ATLANTIC and OPTIMUS ACCOUNTABLE CARE ORGANIZATIONs CMS QUALITY MEASURES

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1 CARE / PATIENT SAFETY ATLANTIC and OPTIMUS ACCOUNTABLE CARE ORGANIZATIONs CMS QUALITY MEASURES This tool is for REFERENCE USE ONLY and serves as an Emergency Backup Documentation Tool (downtime procedure for Online tool) (Record findings of each CMS patient audit in the Health LYNX online data collection tool) PATIENT DEMOGRAPHICS TIN # and Name: Medicare ID: (HICN #) Patient Last Name Patient First Name Gender: M F Unk BirthDate (MM/DD/YYYY): Abstraction Date: Medical Record Found? t Qualified for Sample IF t Qualified for Sample -- Indicate Deceased In hospice Moved out of Other CMS approved the Reason: country reason Date: Date: Date: Date: CARE COORDINATION/PATIENT SAFETY MEASURES: MEDication RECONCILIATION (Age > 65) Medication Reconciliation must be documented by a clinician within 30 days of each inpatient stay for patient. (Inpatient acute, rehab, subacute, psychiatric, any overnight stay). Inpatient Discharge Date (+/- 1-2 days of prepopulated date is ok) Office Date Reconciliation Documented by provider Was patient screened for FALL RISK in 2013? (Age > 65) Screening documented Patient not screened, Medical Reasons Patient not ambulatory or other medical reasons (e.g. no time to complete screening due to emergency or urgent situation) COMMENTS: (Medication Reconciliation Abstraction tes - see below) Acceptable Clinicians for Medication Reconciliation: Physician, PA, NP, Clinical Pharmacist Documentation needs to indicate clinician is aware of inpatient medications and covers the following: te that the DC medications were reconciled with the current medication list (including dosage) in the outpatient record te further outlining whether the meds are staying status quo or changing (discontinuation, adding new, changing dosage) COMMENTS: (Fall Screening) no falls in the past year, one fall without injury, 2 or more falls in past year with/without injury) CMS Quality Measures 2013 (01_08_14) Page 1

2 PREVENTION PREVENTIVE MEASURES INFLUENZA Patients seen for visit between 10/1/2012 3/31/2013 received influenza immunization OR reported receiving vaccine from another provider prior to visit (e.g.vaccine at CVS, Walmart or other provider- can go back as far as August 2012) Patient age: > 6 months Patient received influenza immunization Patient did not receive an influenza immunization, Patient Reason Patient declined, other patient reasons, System Reason Immunization not available or eligible professional out of vaccine or other system reasons, Medical Reason Patient did not receive influenza for medical reasons e.g. allergy, other Did patient ever receive a PNEUMONIA vaccination? (at any time in their history) Patient age: > 65 yrs Patient HAS received the pneumonia vaccination Patient has never received pneumonia vaccination, Medical Reason Medical reason such as allergy, anaphylactic reaction, other medical reason documented by provider Was BMI Calculated within the past six months or during the most recent 2013 visit? BMI NOT calculated, Medical Reason Pregnancy, terminal illness or patient is under/over-weight and managed by another provider; receiving palliative care. Patient in urgent situation, Patient Reason Patient refused or other documentation in record by provider IF YES, was it within normal values for their age? rmal BMI: Patients > 65 years: BMI > 23, < 30. For years: BMI > 18.5, < 25 Caution: rmal /Out of range values may differ from what is found in your EMR IF result was out of normal range, was follow-up plan documented? (followup apt, education, referral, dietary supplements, exercise or nutrition counseling, pharmacological), Follow-up plan was NOT documented, Follow-up plan WAS documented in CY 2013 Was patient SCREENED for TOBACCO use within last 24 months (2012, 2013) (Tobacco use includes any type of tobacco cigarettes, smokeless tobacco, cigars, pipe, snuff, chew). Cessation intervention includes brief (< 3 minute) counselling and/or pharmacotherapy te: If there is more than 1 patient query re tobacco use, use the most recent. Age >18 yrs t screened, Screened and a non-tobacco user Patient was screened but was not a tobacco user. Screened and a tobacco user IF tobacco user, was smoking cessation plan documented?, did not receive tobacco cessation intervention, did receive tobacco cessation intervention, Medical Reason Patient was not screened for medical reasons (e.g. limited life expectancy) CMS Quality Measures 2013 (01_08_14) Page 2

3 Was patient SCREENED for CLINICAL DEPRESSION in 2013 using an age appropriate, standardized tool (e.g. if patient > 18 yrs: PHQ-2, PHQ-9, Beck Depression, CES-D, Duke Anxiety Depression Scale, Geriatric Depression Scale, Cornell Scale Screen, PRIME MD-PHQ-2; if > 12 years of age and < 18 use appropriate adolescent tool) NOTE: Must be completed in the office of the provider filing the code. Intervention must be on same day as positive screen. Patient was screened; reliable, age appropriate tool was used Patient was not screened using a standardized tool, Medical Reason Patient not capable of participating due to cognitive or physical incapacity of expressing themselves e.g. delirium; urgent or emergent situation; active dx of depression or bipolar disorder), Patient Reason Patient refused to participate, patient motivation may impact accuracy of results IF patient was screened, was the DEPRESSION SCREEN POSITIVE? IF POSITIVE, was follow-up plan documented? (follow-up must include one or more of the following: additional eval, suicide risk assessment, referral to qualified provider to diagnose and treat depression, pharmacological or other intervention/s for diagnosis or treatment of depression) COLORECTAL SCREENING current in 2013? Patient age yrs (Current up to date or current noted in medical record is acceptable) Current Screening Guidelines: Fecal Occult Blood Test (FOBT) within 12 months; Flex Sig within 5 years ( ); Colonoscopy within 10 years ( ) FOBT includes: ColoCare, Coloscreen, EZ detech, Fecal occult blood test, guiac smear, hemoccult, seracult, etc Colorectal screening is current for this patient Colorectal screening is not current, Medical Reason t current for medical reasons (colorectal cancer, total colectomy, terminal illness or other reason documented by provider BREAST CANCER SCREENING performed within past 24 months (CY ) Females yrs Screening was performed ( ) AND there is documentation of findings (Screening- breast imaging, breast xray, mammogram, digital or screening mammography) Must include both the following: date of screening AND result of finding. Screening was NOT performed, Medical Reason Medical reasons: two unilateral mastectomies, bilateral mastectomy CMS Quality Measures 2013 (01_08_14) Page 3

4 DIABETES Was the patient SCREENED for HIGH BLOOD PRESSURE at least once during 2013 and a recommended followup plan is documented? Age > 18 yrs BP was NOT screened for high blood pressure during 2013, Medical Reason Patient has active diagnosis of hypertension or there is an emergent or urgent issue which precludes obtaining BP Patient Reason Patient refuses BP measurement Patient screened for high blood pressure and a recommended follow-up plan is documented per guideline below BP CLASS SYSTOLIC BP DIASTOLIC BP Follow-UP rmal < 120 AND < 80 ne required Pre-hypertensive >120 and < 139 OR > 80 AND < 89 Rescreen BP w/in 1 yr AND recommend lifestyle modification OR referral to PCP or alternative provider 1 st hypertensive reading >140 OR > 90 Rescreen BP w/in min of > 1 day and < 4 weeks AND recommend lifestyle modification OR Referral to PCP or alternative provider 2 nd hypertensive reading >140 OR > 90 Recommend lifestyle modification AND 1 or more of the 2 nd reading interventions (e.g. Rx, Lab test or ECG) OR Referral to alternative provider or PCP PREVENTION/COMMENTS: DIABETES MELLITUS (DM) MEASURES: Does patient have history of diabetes documented during 2012 or 2013? (confirmation of diagnoses) Age yrs. - confirmed t confirmed -- STOP t confirmed, medical reasons (polycystic ovaries, gestational diabetes, steroid induced diabetes -- STOP Other CMS approved reason Did patient have more one or more HbA1c TESTS PERFORMED in 2013? If YES, provide the most recent: Determining Priority for Date: Lab report draw date Lab report date Flow sheet documentation Practitioner notes Other documentation Date the test was performed (MM/DD/2013): HbA1c value: te: if test performed but not documented, report 0 (zero) value CMS Quality Measures 2013 (01_08_14) Page 4

5 BP MANAGEMENT: Was the diabetic patient s blood pressure (BP) recorded in 2013? IF YES, provide most recent measurement date in 2013: (MM/DD/YYYY): Provide most recent systolic value: Provide most recent diastolic value: IF multiple BP s on the same date of service, use lowest systolic and lowest diastolic BP on that date as representative BP NOTE: Identify the most recent visit in 2013 to the providers office or clinic in which a blood pressure was recorded. BP must be obtained during visit to practitioner s office or other non-emergency outpatient facility (clinic, urgent care center). Outpatient visits for sole purpose of diagnostic visit or surgical procedure (e.g. colonoscopy, removal of mole) are not eligible. BP obtained same day as major dx or surg procedure (e.g. stress test, interventional radiology, endoscopy or ER) are not eligible LIPID CONTROL: Did diabetic patient have one or more LDL-C tests in 2013? YES IF YES, provide most recent date blood was drawn for LDL-C (MM/DD/YYYY): Record the most recent LDL-C value: Determining Priority for Date: Lab report draw date Lab report date Flow sheet documentation Practitioner notes Other documentation If the lab was unable to calculate the LDL-C value due to high trigylcerides, record 0 (zero) If test result is labeled Unreliable and a result is provided, record 0 (zero) Do not enter a ratio was a value (it is not a valid value) If test was performed but not documented, record a 0 A calculated LDL may be used for LDL-C measure Was diabetic patient screened and identified as a tobacco non user in 2013? (NOTE, this question only allows for screening in 2013 which is different than the Preventive Screening measure which allows a 24 month look back), Screened and identified as a tobacco user, Screened and identified as a tobacco non-user t Screened CMS Quality Measures 2013 (01_08_14) Page 5

6 HTN Does the diabetic patient also have a documented history of Ischemic Vascular Disease (IVD)? (See resource section for listing of approved diagnoses to help determine ischemic vascular disease. The coding used for this measure is not the same as used for IVD module. Cardiac surgery does not qualify as IVD for diabetes module) YES IF YES, is patient taking aspirin or antiplatelet medication in 2013?, Medical Reason e.g. allergy to aspirin; Anticoagulant use Lovenox (enoxaparin) or Coumadin (warfarin); any history of GI or intracranial bleed. The following may be exclusions if specifically documented by the physician (use of non steroidal antiinflammatory agents, risk of drug interaction, uncontrolled hypertension systolic > 180, diastolic >110, other documented reasons, GERD if specifically documented as a contraindication by physician DIABETES/COMMENTS: te: HYPERTENSION Measures Age = years of age Hypertension diagnosis confirmed? t confirmed Other CMS approved reason Was the hypertensive patient s most recent blood pressure (BP) recorded in 2013?, Medical Reasons ESRD, Pregnancy, Urgent situation IF YES, provide the most recent measurement date (MM/DD/YYYY): If there are multiple BP s on same date of service, use lowest systolic and lowest diastolic available HYPERTENSION/COMMENTS: Provide the most recent systolic value: Provide th1e most recent diastolic value: ISCHEMIC VASCULAR DISEASE (IVD) MEASURES: Patient age > 18 IVD diagnosis confirmed? t confirmed Other CMS approved reasons Abstraction te: Diagnosis confirmation - documented diagnosis of IVD or patient was discharged alive for AMI, CABG or PCI anywhere in the medical record or at anytime in patients history. CMS Quality Measures 2013 (01_08_14) Page 6

7 HEART FAILURE ISCHEMIC VASCULAR DISEASE Did the patient with IVD have at least one LIPID PROFILE (or ALL component tests) done in 2013? NOTE: This question requires the full LIPID PANEL either at one time or through the 2013 calendar year. This is different from the Diabetes question which only required LDL. LIPID PROFILE = Total Cholesterol, HDL, LDL, Triglycerides IF YES, provide the most recent date blood was drawn in 2013 (MM/DD/YYYY): Record the most recent LDL-C value: If the LDL C could not be calculated, count as complete Lipid Profile If the lab was unable to calculate the LDL-C value due to high trigylcerides, record 0 (zero) If test result is labeled Unreliable and a result is provided, record 0 (zero) Do not enter a ratio was a value (it is not a valid value) Does the patient with Ischemic Vascular Disease (IVD) have documented use of aspirin or another antithrombotic in 2013? (See resources to help determine the diagnosis of Ischemic Vascular Disease. Oral antithrombotic treatment = aspirin; clopidogrel or combination of aspirin and extended release dipyridamole) ISCHEMIC VASCULAR DISEASE/COMMENTS HEART FAILURE (HF) MEASURES Heart Failure diagnosis confirmed? t confirmed Other CMS approved reason Age > 18 years Heart failure diagnosis can be active or a history of heart failure at any time (see list of heart failure synonyms for reference) LVSD = Left Ventricular Systolic Dysfunction LVEF = Left Ventricular Ejection Fraction Does the HF patient have (or did they ever have) LVSD (LVEF < 40% or documented as moderate or severe)? IF YES, was patient prescribed beta blocker at any time during 2013? (Either within 2013 when seen in the outpatient setting OR at each hospital discharge in 2013 OR for pre-existing heart failure?) (Bisoprolol, Carvedilol, Metoprolol succinate sustained release), Medical Reasons (clinical contraindication to beta blockers documentation of reason - low BP, fluid overload, asthma, allergy, pt recently treated with IV positive inotropic agent, intolerance, other; provider prescribed a different beta blocker than those listed above), Patient Reasons patient declined, System Reasons HEART FAILURE/COMMENTS: CMS Quality Measures 2013 (01_08_14) Page 7

8 CORONARY ARTERY DISEASE CORONARY ARTERY DISEASE (CAD) MEASURES Age > 18 CAD diagnosis confirmed? t confirmed Other CMS approved reason See reference list for eligible diagnoses and synonyms LIPID CONTROL. Is patients LDL-C in range or appropriate plan of care in place for elevated LDL-C? NOTE: If lab unable to calculate LDL C due to high triglycerides, select NO below If more than one LDL-C performed, use most recent date in 2013 A prescribed statin combination drug (i.e. lovastatin/niacin (Advicor) meets requirements BUT niacin along does NOT meet the requirements of the measure LDL-C result < 100 mg/dl OR > 100 mg/dl with a documented plan of care, including, at a minimum, the prescription of a statin. Plan of care without a statin does not meet measure requirement Patient did not have an LDL-C performed: OR Patient had an LDL-C result > 100 mg/dl and did not have a documented plan of care. Plan of care must include, at a minimum, the prescription for a statin. Plan of care may include diet, exercise modifications or scheduled reassessment of LDL-C., Medical Reasons Patient not prescribed statin for medical reasons (allergy, intolerance, other), Patient Reasons t prescribed statin for patient reasons patient declined, System Reasons t prescribed statin for system reasons e.g. financial issues, other health system reason Does the CAD patient also have diabetes? If YES, answer last question Does the CAD patient have (or have they ever had) LVSD? (LVEF < 40% or documented as moderate or severe) IF YES, answer last question IF CAD patient also had either Diabetes and/or LVSD, were they prescribed ACE Inhibitor or ARB therapy at any time during 2013? (see reference list of list of ACE Inhibitors or ARB therapy), Medical Reasons e.g. allergy, intolerance, other medical reason, Patient Reasons Patient declined, System Reasons Lack of drug availability, other health system reasons CAD/COMMENT CMS Quality Measures 2013 (01_08_14) Page 8