. Numerators: An LDL-C test performed during the measurement year as determined by administrative data or medical record LDL-C Control <100 mg/dl The most recent LDL-C level performed during the measurement year is <100 mg/dl, as documented through automatic laboratory data or medical record review. See page 138 of 2013 Tech Specs Vol 2. Claims See page 86 of 2013 Tech Specs Vol 2. 6

7 Breast Cancer Screening (BCS) Flu Shots for Older Adults. (FSO) Pneumococcal Vaccination Status for Older Adults (PNU) Screening for Clinical Depression and Follow Up++ Like The percentage of women years of age who had a mammogram to screen for breast cancer. The percentage of members years of age and older as of January 1 of the measurement year who received an influenza vaccination measurement year. Like The percentage of Medicare members 65 years of age and older as of January 1 of the measurement year who have ever received a pneumococcal vaccine. Percentage of patients aged 18 years and older screened for clinical depression using a standardized tool AND follow-up documented. Depression Remission MCM A measure of the percentage of patients who have reached remission at six months (+/-30 days) after being identified as having an initial PHQ-9 score greater than nine. Claims See page 81 of 2013 Tech Specs Vol 2. Claims/ Minnesota Immunization Information Connections (MIIC) Minnesota Immunization Information Connections (MIIC)/ claims Population defined through EMR or through a query of a practice management system. See page 235 of 2013 Tech Spec Vol 2. This is like measure as the suggestion is to change the age to versus the measure of This measure will not be collected via CAHPS survey. See page 238 of 2013 Tech Spec Vol 2. This measure becomes like due to the suggested age change. Waiting for additional recommendation from consultant. The PHQ-9 is written from the DMS IV description and is as good a screening tool as any. Education for providers who use the tool in patients with chronic disabling conditions should focus on using this tool for screening and not as a diagnostic tool with unnecessarily rigid adherence to the numerical aggregate and being assured that providers should feel free to use their professional judgment as to whether the scores of 10 and greater reflect depression or co-morbidities. Additionally, if Depression Remission is using PHQ-9, introducing another tool would not be helpful. 7

8 Remission is defined as a PHQ-9 score less than five. Measurement period will be a fixed 12 month period: mm/dd/yyyy to mm/dd/yyyy. Data elements are either extracted from an EMR or abstracted through medical record review. Adult Body Mass Index (BMI) Assessment Assessment and Management of Chronic Pain Aspirational Best Practice Incentive S&P: Care Transitions Wong- Baker Faces (tool is also available in Spanish) MCM MCM document defines denominator, eligible specialties, eligible providers, numerator, allowable exclusions and ICD-9 codes. Percentage of members years of age who had an outpatient visit and who had their BMI documented during the measurement year or the year prior to the measurement year and follow up with enrolling in some type of exercise program. Percentage of patients with pain lasting more than 6 months who report pain as greater than 4 on a 10-point scale that have an articulated plan of care including education about non-pharmaceutical selfmanagement options along with pharmaceutical interventions when necessary. Percentage of patients with selected clinical conditions that have a follow-up telephonic/ electronic contact within three days of discharge OR a follow-up face-toface visit with a health care provider (physician, physician assistant, nurse practitioner, nurse, care-coordinator) Evidence of addressing pain should be able to be found via audits of nursing and provider dictation. Population identification is accomplished via a query of a practice management system or Electronic Medical Record (EMR) to identify the population of eligible What are the measures, best definition, description, and data source This was a suggested measure what is the definition, description, data source and are their suggested tools? Would be determined by SNP/ICSP protocols. Per HCH Protocol : Patient Population Follow-up Face to Face Visit after Discharge: Established patient who meets each of the 8

9 Best Practice Incentive S&P: Evidence of within seven days of hospital discharge. Clinical conditions represent those with the highest volume of readmissions include: Heart failure Pneumonia Ischemic vascular disease Chronic obstructive pulmonary disease Measurement period will be a fixed 12 month period: mm/dd/yyyy to mm/dd/yyyy. Defined in the MCM document: Electronic and face to face visits Eligible Clinics Eligible specialties Eligible providers Patient Exclusions Suggested content for follow up contact or visit Diagnosis codes for inclusion Included in the MCM document is guidance for established patient criteria face-to-face visits for denominator and telephonic, electronic and face-to face contacts for numerator. CPT codes are included. patients (denominator). Data elements are either extracted from an EMR system or abstracted through medical record review. TBD following criteria is included in the population: Patients age 65 and older at the start of the measurement period (date of birth was on or less than mm/dd/yyyy) AND Has one or more of the following diagnoses: heart failure, pneumonia, ischemic vascular disease or COPD. Please see tables below for diagnosis codes. Diagnosis codes in either the principle or secondary diagnosis position OR diagnosis is active on the problem list AND Hospitalized with an inpatient discharge date within the measurement year AND Meets the following established patient criteria: o Patient was seen by an eligible provider in an eligible specialty face-to-face at least two times during the last two years (mm/dd/yyyy to mm/dd/yyyy) for any reason by a certified health care home clinic. o Patient was seen by an eligible provider in an eligible specialty face-to-face at least one time during the last 12 months (mm/dd/yyyy to mm/dd/yyyy) for any reason by a certified health care home clinic. Care plan includes both medical and community services. 9

10 Integrated Care Plan for Phase 2 Community Members Best Practice Incentive S&P: Evidence of increased ongoing PCP/Care Coordinator communication S&P: Evidence of behavioral and physical health integration, communications and care planning TBD Goal to incent meaningful communication strategies between PCP and care coordinators, ICSP to develop/follow protocols. Phase 2 Chart audit, reporting Phase 2. * indicates a measure that is also requested on the SNBC evaluation work plan. ++ Health Home Core Quality Measures. 10