Numerator Details. - An acute or nonacute inpatient admission with a diagnosis of AOD (AOD Dependence

Transcription

1 Description Measure 0004: Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET) (National Committee for Quality Assurance) The percentage of adolescent and adult patients with a new episode of alcohol or other drug (AOD) dependence who received the following. - Initiation of AOD Treatment. The percentage of patients who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis. - Engagement of AOD Treatment. The percentage of patients who initiated treatment and who had two or more additional services with a diagnosis of AOD within 30 days of the initiation visit. Initiation of AOD Dependence Treatment: Initiation of AOD treatment through an inpatient admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the index episode start date. --- Engagement of AOD Treatment: Initiation of AOD treatment and two or more inpatient admissions, outpatient visits, intensive outpatient encounters or partial hospitalizations with any AOD diagnosis within 30 days after the date of the Initiation encounter (inclusive). Index Episode Start Date: The earliest date of service for an inpatient, intensive outpatient, partial hospitalization, outpatient, detoxification or ED encounter during the first 10 and ½ months of the measurement year (e.g., January 1 to November 15) with a diagnosis of AOD. - For an outpatient, intensive outpatient, partial hospitalization, detoxification or ED visit (not resulting in an inpatient stay), the Index Episode Start Date is the date of service. - For an inpatient (acute or nonacute) event, the Index Episode Start Date is the date of discharge. - For an ED visit that results in an inpatient event, the Index Episode Start Date is the date of the inpatient discharge. - For direct transfers, the Index Episode Start Date is the discharge date from the second admission INITIATION OF AOD TREATMENT If the Index Episode was an inpatient discharge, the inpatient stay is considered initiation of treatment and the patient is compliant If the Index Episode was an outpatient, intensive outpatient, partial hospitalization, detoxification or ED visit, the patient must have an inpatient admission, outpatient visit, intensive outpatient encounter or partial hospitalization, with an AOD diagnosis, on the Index Episode Start Date or in the 13 days after the Index Episode Start Date (14 total days). If the Index Episode Start Date and the initiation visit occur on the same day, they must be with different providers in order to count. Any of the following code combinations meet criteria: - An acute or nonacute inpatient admission with a diagnosis of AOD (AOD Dependence

2 Value Set). To identify acute and nonacute inpatient admissions: 1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set). 2. Identify the admission date for the stay. - IET Stand Alone Visits Value Set WITH AOD Dependence Value Set - IET Visits Group 1 Value Set WITH IET POS Group 1 Value Set AND AOD Dependence Value Set - IET Visits Group 2 Value Set WITH IET POS Group 2 Value Set AND AOD Dependence Value Set. (See corresponding Excel document for appropriate value sets) Do not count Index Episodes that include detoxification codes (including inpatient detoxification) as being initiation of treatment - See corresponding Excel document for the Detoxification Value Set. --- ENGAGEMENT OF AOD TREATMENT Identify all patients who meet the following criteria: 1) compliant for the Initiation of AOD Treatment numerator and 2) Two or more inpatient admissions, outpatient visits, intensive outpatient encounters or partial hospitalizations with any AOD diagnosis, beginning on the day after the initiation encounter through 29 days after the initiation event (29 total days). Multiple engagement visits may occur on the same day, but they must be with different providers in order to count. Any of the following code combinations meet criteria: An acute or nonacute inpatient admission with a diagnosis of AOD (AOD Dependence Value Set). To identify acute or nonacute inpatient admissions: First Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set), Then Identify the admission date for the stay. IET Stand Alone Visits Value Set with AOD Dependence Value Set. IET Visits Group 1 Value Set with IET POS Group 1 Value Set and AOD Dependence Value Set. IET Visits Group 2 Value Set with IET POS Group 2 Value Set and AOD Dependence Value Set. For patients who initiated treatment via an inpatient admission, the 29-day period for the two engagement visits begins the day after discharge. Do not count events that include inpatient detoxification or detoxification codes (Detoxification Value Set) when identifying engagement of AOD treatment. The time frame for engagement, which includes the initiation event, is 30 total days. Denominator Patients age 13 years of age and older who were diagnosed with a new episode of alcohol or other drug dependency (AOD) during the first 10 and ½ months of the measurement year (e.g., January 1-November 15). Denominator Identify the Index Episode. Identify all patients in the specified age range who during the first 10 and ½ months of the measurement year (e.g., January 1 to November 15) had one of the following: An outpatient visit, intensive outpatient encounter or partial hospitalization with a diagnosis of AOD. Any of the following code combinations meet criteria:

3 IET Stand Alone Visits Value Set WITH AOD Dependence Value Set. IET Visits Group 1 Value Set WITH IET POS Group 1 Value Set AND AOD Dependence Value Set. IET Visits Group 2 Value Set WITH IET POS Group 2 Value Set AND AOD Dependence Value Set. (See corresponding Excel document for the appropriate value sets) A detoxification visit (See corresponding Excel document for the Detoxification Value Set) An ED visit with a diagnosis of AOD (See corresponding Excel document for the ED Value Set and the AOD Dependence Value Set). An acute or nonacute inpatient discharge with either a diagnosis of AOD (AOD Dependence Value Set) or an AOD procedure code (AOD Procedures Value Set). To identify acute and nonacute inpatient discharges: First, identify all acute and nonacute inpatient stays (Inpatient Stay Value Set), Second, identify the discharge date for the stay. For patients with more than one episode of AOD, use the first episode. For patients whose first episode was an ED visit that resulted in an inpatient event, use the inpatient discharge. Exclusions Select the Index Episode Start Date. Exclude patients who had a claim/encounter with a diagnosis of AOD during the 60 days (2 months) before the Index Episode Start Date. (See corresponding Excel document for the AOD Dependence Value Set) Exclusion details Risk Adjustment Exclude from the denominator for both indicators (Initiation of AOD Treatment and Engagement of AOD Treatment) patients whose initiation of treatment event is an inpatient stay with a discharge date after December 1 of the measurement year. Exclude patients who had a claim/encounter with a diagnosis of AOD during the 60 days (2 months) before the Index Episode Start Date. (See corresponding Excel document for the AOD Dependence Value Set) - For an inpatient Index Episode Start Date, use the admission date to determine if the patient had a period of 60 days prior to the Index Episode Start Date with no claims with a diagnosis of AOD dependence. - For an ED visit that results in an inpatient event, use the ED date of service to determine if the patient had a period of 60 days prior to the Index Episode Start Date with no claims with a diagnosis of AOD dependence. - For direct transfers, use the first admission to determine if the patient had a period of 60 days prior to the Index Episode Start Date with no claims with a diagnosis of AOD dependence. No risk adjustment or risk stratification Stratification The total population is stratified by age: and 18+ years of age. Report two age stratifications and a total rate.

4 Time window Type Process Type of Score The total is the sum of the age stratifications. Initiation : 14 days after diagnosis. Engagement : 30 days after the date of initiation encounter Denominator: The first 10 and ½ months of the measurement year (e.g., January 1 to November 15) Rate/proportion Data Source Administrative claims, Electronic Clinical Data Level Health Plan, Integrated Delivery System Setting Ambulatory Care : Clinician Office/Clinic, Ambulatory Care : Urgent Care, Behavioral Health/Psychiatric : Inpatient, Behavioral Health/Psychiatric : Outpatient, Emergency Medical Services/Ambulance, Hospital/Acute Care Facility Created on: 06/11/2016 at 02:30 AM

5 Description Measure 0027: Medical Assistance With Smoking and Tobacco Use Cessation (MSC) (National Committee for Quality Assurance) Assesses different facets of providing medical assistance with smoking and tobacco use cessation: Advising Smokers and Tobacco Users to Quit: A rolling average represents the percentage of patients 18 years of age and older who were current smokers or tobacco users and who received advice to quit during the measurement year. Discussing Cessation Medications: A rolling average represents the percentage of patients 18 years of age and older who were current smokers or tobacco users and who discussed or were recommended cessation medications during the measurement year. Discussing Cessation Strategies: A rolling average represents the percentage of patients 18 years of age and older who were current smokers or tobacco users and who discussed or were provided cessation methods or strategies during the measurement year. Component 1: Advising Smokers and Tobacco Users to Quit (ASTQ) Patients who received advice to quit smoking or using tobacco from their doctor or health provider Component 2: Discussing Cessation Medications (DSCM) Patients who discussed or received recommendations on smoking or tobacco cessation medications from their doctor or health provider Component 3: Discussing Cessation Strategies (DSCS) Patients who discussed or received recommendations on smoking or tobacco cessation methods and strategies other than medication from their doctor or health provider For the Commercial product line: - Advising Smokers and Tobacco Users to Quit: The number of patients in the denominator who indicated that they received advice to quit smoking or tobacco use from a doctor or other health provider by answering Sometimes or Usually or Always to CAHPS question Q47: In the last 12 months, how often were you advised to quit smoking or using tobacco by a doctor or other health provider in your plan? - Discussing Smoking Cessation Medications: The number of patients in the denominator who indicated that their doctor or health provider recommended or discussed medication to assist with quitting smoking or using tobacco by answering Sometimes or Usually or Always to CAHPS question Q48: In the last 12 months, how often was medication recommended or discussed by a doctor or health provider to assist you with quitting smoking or using tobacco? Examples of medication are: nicotine gum, patch, nasal spray, inhaler, or prescription medication. - Discussing Cessation Strategies: The number of patients in the denominator who indicated that their doctor or health provider discussed or provided methods and strategies other than medication to assist with quitting smoking or using tobacco by answering Sometimes or Usually or Always to CAHPS question Q49: In the last 12 months, how often did your doctor or health

6 provider discuss or provide methods and strategies other than medication to assist you with quitting smoking or using tobacco? Examples of methods and strategies are: telephone helpline, individual or group counseling, or cessation program. Response options for all questions: Never, Sometimes, Usually, Always --- For the Medicaid product line: - Advising Smokers and Tobacco Users to Quit: The number of patients in the denominator who indicated that they received advice to quit smoking or tobacco use from a doctor or other health provider by answering Sometimes or Usually or Always to CAHPS question Q40: In the last 6 months, how often were you advised to quit smoking or using tobacco by a doctor or other health provider in your plan? - Discussing Smoking Cessation Medications: The number of patients in the denominator who indicated that their doctor or health provider recommended or discussed medication to assist with quitting smoking or using tobacco by answering Sometimes or Usually or Always to CAHPS question Q41: In the last 6 months, how often was medication recommended or discussed by a doctor or health provider to assist you with quitting smoking or using tobacco? Examples of medication are: nicotine gum, patch, nasal spray, inhaler, or prescription medication. - Discussing Cessation Strategies: The number of patients in the denominator who indicated that their doctor or health provider discussed or provided methods and strategies other than medication to assist with quitting smoking or using tobacco by answering Sometimes or Usually or Always to CAHPS question Q42: In the last 6 months, how often did your doctor or health provider discuss or provide methods and strategies other than medication to assist you with quitting smoking or using tobacco? Examples of methods and strategies are: telephone helpline, individual or group counseling, or cessation program. Response options for all questions: Never, Sometimes, Usually, Always --- For the Medicare product line: - Advising Smokers or Tobacco Users to Quit The number of patients in the denominator who indicated that they received advice to quit smoking or using tobacco from a doctor or other health provider by answering Sometimes or Usually or Always to CAHPS question Q66 : In the last 6 months, how often were you advised to quit smoking or using tobacco by a doctor or other health provider in your plan? Response options for all questions: Never, Sometimes, Usually, Always, I had no visits in the last 6 months

7 Denominator Patients 18 years and older who responded to the CAHPS survey and indicated that they were current smokers or tobacco users during the measurement year or in the last 6 months for Medicaid and Medicare. Denominator For the Commercial and Medicaid Product Lines: Number of patients who responded to the survey and indicated that they were current tobacco users. - Advising Smokers and Tobacco Users to Quit The number of patients who responded to the survey and indicated that they were current smokers or tobacco users by answering Every day or Some days to CAHPS question Q46 and by answering Q47 with any response ( Never or Sometimes or Usually or Always ). Q46: Do you now smoke cigarettes or use tobacco every day, some days, or not at all? Response options for Q46: Every day, Some days, Not at all, Don t know Q47: In the last 12 months, how often were you advised to quit smoking or using tobacco by a doctor or other health provider in your plan? Response Choices: Never, Sometimes, Usually, Always - Discussing Cessation Medications The number of patients who responded to the survey and indicated that they were current smokers or tobacco users by answering Every day or Some days to CAHPS question Q46 and by answering Q48 with any response ( Never or Sometimes or Usually or Always ). Q46: Do you now smoke cigarettes or use tobacco every day, some days, or not at all? Response Choice: Every day, Some days, Not at all, Don t know Q48: In the last 12 months, how often was medication recommended or discussed by a doctor or health provider to assist you with quitting smoking or using tobacco? Examples of medication are: nicotine gum, patch, nasal spray, inhaler, or prescription medication. Response Choices: Never OR Sometimes OR Usually OR Always - Discussing Cessation Strategies The number of patients who responded to the survey and indicated that they were current smokers or tobacco users by answering Every day or Some days to CAHPS question Q46 and by answering Q49 with any response ( Never or Sometimes or Usually or Always ). Q46: Do you now smoke cigarettes or use tobacco every day, some days, or not at all? Response Choice: Every day, Some days, Not at all, Don t know Q49: In the last 12 months, how often did your doctor or health provider discuss or provide methods and strategies other than medication to assist you with quitting smoking or using tobacco? Examples of methods and strategies are: telephone helpline, individual or group counseling, or cessation program.

8 Response Choices: Never, Sometimes, Usually, Always --- For the Medicaid Product Lines: - Advising Smokers and Tobacco Users to Quit The number of patients who responded to the survey and indicated that they were current smokers or tobacco users by answering Every day or Some days to CAHPS question Q39 and by answering Q40 with any response ( Never or Sometimes or Usually or Always ). Q39: Do you now smoke cigarettes or use tobacco every day, some days, or not at all? Response options for Q39: Every day, Some days, Not at all, Don t know Q40: In the last 6 months, how often were you advised to quit smoking or using tobacco by a doctor or other health provider in your plan? Response Choices: Never, Sometimes, Usually, Always - Discussing Cessation Medications The number of patients who responded to the survey and indicated that they were current smokers or tobacco users by answering Every day or Some days to CAHPS question Q39 and by answering Q41 with any response ( Never or Sometimes or Usually or Always ). Q39: Do you now smoke cigarettes or use tobacco every day, some days, or not at all? Response Choice: Every day, Some days, Not at all, Don t know Q41: In the last 6 months, how often was medication recommended or discussed by a doctor or health provider to assist you with quitting smoking or using tobacco? Examples of medication are: nicotine gum, patch, nasal spray, inhaler, or prescription medication. Response Choices: Never OR Sometimes OR Usually OR Always - Discussing Cessation Strategies The number of patients who responded to the survey and indicated that they were current smokers or tobacco users by answering Every day or Some days to CAHPS question Q39 and by answering Q42 with any response ( Never or Sometimes or Usually or Always ). Q39: Do you now smoke cigarettes or use tobacco every day, some days, or not at all? Response Choice: Every day, Some days, Not at all, Don t know Q42: In the last 6 months, how often did your doctor or health provider discuss or provide methods and strategies other than medication to assist you with quitting smoking or using tobacco? Examples of methods and strategies are: telephone helpline, individual or group counseling, or cessation program. Response Choices: Never, Sometimes, Usually, Always ---

9 Exclusions Exclusion details Risk Adjustment For the Medicare Product Lines: Advising Smokers or Tobacco Users to Quit The number of patients who responded to the survey and indicated that they were current smokers or tobacco users by answering Every day or Some days to CAHPS question Q65, had one or more visits during the last 6 months, and by answering Q66 with any response ( Never or Sometimes or Usually or Always ). Q65: Do you now smoke cigarettes or use tobacco every day, some days, or not at all? Response options for Q65: Not at all, Some days, Every day, Don t know Q66: In the last 6 months, how often were you advised to quit smoking or using tobacco by a doctor or other health provider in your plan? Response choices: Never, Sometimes, Usually, Always, I had no visits in the last 6 months The Medicare results for the Advising Smokers and Tobacco Users to Quit Rate requires a minimum denominator of at least 30 responses. None N/A Stratification None Time window Type Process Type of Score No risk adjustment or risk stratification This measure is collected annually via patient survey using the CAHPS 5.0H, Adult Version (Commercial and Medicaid Product lines) and Medicare CAHPS survey. Rates are averaged over two years. Rate/proportion Data Source Patient Reported Data/Survey Level Health Plan, Integrated Delivery System Setting Ambulatory Care : Clinician Office/Clinic, Other Created on: 06/11/2016 at 02:30 AM

10 Description Measure 0576: Follow-Up After Hospitalization for Mental Illness (FUH) (National Committee for Quality Assurance) The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported: - The percentage of discharges for which the patient received follow-up within 30 days of discharge - The percentage of discharges for which the patient received follow-up within 7 days of discharge. 30-Day Follow-Up: An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 30 days after discharge. Include outpatient visits, intensive outpatient visits or partial hospitalizations that occur on the date of discharge. 7-Day Follow-Up: An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 7 days after discharge. Include outpatient visits, intensive outpatient visits or partial hospitalizations that occur on the date of discharge. For both indicators, any of the following meet criteria for a follow-up visit: - A visit (FUH Stand Alone Visits Value Set) with a mental health practitioner. - A visit (FUH Visits Group 1 Value Set and FUH POS Group 1 Value Set) with a mental health practitioner. - A visit (FUH Visits Group 2 Value Set and FUH POS Group 2 Value Set) with a mental health practitioner. - A visit to a behavioral healthcare facility (FUH RevCodes Group 1 Value Set). - A visit to a non-behavioral healthcare facility (FUH RevCodes Group 2 Value Set) with a mental health practitioner. - A visit to a non-behavioral healthcare facility (FUH RevCodes Group 2 Value Set) with a diagnosis of mental illness (Mental Illness Value Set). - Transitional care management services (TCM 7 Day Value Set) where the date of service on the claim is 29 days after the date the patient was discharged with a principal diagnosis of mental illness. The following meets criteria for only the 30-Day Follow-Up indicator: - Transitional care management services (TCM 14 Day Value Set) where the date of service on the claim is 29 days after the date the patient was discharged with a principal diagnosis of mental illness. (See corresponding Excel document for the value sets referenced above) Note: Transitional care management is a 30-day period that begins on the date of discharge and continues for the next 29 days. The date of service on the claim is 29 days after discharge and not the date of the face-to-face visit. Denominator Patients 6 years and older as of the date of discharge who were discharged from an acute inpatient setting (including acute care psychiatric facilities) with a principal diagnosis of mental illness during the first 11 months of the measurement year (e.g., January 1 to December 1).

11 Denominator An acute inpatient discharge with a principal diagnosis of mental illness (Mental Illness Value Set) on or between January 1 and December 1 of the measurement year. To identify acute inpatient discharges: 1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set). 2. Exclude nonacute inpatient stays (Nonacute Inpatient Stay Value Set). 3. Identify the discharge date for the stay. Use only facility claims to identify discharges and diagnoses for denominator events (including readmissions or direct transfers). Do not use professional claims. The denominator for this measure is based on discharges, not on patients. If patients have more than one discharge, include all discharges on or between January 1 and December 1 of the measurement year. Acute facility readmission or direct transfer: If the discharge is followed by readmission or direct transfer to an acute inpatient care setting for a principal diagnosis of mental health (Mental Health Diagnosis Value Set) within the 30-day follow-up period, count only the last discharge. To identify readmissions to an acute inpatient care setting: 1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set). 2. Exclude nonacute inpatient stays (Nonacute Inpatient Stay Value Set). 3. Identify the admission date for the stay. Exclusions (See corresponding Excel document for the value sets referenced above) Exclude both the initial discharge and the readmission/direct transfer discharge if the readmission/direct transfer discharge occurs after the first 11 months of the measurement year (e.g., after December 1). Exclude discharges followed by readmission or direct transfer to a nonacute facility within the 30-day follow-up period, regardless of principal diagnosis for the readmission. Exclude discharges followed by readmission or direct transfer to an acute facility within the 30-day follow-up period if the principal diagnosis was for non-mental health (any principal diagnosis code other than those included in the Mental Health Diagnosis Value Set). Exclusion details These discharges are excluded from the measure because rehospitalization or transfer may prevent an outpatient follow-up visit from taking place. Exclude both the initial discharge and the readmission/direct transfer discharge if the last discharge occurs after December 1 of the measurement year. Exclude discharges followed by readmission or direct transfer to a nonacute care setting within the 30-day follow-up period, regardless of principal diagnosis for the readmission. To identify readmissions to a nonacute inpatient care setting: 1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set). 2. Confirm the stay was for nonacute care based on the presence of a nonacute code (Nonacute Inpatient Stay Value Set) on the claim. 3. Identify the admission date for the stay. Exclude discharges followed by readmission or direct transfer to an acute inpatient care

12 Risk Adjustment Stratification N/A Time window Type Process Type of Score setting within the 30-day follow-up period if the principal diagnosis was for non-mental health (any principal diagnosis code other than those included in the Mental Health Diagnosis Value Set). To identify readmissions to an acute inpatient care setting: 1. Identify all acute and nonacute inpatient stays (Inpatient Stay Value Set). 2. Exclude nonacute inpatient stays (Nonacute Inpatient Stay Value Set). 3. Identify the admission date for the stay. These discharges are excluded from the measure because rehospitalization or transfer may prevent an outpatient follow-up visit from taking place. - See corresponding Excel document for the Value Sets referenced above. No risk adjustment or risk stratification : Date of discharge through 30 days after discharge Denominator: On or between January 1 and December 1 of the measurement year (11 month period) Rate/proportion Data Source Administrative claims, Electronic Clinical Data Level Health Plan, Integrated Delivery System Setting Ambulatory Care : Clinician Office/Clinic, Ambulatory Care : Urgent Care, Behavioral Health/Psychiatric : Inpatient, Behavioral Health/Psychiatric : Outpatient, Hospital/Acute Care Facility Created on: 06/11/2016 at 02:30 AM

13 Measure 1651: TOB-1 Tobacco Use Screening (The Joint Commission) Description Hospitalized patients age 18 years and older who are screened within the first day of admission for tobacco use (cigarettes, smokeless tobacco, pipe and cigars) within the past 30 days. This measure is intended to be used as part of a set of 4 linked measures addressing Tobacco Use (TOB-2 Tobacco Use Treatment Provided or Offered (during the hospital stay); TOB-3 Tobacco Use Treatment Provided or offered at Discharge; TOB-4 Tobacco Use: Assessing Status After Discharge [temporarily suspended].) The number of patients who were screened for tobacco use status within the first day of admission. There is one data element used to calculate the numerator: Tobacco Use Status: Documentation of the types of tobacco used, volume, frequency of use over the past 30 days prior to admission or that the patient does not use tobacco products or refused to be screened or could not be screened due to cognitive impairment. Cognition refers to mental activities associated with thinking, learning, and memory. Cognitive impairment for the purposes of this measure set is related to documentation that the patient cannot be screened for tobacco and alcohol use due to the impairment (e.g., comatose, obtunded, confused, memory loss). Temporary cognitive impairment due to acute substance use such as overdose or acute intoxication does not meet the definition of cognitive impairment. There are 6 allowable values: 1. The patient has smoked cigarettes daily on average in a volume of five or more cigarettes (=> 1/4 pack) per day and/or cigars daily and/or pipes daily during the past 30 days. 2. The patient has smoked cigarettes daily on average in a volume of four or less cigarettes (< ¼ pack) per day and/or used smokeless tobacco and/or smoked cigarettes but not daily and/or cigars but not daily and/or pipes but not daily during the past 30 days. 3. The patient has not used any forms of tobacco in the past 30 days. 4. The patient refused the tobacco use screen. 5. The patient was not screened for tobacco use during this hospitalization or unable to determine the patient s tobacco use status from medical record documentation. 6. The patient was not screened for tobacco use during the first day of admission because of cognitive impairment. Tobacco Use Status is used to screen or examine methodologically in order to make a separation into different groups that address the various tobacco products or combinations thereof and the volume and frequency of use as well as the timeframe of use. Notes for abstraction are included along with suggested data sources. Full specifications can be viewed on the Joint Commission web site at the following link: ality_measures/ Denominator The number of hospitalized inpatients 18 years of age and older Denominator Five data elements are used to calculate the denominator: 1. Admission Date - The month, day and year of admission to acute inpatient care.

14 2. Birthdate - The month, day and year the patient was born. 3. Discharge Date - The month day and year the patient was discharged from acute care, left against medical advice or expired during the stay. 4. Comfort Measures Only- Documentation that the patient was receiving medical treatment where the natural dying process is permitted to occur while assuring maximum comfort. There are four allowable values: 1 Day 0 or 1: The earliest day the physician/apn/pa documented comfort measures only was the day of arrival (Day 0) or day after arrival (Day 1). 2 Day 2 or after: The earliest day the physician/apn/pa documented comfort measures only was two or more days after arrival day (Day 2+). 3 Timing unclear: There is physician/apn/pa documentation of comfort measures only during this hospital stay, but whether the earliest documentation of comfort measures only was on day 0 or 1 OR after day 1 is unclear. 4 Not Documented/UTD: There is no physician/apn/pa documentation of comfort measures only, or unable to determine from medical record documentation. Exclusions Exclusion details 5. Tobacco Use Status- Documentation of the types of tobacco used, volume, frequency of use over the past 30 days prior to admission or that the patient does not use tobacco products or refused to be screened or could not be screened due to cognitive impairment. Cognition refers to mental activities associated with thinking, learning, and memory. Cognitive impairment for the purposes of this measure set is related to documentation that the patient cannot be screened for tobacco and alcohol use due to the impairment (e.g., comatose, obtunded, confused, memory loss). Temporary cognitive impairment due to acute substance use such as overdose or acute intoxication does not meet the definition of cognitive impairment. There are 6 allowable values: 1. The patient has smoked cigarettes daily on average in a volume of five or more cigarettes (=> 1/4 pack) per day and/or cigars daily and/or pipes daily during the past 30 days. 2. The patient has smoked cigarettes daily on average in a volume of four or less cigarettes (< ¼ pack) per day and/or used smokeless tobacco and/or smoked cigarettes but not daily and/or cigars but not daily and/or pipes but not daily during the past 30 days. 3. The patient has not used any forms of tobacco in the past 30 days. 4. The patient refused the tobacco use screen. 5. The patient was not screened for tobacco use during this hospitalization or unable to determine the patient s tobacco use status from medical record documentation. 6. The patient was not screened for tobacco use during the first day of admission because of cognitive impairment. The denominator has four exclusions: Patients less than 18 years of age Patients who are cognitively impaired Patients who a have a length of stay less than or equal to one day or greater than 120 days Patients who are receiving comfort measures only The patient age in years is equal to the admission date minus the birthdate. The month and day portion of the admission date and birthdate are used to yield the most accurate

15 Risk Adjustment age. If the patient age is less than 18 years the patient is not in the population. Length of stay (LOS) in days is equal to the discharge date minus the admission date. If the LOS is greater than 120 days or equal to or less than 1 day, the patient is not in the population. If the patient is receiving comfort measures only which is medical treatment where the natural dying process is permitted to occur while assuring maximum comfort, the patient will be excluded from the population. Tobacco Use Status is used to exclude patients with cognitive impairment. No risk adjustment or risk stratification Stratification Not Applicable, the measure is not stratified. Time window Type Process Type of Score Episode of care which is the entire hospitalization from admission to discharge. Rate/proportion Data Source Electronic Clinical Data, Paper Medical Records Level Facility, Population : National Setting Behavioral Health/Psychiatric : Inpatient, Hospital/Acute Care Facility Created on: 06/11/2016 at 02:30 AM

16 Measure 1654: TOB - 2 Tobacco Use Treatment Provided or Offered and the subset measure TOB-2a Tobacco Use Treatment (The Joint Commission) Description The measure is reported as an overall rate which includes all hospitalized patients 18 years of age and older to whom tobacco use treatment was provided during the hospital stay, or offered and refused, and a second rate, a subset of the first, which includes only those patients who received tobacco use treatment during the hospital stay. Refer to section 2a1.10 Stratification /Variables for the rationale for the addition of the subset measure. These measures are intended to be used as part of a set of 4 linked measures addressing Tobacco Use (TOB-1 Tobacco Use Screening; TOB-3 Tobacco Use Treatment Provided or Offered at Discharge; TOB-4 Tobacco Use: Assessing Status After Discharge [temporarily suspended].) TOB-2: The number of patients who received or refused practical counseling to quit AND received or refused FDA-approved cessation medications during the hospital stay. TOB-2a: The number of patients who received practical counseling to quit AND received FDA-approved cessation medications during the hospital stay. There are six data elements used to calculate the numerator: 1. ICD-10-CM Other Diagnosis Codes- The CMS ICD-10-CM master code table for other or secondary ICD-10-CM codes associated with the diagnosis for this hospitalization. 2. ICD-10-CM Principal Diagnosis Code- The CMS ICD-10-CM master code table for the diagnosis code that is primarily responsible for the admission of the patient to the hospital for care during this hospitalization. 3. Reason for No Tobacco Cessation Medication During the Hospital Stay- Documentation of reasons for not administering an FDA-approved tobacco cessation medication during the hospital stay which include: Allergy to all of the FDA-approved tobacco cessation medications. Drug interaction (for all of the FDA-approved medications) with other drugs the patient is currently taking. Other reasons documented by physician, advanced practice nurse (APN), physician assistant (PA), or pharmacist. There are two allowable values: Y (Yes) and N (No)/UTD. 4. Tobacco Use Status: Documentation of the types of tobacco used, volume, frequency of use over the past 30 days prior to admission or that the patient does not use tobacco products or refused to be screened or could not be screened due to cognitive impairment. Cognition refers to mental activities associated with thinking, learning, and memory. Cognitive impairment for the purposes of this measure set is related to documentation that the patient cannot be screened for tobacco and alcohol use due to the impairment (e.g., comatose, obtunded, confused, memory loss). Temporary cognitive impairment due to acute substance use such as overdose or acute intoxication does not meet the definition of cognitive impairment. There are 6 allowable values: 1. The patient has smoked cigarettes daily on average in a volume of five or more cigarettes (=> 1/4 pack) per day and/or cigars daily and/or pipes daily during the past 30 days.

17 2. The patient has smoked cigarettes daily on average in a volume of four or less cigarettes (< ¼ pack) per day and/or used smokeless tobacco and/or smoked cigarettes but not daily and/or cigars but not daily and/or pipes but not daily during the past 30 days. 3. The patient has not used any forms of tobacco in the past 30 days. 4. The patient refused the tobacco use screen. 5. The patient was not screened for tobacco use during this hospitalization or unable to determine the patient s tobacco use status from medical record documentation. 6. The patient was not screened for tobacco use during the first day of admission because of cognitive impairment. 5. Tobacco Use Treatment FDA-Approved Cessation Medication - Documentation the patient received FDA-approved tobacco cessation medication during the hospital stay. There are 3 allowable values: 1. The patient received one of the FDA-approved tobacco cessation medications during the hospital stay. 2. The patient refused the FDA-approved tobacco cessation medications during the hospital stay. 3. FDA-approved tobacco cessation medications were not offered to the patient during the hospital stay or unable to determine from medical record documentation. 6.Tobacco Use Treatment Practical Counseling- Documentation that the patient received all three components of practical counseling which requires interaction with the patient to address the following: recognizing danger situations, developing coping skills, and providing basic information about quitting. There are three allowable values: 1. The patient received all components of practical counseling during the hospital stay. 2. The patient refused/declined practical counseling during the hospital stay. 3. Practical counseling was not offered to the patient during the hospital stay or unable to determine if tobacco use treatment was provided from medical record documentation. The ICD-10-CM Principal and Other Diagnosis Codes are used to identify pregnant tobacco users as this is one of the populations that is excluded from receiving the FDA approved cessation medications. For ease of data collection burden, the codes are used to remove this group from the need for FDA approved cessation medication. Reason for No Tobacco Cessation Medication During the Hospital Stay will allow those cases with good reason to not receive cessation medication to still receive credit for the measures. If counseling is provided these cases will flow to the numerator. Tobacco Use Status is used if a value is selected that indicates the patient uses tobacco products, he/she will be in the measure population and eligible to receive treatment. However this data element is also used to exclude certain populations (light smokers and smokeless tobacco users) from receiving FDA approved medications (a numerator condition). Tobacco Use Treatment Practical Counseling and Tobacco Use Treatment FDA-Approved Cessation Medication will flow cases to the numerator if the patient receives the treatment. Practical counseling must include a bedside discussion with the clinician, and address danger situations, developing coping skills and provide basic information about quitting. If these components are not addressed, credit cannot be given. For all data elements, notes for abstraction are included along with suggested data sources in the data dictionary. Full specifications can be viewed on the Joint Commission web site at the following link:

18 ality_measures/ Denominator The number of hospitalized inpatients 18 years of age and older identified as current tobacco users Denominator There are five data elements that define the denominator: 1. Admission Date - The month, day and year of admission to acute inpatient care. 2. Birthdate - The month, day and year the patient was born. 3. Comfort Measures Only- Documentation that the patient was receiving medical treatment where the natural dying process is permitted to occur while assuring maximum comfort. There are four allowable values: 1 Day 0 or 1: The earliest day the physician/apn/pa documented comfort measures only was the day of arrival (Day 0) or day after arrival (Day 1). 2 Day 2 or after: The earliest day the physician/apn/pa documented comfort measures only was two or more days after arrival day (Day 2+). 3 Timing unclear: There is physician/apn/pa documentation of comfort measures only during this hospital stay, but whether the earliest documentation of comfort measures only was on day 0 or 1 OR after day 1 is unclear. 4 Not Documented/UTD: There is no physician/apn/pa documentation of comfort measures only, or unable to determine from medical record documentation. 4. Discharge Date - The month day and year the patient was discharged from acute care, left against medical advice or expired during the stay. Exclusions 5. Tobacco Use Status - Documentation of the types of tobacco used, volume, frequency of use over the past 30 days prior to admission or that the patient does not use tobacco products or refused to be screened or could not be screened due to cognitive impairment. Cognition refers to mental activities associated with thinking, learning, and memory. Cognitive impairment for the purposes of this measure set is related to documentation that the patient cannot be screened for tobacco and alcohol use due to the impairment (e.g., comatose, obtunded, confused, memory loss). Temporary cognitive impairment due to acute substance use such as overdose or acute intoxication does not meet the definition of cognitive impairment. There are 6 allowable values: 1. The patient has smoked cigarettes daily on average in a volume of five or more cigarettes (=> 1/4 pack) per day and/or cigars daily and/or pipes daily during the past 30 days. 2. The patient has smoked cigarettes daily on average in a volume of four or less cigarettes (< ¼ pack) per day and/or used smokeless tobacco and/or smoked cigarettes but not daily and/or cigars but not daily and/or pipes but not daily during the past 30 days. 3. The patient has not used any forms of tobacco in the past 30 days. 4.The patient refused the tobacco use screen. 5. The patient was not screened for tobacco use during this hospitalization or unable to determine the patient s tobacco use status from medical record documentation. 6. The patient was not screened for tobacco use during the first day of admission because of cognitive impairment. The denominator has six exclusions:

19 Exclusion details Risk Adjustment 1. Patients less than 18 years of age 2. Patients who are cognitively impaired 3. Patients who are not current tobacco users 4. Patients who refused or were not screened for tobacco use during the hospital stay. 5. Patients who have a duration of stay less than or equal to day or greater than 120 days 6. Patients with Comfort Measures Only documented The patient age in years is equal to the admission date minus the birthdate. The month and day portion of the admission date and birthdate are used to calculate the most accurate age. If the patient age is less than 18 years the patient is not in the population. Length of stay (LOS) in days is equal to the discharge date minus the admission date. If the LOS is greater than 120 days or equal to or less than 1 day, the patient is not in the population. Tobacco Use Status is used to exclude patients who have not used tobacco products, patients who refused the tobacco use screen or patients with cognitive impairment. If the patient is receiving comfort measures only which is medical treatment where the natural dying process is permitted to occur while assuring maximum comfort, the patient will also be excluded from the population. No risk adjustment or risk stratification Stratification Not Applicable, the measure is not stratified. However there is a subset mesure TOB-2a which removes patients from the numerator who refused the bedside counseling and an FDA-approved tobacco cessation medication. This measure was added as a result of a sub-analysis performed on the pilot data. Because those who refuse counseling or medication are put in the numerator, we looked at the numerator to determine how many patients actually received the counseling and FDA approved medications. Only 45% of those who were in the numerator received both counseling and medication. For measures that are to be publicly reported, it was felt transparency was important so this measure was added as a subset. Time window Type Process Type of Score Episode of Care which is the entire hospitalization from admission to discharge. Rate/proportion Data Source Electronic Clinical Data, Paper Medical Records Level Facility, Population : National Setting Behavioral Health/Psychiatric : Inpatient, Hospital/Acute Care Facility Created on: 06/11/2016 at 02:30 AM

20 Measure 1656: TOB-3 Tobacco Use Treatment Provided or Offered at Discharge and the subset measure TOB-3a Tobacco Use Treatment at Discharge (The Joint Commission) Description The measure is reported as an overall rate which includes all hospitalized patients 18 years of age an older to whom tobacco use treatment was provided, or offered and refused, at the time of hospital discharge, and a second rate, a subset of the first, which includes only those patients who received tobacco use treatment at discharge. Treatment at discharge includes a referral to outpatient counseling and a prescription for one of the FDA-approved tobacco cessation medications. Refer to section 2a1.10 Stratification /Variables for the rationale for the addition of the subset measure. These measures are intended to be used as part of a set of 4 linked measures addressing Tobacco Use (TOB-1 Tobacco Use Screening; TOB 2 Tobacco Use Treatment Provided or Offered During the Hospital Stay; TOB-4 Tobacco Use: Assessing Status After Discharge [temporarily suspended]). TOB-3: The number of patients who received or refused evidence-based outpatient counseling AND received or refused a prescription for FDA-approved cessation medication at discharge TOB-3a: The number of patients who were referred to evidence-based outpatient counseling AND received a prescription for FDA-approved cessation medication at discharge. There are six data elements that are used to calculate the numerator. 1. ICD-10-CM Other Diagnosis Codes- The CMS ICD-10-CM master code table for other or secondary ICD-10-CM codes associated with the diagnosis for this hospitalization. 2. ICD-10-CM Principal Diagnosis Code- The CMS ICD-10-CM master code table for the diagnosis code that is primarily responsible for the admission of the patient to the hospital for care during this hospitalization. 3. Prescription for Tobacco Cessation Medication Documentation that a FDAapproved cessation medication was prescribed at the time of discharge. There are 4 allowable values: 1. A prescription for an FDA-approved tobacco cessation medication was given to the patient at discharge. 2. A prescription for an FDA-approved tobacco cessation medication was offered at discharge and the patient refused. 3. The patient s residence is not in the USA. 4. A prescription for an FDA-approved tobacco cessation medication was not offered at discharge or unable to determine from medical record documentation. 4. Reason for No Tobacco Cessation Medication at Discharge Documentation Reasons for not prescribing an FDA-approved tobacco cessation medication at discharge include: allergy to all of the FDA-approved tobacco cessation medications and drug interaction (for all of the FDA-approved medications) with other drugs the patient is currently taking and other reasons documented by physician, advanced practice nurse (APN), physician assistant (PA), or pharmacist. There are two allowable values: Y (Yes) and N (No)/UTD

21 5. Referral for Outpatient Tobacco Cessation Counseling - Documentation that a referral was made at discharge for ongoing evidence-based counseling with clinicians (physician or non-physician such as nurse, psychologist, counselor). There are 5 allowable values for this data element: 1 The referral to outpatient tobacco cessation counseling treatment was made by the healthcare provider or health care organization at any time prior to discharge. 2 Referral information was given to the patient at discharge but the appointment was not made by the provider or health care organization prior to discharge. 3 The patient refused the referral for outpatient tobacco cessation counseling treatment and the referral was not made. 4 The patient s residence is not in the USA. 5 The referral for outpatient tobacco cessation counseling treatment was not offered at discharge or unable to determine from the medical record documentation. 6. Tobacco Use Status: Documentation of the types of tobacco used, volume, frequency of use over the past 30 days prior to admission or that the patient does not use tobacco products or refused to be screened or could not be screened due to cognitive impairment. Cognition refers to mental activities associated with thinking, learning, and memory. Cognitive impairment for the purposes of this measure set is related to documentation that the patient cannot be screened for tobacco and alcohol use due to the impairment (e.g., comatose, obtunded, confused, memory loss). Temporary cognitive impairment due to acute substance use such as overdose or acute intoxication does not meet the definition of cognitive impairment. There are 6 allowable values: 1. The patient has smoked cigarettes daily on average in a volume of five or more cigarettes (=> 1/4 pack) per day and/or cigars daily and/or pipes daily during the past 30 days. 2. The patient has smoked cigarettes daily on average in a volume of four or less cigarettes (< ¼ pack) per day and/or used smokeless tobacco and/or smoked cigarettes but not daily and/or cigars but not daily and/or pipes but not daily during the past 30 days. 3. The patient has not used any forms of tobacco in the past 30 days. 4. The patient refused the tobacco use screen. 5. The patient was not screened for tobacco use during this hospitalization or unable to determine the patient s tobacco use status from medical record documentation. 6. The patient was not screened for tobacco use during the first day of admission because of cognitive impairment. The ICD-10-CM Principal and Other Diagnosis Codes are used to identify pregnant tobacco users as this is one of the populations that is excluded from receiving the FDA approved cessation medications. For ease of data collection burden, the codes are used to remove this group from the need for FDA approved cessation medication. Prescription for Tobacco Cessation Medication identifies those patients who were given a prescription for FDA-approved cessation medication at discharge as well as those who had documented on the discharge medication list over the counter cessation medications. This is a condition to be satisfied for the numerator. Reason for No Tobacco Cessation Medication at Discharge allows for documentation by the practitioner of a reason for not