PERFORMANCE MEASURE TECHNICAL SPECIFICATIONS 1. Rate of Emergency Department Visits The number of visits experienced by PACE participants to acute care hospital Emergency Departments, urgent care clinics, or equivalent outpatient healthcare facilities (not including the PACE Center clinic) requiring emergent evaluation by the facility s clinical specialists that does not result in an inpatient hospital day The sum of the number of ER visits for four (4) quarters Numerator Denominator The sum of member months for four (4) quarters/ 12 Exclusions Emergency visits to the PACE Center clinic; and Emergency visits to hospital Emergency Department, urgent care clinics or equivalent that result in inpatient admissions Domain Quality Measure Type Utilization Data Source Claims data ; EHR data file ; Tracking log of unscheduled emergency care outside the PACE clinic
2. Advance Care Planning Percentage of participants with documentation of Advance Directives Numerator Number of participants with written record of Advance Directives Denominator Total number of participants continuously enrolled within reporting period (e.g., within 3 months of enrollment and on an annual basis) Exclusions None Domain Quality Data Source EHR data file; medical record Supplemental Advance Directives includes any or all of the following: Information A properly executed Advance Health Care Directive including Power of Attorney for health care decisions A living will A written or oral statement by a participant on his or her treatment preferences documented in an electronic medical record or recorded in the form of a personal statement in paper copy placed in the medical record Discussion about Participant Wishes regarding treatment options and health wishes include, but is not limited to the following: Desire of the participant to choose whether a family members or close friends in the discussion of his/her condition and health wishes Explanation of participant s current health condition, diagnosis, and prognosis Explanation of life-prolonging measures, including cardiopulmonary resuscitation (CPR) endotracheal intubation and mechanical ventilation, tube feeding (chronic or temporary), and other measures pertinent to participant s current medical status. This includes the purpose and probable outcome of the treatment considered The participant s thoughts or concerns about designating another person to act as a participant s decision-making representative should the participant become unable to make health care decisions Explanation of Advance Health Care Directive including Power of Attorney for health care decisions and an opportunity to execute such a document Desire of the participant and/or participant s representative to discuss, modify, and review health wishes as the participant s medical condition changes over time 2
Numerator Denominator Exclusions Domain Measure Type Data Source Level of Analysis Frequency of Supplemental Information 3. Rate of Falls Resulting in Injury Total number of falls for PACE participants resulting in an Injury Severity Rating* level of III-V in all locations Number of participant falls with an Injury Severity Rating Level of III-V Number of falls in all locations Numerator: Falls with an Injury Severity Rating level of I or II Safety Outcome Falls report; incident report Participant Quarterly Injury analysis by severity levels enables clinical and administrative staff to profile both vulnerability of participants and effectiveness of safety programs. Fall (as defined in the PACE Level Two Guidance) is a sudden, often unexpected change in position, in which the person comes to rest unintentionally on the floor. Will require/include the following fields Participant ID Date of the fall Location of the fall Severity level of the fall *Severity Injury Ratings: Level I (None) = Participant had no injuries (no signs of symptoms) resulting from the fall; if an x-ray, CT scan or other post fall evaluation results in a finding of no injury Level II (Minor) = Resulted in application of dressing, cleaning wound, ice, limb evaluation, topical medication, pain, bruise or abrasion Level III (Moderate) = Resulted in suturing, application of steri-strips/skin glue in place of suturing, splint: possible, muscle/joint strain Level IV (Major) = Resulted in fracture, surgery, casting, traction or required neurological or internal injury consultation: possibly resulting in hospitalization: possibly resulting in permanent loss of function. Level V (Death) = Participant died as a result of injuries from the fall (not from pathologic events causing the fall) Locations of Fall: 1 PACE Center; 2 Participant home; 3 Nursing facility; 4 Assisting living; 5 Van transportation; 6 Other 3
Numerator Denominator Exclusions Domain Measure Type Data Source Level of Analysis Frequency of Supplemental Information 4. Number of Falls Number of falls resulting in an Injury Severity Rating* level of I V Number of falls in all locations Falls/1000 participants None Safety Process Falls report; incident report Participant Quarterly Fall, as defined in the PACE Level Two Guidance, is a sudden, often unexpected change in position, in which the person comes to rest unintentionally on the floor. *Severity Injury Ratings: Level I (None) = Participant had no injuries (no signs of symptoms) resulting from the fall; if an x-ray, CT scan or other post fall evaluation results in a finding of no injury Level II (Minor) = Resulted in application of dressing, cleaning wound, ice, limb evaluation, topical medication, pain, bruise or abrasion Level III (Moderate) = Resulted in suturing, application of steri-strips/skin glue in place of suturing, splint: possible, muscle/joint strain Level IV (Major) = Resulted in fracture, surgery, casting, traction or required neurological or internal injury consultation: possibly resulting in hospitalization: possibly resulting in permanent loss of function. Level V (Death) = Participant died as a result of injuries from the fall (not from pathologic events causing the fall) 4
5. Percentage of Eligible Participants who Received Flu Immunization Number of eligible participants who received flu immunization/number of participants who were eligible to receive flu immunization during the current flu season Eligible participants are enrollees who have not received flu immunization as of the first day of the current flu season and did not meet the exclusion criteria Numerator Number of eligible participants immunized for flu as of April 30 th Denominator Total number of participants as of April 30 th Exclusions Denominator: All enrolled participants who in the current flu season: Have documented medical contraindications per CDC guidelines Domain Immunizations/Preventive Care Measure Type Utilization Data Source EHR data file; medical record; immunization log Frequency of Annual (Seasonal flu period is Sep. 1 - Apr. 30) Supplemental 5b. Percentage of Declinations Measures Number of eligible participants who were offered flu immunization but were documented as refusing to be immunized or have signed a declination form 5c. Percentage of Contraindications Number of participants who have documented medical contraindications as defined by the CDC guidelines Title 6. Percentage of Eligible Participants who Received Pneumococcal Immunization Number of eligible participants who received a pneumococcal immunization in the last 10 years /number of participants who were eligible to receive pneumococcal immunization. Numerator Number of eligible participants immunized for pneumococcus during the reporting period Denominator Total number of participants during the reporting period Exclusions Denominator: All enrolled participants who during the reporting period: Have documented medical contraindications per CDC guidelines Domain Immunizations/Preventive Care Measure Type Utilization. Data Source EHR data file; medical record; immunization log Frequency of Semi-annual ( periods are Jan. 1 Jun. 30 and Jul.1 Dec.31) Supplemental Immunized is defined as PACE participants who have received a pneumococcal immunization in the last 10 years Information Eligible participants are enrollees who meet CDC guidelines for pneumococcal immunization but have not received pneumococcal immunization as of the last day of the reporting period and did not meet the denominator exclusion criteria 5
Numerator Denominator Exclusions 7. Pressure Ulcer Prevalence The proportion of participants with (Stage III, Stage IV or Unstageable) pressure ulcer(s) on the last day of the reporting period Number of participants with one or more Stage III (707.23), Stage IV (707.24) &/ or Unstageable (707.25) pressure ulcers on the last day of the reporting period. Acquired while enrolled in PACE Number of active participants enrolled on the last day of the quarter Numerator Exclusion: Pressure ulcers present on enrollment to the PACE organization Denominator Exclusion: Participants not active on last day of the reporting period Domain Quality Data Source Program-specific data source reported on standardized form provided by NPA Supplemental PRESSURE ULCER STAGING Information Stage III: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle is not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. Further description -- The depth of a stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep stage III pressure ulcers. Bone/tendon is not visible or directly palpable. Stage IV: Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present on some parts of the wound bed. Often include undermining and tunneling. Further description -- The depth of a stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis possible. Exposed bone/tendon is visible or directly palpable. Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green or brown) and/or eschar (tan, brown or black) in the wound bed. Further description -- Until enough slough and/or eschar is removed to expose the base of the wound, the true depth, and therefore stage, cannot be determined. Stable (dry, adherent, intact without erythema or fluctuance) eschar on the heels serves as "the body's natural (biological) cover" and should not be removed. Prevalence refers to the number of both new and old cases at any one time in the population, such as the proportion of patients in a long term care facility with pressure ulcers on a specified day--a cross-sectional view of the problem. 6
8. Depression Screening Performed During Enrollment Year Percentage of participants screened during initial enrollment for depression using a nationally recognized assessment tool (i.e., PHQ- 9, GDS-15, GDS-30, MDS, Cornell Scale ) Numerator Number of participants who were screened for depression (using a standardized depression screening tool) by day 30 after enrollment Denominator Number of participants enrolled for at least 30 days Exclusions None Domain Health and Well-Being Data Source EHR data file; claims data Title 9. Depression Screening Performed Annually Percentage of participants screened annually for depression using a nationally recognized assessment tool (i.e., PHQ-9, GDS-15, GDS-30, MDS, Cornell Scale ) Numerator Number of participants who were screened for depression (using a standardized depression screening tool) within the past 12 months Denominator Number of participants enrolled for a continuous 12 month period Exclusions None Domain Health and Well-Being Data Source EHR data file; claims data 7
10. 30-Day All Cause Acute Hospital Readmission The number of acute inpatient admissions for participants that were followed by an acute admission for any diagnosis within 30 days Numerator The number of acute inpatient admissions for participants that were followed by an acute admission for any diagnosis within 30 days Denominator All acute inpatient discharges for participants who had one or more discharges Exclusions Denominator Exclusions: Initial inpatient admission with discharge for death * Hospital admissions where the admission date is less than 24 hours Admission from an acute hospital to another acute hospital Psychiatric hospital admissions Domain Quality Measure Type Utilization. Data Source Claims data; EHR data file; standard electronic data file with necessary fields to capture required information Supplemental Will require/include the following fields Information PACE enrollment files Inpatient file: Participant ID Admission dates Discharge dates Discharge reason (i.e., death) Please note, the death date must match the discharge date in the enrollment file All final discharge diagnosis codes Final discharge diagnosis codes will be necessary for data drill down and will allow the identification of leading causes for readmissions in PACE at a PO, state, regional and national level. This will also provide the ability to identify notable practices used by POs to reduce readmissions. The second calendar day begins the clock and the day of discharge would be counted. *Any readmissions within 30 days resulting in death should be included in the denominator 8
11. Reconciled Medication List Percent of relevant participant transfers to the PACE organization s ambulatory setting who received medication reconciliation Numerator Number of participant transfers when a medication reconciliation is relevant and completed Denominator Number of participant transfers to a PACE organization receiving a participant transfer when a medication reconciliation is relevant Exclusions Numerator Exclusions: Setting of care that is not relevant to PACE providers Inpatient hospice (Part B) Dialysis administered medications Transfers to non-ambulatory non-part D covered settings regardless of level of PO provider involvement (i.e., acute inpatient or sub-acute rehab, skilled care) Short term skilled stays that converts to long term care is a level of care and not a site of care there are not included in this measure Domain Transitional Care Data Source EHR; medical record Supplemental Eligible providers who receive a participant from another setting of care that is relevant should perform a medication Information reconciliation to identify the most accurate medication list Relevant is defined as the transfer from a setting of care to the final ambulatory setting Inclusion is the ambulatory setting for PACE long term participants is the nursing home setting. Therefore long term care participants discharged from an acute setting back directly to their long term setting will be included in measure. 9