Category C Outcome Bundles for Hospitals, Clinics and Physician Practices PROPOSED June 2017

Point Assignments RHP 15 MINIMUM POINT THRESHOLDS (scale = 1 to 75) El Paso Children's Hospital 1 pt Providence Memorial Hospital 15 pts City of El Paso Department of Health 16 pts Sierra Providence East Medical Center 17 pts Emergence Health Network 31 pts Texas Tech University Health Sciences Center El Paso 31 pts Las Palmas – Del Sol Medical Center 46 pts University Medical Center of El Paso 75 pts

KEY Italicized Text - No points associated with this measure Yellow Text - Required Measure White Text – Points associated with this measure

A1: Improved Chronic Disease Management: Diabetes Care 15 pts A1-111 Comprehensive Diabetes Care: Eye Exam (retinal) performed (IT-1.12) A1-112 Comprehensive Diabetes Care: Foot Exam (IT-1.13) A1-113 Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) testing (NQF-0057) A1-115 Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) (IT-1.10) A1-116 Comprehensive Diabetes Care: Medical Attention for Nephropathy (IT-1.14) A1-207 Diabetes care: BP control (<140/90mm Hg) (IT-1.11) A1-208 Comprehensive Diabetes Care LDL-C Screening (IT-1.20) A1-247 Reduce Emergency Department visits for Diabetes (IT-9.4b) A1-321 Diabetic Foot & Ankle Care, Peripheral Neuropathy – Neurological Evaluation (eMeasure) (NQF-0417)

A2: Improved Chronic Disease Management: Heart Disease 15 pts A2-103 Controlling High Blood Pressure (IT-1.7) A2-104 Medical Assistance with Smoking and Tobacco Use Cessation (MSC) (IT-1.33) A2-147 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up A2-206 Cholesterol management for patients with cardiovascular conditions (IT-1.6) A2-208 Comprehensive Diabetes Care: LDL-C Screening (NQF 0063) A2-210 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented (PQRS 317) A2-246 Reduce Emergency Department visits for Selected Condition or: Congestive Heart Failure, Diabetes, Angina/Hypertension, Behavioral Health & Substance Abuse, COPD, or Dental (IT-9.4) A2-384 Hospital 30-Day, All-Cause, Risk Standardized Readmission Rate (RSRR): following Chronic Obstructive Pulmonary Disease (COPD) Hospitalization (CMS 1891)

B1: Care Transitions & Hospital Readmissions 6 pts B1-124 Medication Reconciliation Post-Discharge (NQF 0097) B1-141 Hospital 30-day all-cause risk-standardized readmission rate for selected conditions: heart failure hospitalization, coronary artery bypass graft (CABG) surgery, CHF, Diabetes, AMI, Stroke, COPD, Behavioral Health Substance (NQF 0330 / 2515) B1-217 Risk Adjusted All-Cause Readmission (IT-3.22) B1-351 INR Monitoring for Individuals on warfarin after hospital discharge B1-253 Care Transition: Transition Record with Specified Elements Received by Discharged Patients (Inpatient Discharges to Home/Self Care or Any Other Site of Care) (IT-9.9) B1-252 Care Transition: Transition Record with Specified Elements Received by Discharged Patients (Emergency Department Discharges to Ambulatory Care [Home/Self Care] or Home Health Care) (IT-9.8) B1-287 Documentation of Current Medications in the Medical Record

B2: Patient Navigation & ED Diversion 7 pts B2-242 Reduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) (IT-9.2) B2-352 Post-Discharge Appointment B2-354 Post Discharge Evaluation B2- 353 Proportion of Children with ED Visits fro Asthma with Evidence of Primary Care Connection Before the ED Visit B2-250 Reduce low acuity ED visits (IT-9.5) B2-251 Emergency department (ED) visits where patients left without being seen (IT-9.6) B2-246 Reduce Emergency Department visits for Selected Conditions: CHF, Diabetes, Angina/Hypertension, Behavioral Health & Substance Abuse, COPD, or Dental (IT-9.4)

C1: Primary Care Prevention - Healthy Texans 9 pts C1- 269 Preventive Care and Screening: Influenza Immunization (IT-12.6) C1-272 Adults (18+ years) Immunization status (IT-12.10) C1-280 Chlamydia Screening in Women (CHL) (IT-15.6) C1-285 Advance Care Plan C1-147 Preventative Care and Screening: Body Mass Index (BMI) Screening and Follow-Up C1- 268 Pneumonia vaccination status for older adults (IT-12.4) C1-113 Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) testing (NQF 0057) C1-389 Human Papillomavirus Vaccine (ages 14-26) C1-105 Preventative Care & Screening: Tobacco Use: Screening & Cessation Intervention (NQF 0028)

C2: Primary Care Prevention - Cancer Screening 9 pts C2-106 Cervical Cancer Screening (IT-12.2) C2-107 Colorectal Cancer Screening (IT-12.3) Annual cervical cancer screening or follow-up in high-risk women (New) C2-162 Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients C2-186 Breast Cancer Screening (IT-12.1) C2-199 Age Appropriate Screening Colonoscopy (PQRS #439) C2-274 Mammography follow-up rate (IT-12.13) C2-275 Abnormal Pap test follow-up rate (IT-12.15)

C3: Hepatitis C 5 pts C3-368 Hepatitus A Vaccination C3-202 Screening for Hepatocellular Carcinoma (HCC) in Patients with Hepatitis C Cirrhosis (PQRS #401) C3-203 One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk (PQRS #400) C3-311 Discussion and Shared Decision Making Surrounding Treatment Options (PQRS #390) C3-368 Hepatitus A Vaccination C3-369 Hepatitus B Vaccination C3-328 Appropriate Screening Follow-up for Patients Identified with Hepatitis C Virus (HCV) Infection (eMeasure)

D1: Pediatric Primary Care 13 pts D1-108 Childhood Immunization Status (CIS) (IT-12.9) D1-211 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (IT-1.29) D1-271 Tdap/TD MCV and HPV immunizations for Adolescents D1-301 Maternal Depression Screening D1-284 Appropriate Treatment for Children with Upper Respiratory Infection (URI) D1-212 Appropriate Testing for Children With Pharyngitis (IT-1.34) D1-237 Well-Child Visits in the First 15 Months of Life (6 or more visits) (IT-8.21) D1-238 Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (IT-8.22) D1- 240 Adolescent Well-Care Visits ** Behavioral Health Counseling for Childhood Obesity

D2: Pediatric Access to Specialty Care REMOVED

D3: Pediatric Hospital Safety 6 pts D3-330 Pediatric CLABSI D3-331 Pediatric CAUTI D3-333 Pediatric Surgical site infections (SSI) D3-334 Pediatric Adverse Drug Events D3-335 Pediatric Pressure Injuries

D4: Pediatric Chronic Disease Management: Asthma 14 pts D4-139 Asthma Admission Rate (ages 5 -18) D4-173 Medication Management for People with Asthma (IT-1.31) D4-376 Asthma Quality of Life Assessment Tool (Peds QL) D4-209 Asthma Percent of Opportunity Achieved (IT-1.22) D4-249 Pediatric/Young Adult Asthma Emergency Department Visits D4-375 Asthma: Pharmacologic Therapy for Persistent Asthma

D5: Pediatric Chronic Disease Management: Diabetes REMOVED

E1: Improved Maternal Care 13 pts E1-148 Elective Delivery (Patients with elective vaginal deliveries or elective cesarean) (IT-8.3) E1-150 Cesarean Section (Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean section) (IT-8.6) E1-151 Antenatal Steroids (IT-8.4) E1-193 Contraceptive Care – Postpartum Women Ages 15–44 (CCP-AD)* E1-378 Appropriate Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision – Cesarean section (NQF 0472) E1-232 Timeliness of Prenatal/Postnatal Care (IT-8.1) E1-235 Post-Partum Follow-Up and Care Coordination (PQRS #336) (IT-8.19) E1-300 Behavioral Health Risk Assessment (for Pregnant Women) (BHRA-CH) (IT-8.27) ** Preeclampsia Measure

F1: Improved Access to Adult Dental Care 6 pts F1- 226 Chronic Disease Patients Accessing Dental Services (IT-7.8) F1-227 Dental Caries: Adults F1-105 Preventative Care & Screening: Tobacco Use: Screening & Cessation Intervention (NQF 0028) ** Oral Cancer Screening

F2: Pediatric Dental 2 pts F2-224 Dental Sealant: Children (IT-7.1) F2-225 Dental Caries: Children F2-229 Oral Evaluation: Children (IT-7.12) F2-231 Preventive Services for Children at Elevated Caries Risk (IT-7.16)

G1: Palliative Care 6 pts G1-276 Hospice and Palliative Care – Pain assessment (IT-13.1) G1-277 Hospice and Palliative Care – Treatment Preferences (IT-13.2) G1-278 Beliefs and Values - Percentage of hospice patients with documentation in the clinical record of a discussion of spiritual/religious concerns or documentation that the patient/caregiver did not want to discuss. (IT-13.5) G1-285 Advance Care Plan (NQF 0326) G1-361 Patients Treated with an Opioid who are Given a Bowel Regimen (NQF 1617) G1-362 Hospice and Palliative Care - Dyspnea Treatment (NQF 1638) G1-363 Hospice and Palliative Care - Dyspnea Screening (NQF 1639) G1-364 Patients with advanced Cancer screened for pain at outpatient visits

H1: Integration of Behavioral Health in a Primary Care Setting 8 pts H1-255 Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication (ADD-CH) (NQF 0108) H1-286 Depression Remission at Six Months H1-105 Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention NQF#0028 H1-317 Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling ** Engagement in Integrated Behavioral Health H1-146 Screening for Clinical Depression and Follow-Up Plan (CDF-AD) NQF#0418

H2: Behavioral Health and Appropriate Utilization 15 pts H2-160 Follow-Up After Hospitalization for Mental Illness (IT-1.18) H2-305 Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-CH) (NQF 1365) H2-216 Risk Adjusted Behavioral Health/ Substance Abuse 30-Day Readmission Rate H2-387 Reduce Emergency Department visits for Behavioral Health and Substance Abuse H2-259 Assignment of Primary Care Physician to Individuals with Schizophrenia (IT-11.13) H2-265 Housing Assessment for Individuals with Schizophrenia (IT-11.28) H2-266 Independent Living Skills Assessment for Individuals with Schizophrenia (IT-11.29) H2-316 Alcohol Screening and Follow-up for People with Serious Mental Illness H2-319 Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (eMeasure)

H3: Chronic Non-Malignant Pain Management 7 pts H3-257 Care Planning for Dual Diagnosis (IT-11.9) H3-287 Documentation of Current Medications in the Medical Record (NQF 0419) H3-288 Pain Assessment and Follow-up (IT-1.27) ** Patients on Long Term Opioid Therapy checked-in prescription drug monitoring programs (PDMPs) H3-144 Screening for Clinical Depression and Follow-Up Plan (CDF-AD) for individuals with a diagnosis of chronic pain (NQF 0418) H3-197 Use of Opioids at High Dosage – modified denominator (NQF 2940) ** Treatment of Chronic Non-Malignant Pain Management with Multimodal Therapy

H4: Integrated Care for People with Serious Mental Illness 3 pts H4-260 Annual Physical Exam for persons with Mental Illness H4-182 Diabetes Screening for People with Schizophrenia or Bipolar Disorder who are using Antipsychotic Medications (SSD-AD) (NQF 1932) H4-258 Cardiovascular monitoring for people with cardiovascular disease and schizophrenia (SMC) (NQF 1933)

I1: Specialty Care 2 pts I1-385 Assessment of Functional Status or QoL (Modified from NQF 0260-2624) I1-386 Improvement in Functional Status or QoL (modified from PQRS 435)

J1: Hospital Safety 8 pts J1-218 Central line-associated bloodstream infections (CLABSI) rates (IT-4.2) J1-219 Catheter-associated Urinary Tract Infections (CAUTI) rates (IT-4.3) J1-220 Surgical site infections (SSI) rates (IT-4.4) J1-221 Patient Fall Rate (IT-4.5) J1-222 Severe Sepsis and Septic Shock: Management Bundle (IT-4.10) J1-372 National Healthcare Safety Network (NHSN) Facility-Wide Inpatient Hospital-onset Methicillin-Resistant Staphylococcus Aureus (MRSA) Bacteria Outcome Measure (NQF 1716)

K1: Rural Preventative Care Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) (IT-1.10) Comprehensive Diabetes Care: Foot Exam (IT-1.13) ED throughput Measure bundle (IT-9.10) Controlling High Blood Pressure (IT-1.7) Pneumonia vaccination status for older adults Reduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) Advance Care Plan

K2: Rural Emergency Care Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) (IT-1.10) Comprehensive Diabetes Care: Foot Exam (IT-1.13) ED throughput Measure bundle (IT-9.10) Controlling High Blood Pressure (IT-1.7) Pneumonia vaccination status for older adults Reduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) Advance Care Plan