1. Outcome Bundles PROPOSED May 2017
Category C
DRAFT
Outcome Bundles
PROPOSED
May 2017

2. 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

3. KEY Italicized Text - Measure will most likely be removed from bundle
Orange Text - Emergency Department Measures
Blue Text – Hospital Measures
White Text – Outpatient Measures
Green Text – Additionally Proposed Measures

4. A1: Improved Chronic Disease Management: Diabetes Care
Comprehensive Diabetes Care: Eye Exam (retinal) performed (IT-1.12)
Comprehensive Diabetes Care: Foot Exam (IT-1.13)
Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) testing (New)
Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) (IT-1.10)
Comprehensive Diabetes Care: Medical Attention for Nephropathy (IT-1.14)
Diabetes Care: HbA1c Control < 8.0% (New)
Diabetes care: BP control (<140/90mm Hg) (IT-1.11)
Comprehensive Diabetes Care LDL-C Screening (IT-1.20)
Ambulatory Care Sensitive Conditions Admissions Rate (IT-2.21)
Reduce Emergency Department visits for Diabetes (IT-9.4b)
Diabetic Foot & Ankle Care, Peripheral Neuropathy – Neurological Evaluation (eMeasure) (New)
Diabetic Foot & Ankle Care, Ulcer Prevention – Evaluation of Footwear (eMeasure) (New)

5. A1: Additional Measures Proposed
Adult Kidney Disease: Hemodialysis Adequacy (NQF 0323)
LDL-C Control <100 mg/dL (NQF 0064)
Diabetes Long-Term Complications Admission Rate (NQF 0274)
Diabetes Short Term Complications Admission Rate (NQF 0272)
Uncontrolled Diabetes Admission Rate (NQF 0638)
Adherence to Statins for Individuals with Diabetes Mellitus (NQF 0545)
Diabetic Foot Ulcer (DFU) Healing or Closure (CDR-2)

6. A2: Improved Chronic Disease Management: Heart Disease
Comprehensive Diabetes Care LDL-C Screening
Controlling High Blood Pressure (IT-1.7)
Medical Assistance with Smoking and Tobacco Use Cessation (MSC) (IT-1.33)
Cholesterol management for patients with cardiovascular conditions (IT-1.6)
Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up
Reduce Emergency Department visits for Congestive Heart Failure (IT-9.4a)
Reduce Emergency Department visits for Angina and Hypertension (IT-9.4d)
Ambulatory Care Sensitive Conditions Admissions Rate
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented (PQRS 317)

7. A2: Additional Measures Proposed
Adult Kidney Disease: Hemodialysis Adequacy (NQF 0323)
Hospital 30-Day, All-Cause, Risk Standardized Readmission Rate (RSRR): following Chronic Obstructive Pulmonary Disease (COPD) Hospitalization (CMS 1891)
Chronic Stable Coronary Artery Disease: Lipid Control – NQF 0074
Annual Monitoring for Patients on Persistent Medications – NQF 2371
Hypertension Admission Rate - PQI 7 – NQF 0276:
Angina without Procedure - PQI 13 – NQF 0282
Congestive Heart Failure Rate PQI 8 – NQF 0277
Adult current smoking prevalence – NQF 2020
Cardiac Rehab from Inpatient – NQF 0642
Cardiac Rehab from Outpatient – NQF 0643
Post Discharge Eval for HF patients – NQF 2443
LV EF assessment – NQF 0079
ACE/ARB for LVSD – NQF 0081/2907/3050
Beta Blocker Therapy for LVSD prescribed at discharge – NQF 2438
MI - Use of Beta Blocker Therapy – NQF 0613
Ischemic Vascular Disease BP control – NQF 0073
Ischemic Vascular Disease Aspirin or other antiplatelet – NQF 0068
Persistence of Beta Block after a Heart Attack – NQF 0071
Troponin results in ED for AMI/chest pain patients received within 60 minutes of arrival - NQF 0660
Optimal Vascular Care bundle – NQF 0076
Ace Inhibitor / Angiotensin Receptor Blocker Use and Persistence Among Members with Coronary Artery Disease at High Risk for Coronary Events – NQF 0551
Coronary Artery Stenting: Evaluation of Vital Status and NIH Stroke Scale at F/U – NQF 2396
Adherence to Statin Therapy for Individuals with CAD - NQF 0543

8. B1: Care Transitions & Hospital Readmissions
Medication Reconciliation Post-Discharge (New)
Risk Adjusted Behavioral Health /Substance Abuse 30-day Readmission Rate (IT-3.15)
Risk Adjusted All-Cause Readmission (IT-3.22)
Influenza Immunization- Inpatient (IT-12.7)
Transition Record with Specified Elements Received by Discharged Patients (Inpatient Discharges to Home/Self Care or Any Other Site of Care) (IT-9.9)
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)

9. B1: Additional Measures Proposed
Hospital 30-day all-cause unplanned risk-standardized readmission rate following CABG (NQF 2515)
3-Item Care Transition Measure (CTM-3) (NQF 228)
30-Day CHF Readmission (NQF 0330)
Medication Reconciliation: Number of unintentional medication discrepancies per patient (NQF 2456)
Rehospitalization during the first 30 days of home health (NQF 2380)
Documentation of Current Medications in the medical record (NQF 419)
INR Monitoring for Individuals on Warfarin after Hospital Discharge (NQF 2732)

10. B2: Patient Navigation & ED Diversion
Reduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) (IT-9.2)
Reduce Pediatric Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) (IT-9.3)
Emergency Department (ED) visits per 100,000 (IT-9.2a)
Reduce Emergency Department visits for Behavioral Health/Substance Abuse (IT-9.4.e)
Pediatric/Young Adult Asthma Emergency Department Visits (IT-9.4.h)
Reduce low acuity ED visits (IT-9.5)
Emergency department (ED) visits where patients left without being seen (IT-9.6)
Reduce Emergency Department visits for Chronic Obstructive Pulmonary Disease (IT-9.4.f)

11. B2: Additional Measures Proposed
Heart Failure: Post-Discharge Appointment for Heart Failure Patients (NQF 2455)
Post-Discharge Appointment for Heart Failure Patients (NQF 2439)
Proportion of Children with ED Visits for Asthma with Evidence of Primary Care Connection Before the ED Visit (NQF 3170)
Post-Discharge Evaluation for Heart Failure Patients (NQF 2443)
Left Without Being Seen (NQF 0499)
Median Time from ED Arrival to ED Departure for Admitted ED Patients (IT-9.10) (NQF 0495)
(Median) Admit Decision Time to ED Departure Time for Admitted Patients (IT-9.10) (NQF 0497)
Emergency Transfer Communication Measure (NQF 0291)
L1A: Screening for Preferred Spoken Language for Healthcare (NQF 1824)

12. C1: Primary Care Prevention - Healthy Texans
Preventive Care and Screening: Influenza Immunization (IT-12.6)
Adults (18+ years) Immunization status (IT-12.10)
Chlamydia Screening in Women (CHL) (IT-15.6)
Acute Otitis External Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use (New)
Advance Care Plan (New)
Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention (NQF# 0028)
Flu Vaccinations for Adults Ages 18 and Older (New)
Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis (NQF 0058)
Chlamydia Screening and Follow Up (New)
Pneumonia vaccination status for older adults (IT-12.4)
Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up (NQF# 0421 / 2828 eMeasure)
Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) testing (NQF 0057)

13. C1: Additional Measures Proposed
HPV Vaccination

14. C2: Primary Care Prevention - Cancer Screening & Follow Up
Cervical Cancer Screening (IT-12.2)
Colorectal Cancer Screening (IT-12.3)
Annual cervical cancer screening or follow-up in high-risk women (New)
Appropriate Follow-Up Interval for Normal Colonoscopy in Average Risk Patients (New)
Breast Cancer Screening (IT-12.1)
Age Appropriate Screening Colonoscopy (PQRS #439)
Mammography follow-up rate (IT-12.13)
Abnormal Pap test follow-up rate (IT-12.15)
High-risk Colorectal Cancer Follow-up rate within one year (IT-12.16)

15. C2: Additional Measures Proposed
Cervical cancer screening: percentage of women with a high-grade Pap test result who had a follow-up colposcopy within 6 weeks of the index Pap test report date
Colonoscopy Interval for Patients with a History of Adenomatous Polyps – Avoidance of Inappropriate Use (NQF 0659)
Human Papillomavirus for Female Adolescents – HPV (NQF 1959)

16. C3: Hepatitis C (New)
Screening for Hepatocellular Carcinoma (HCC) in Patients with Hepatitis C Cirrhosis (PQRS #401)
Hepatitis C: One-Time Screening for Hepatitis C Virus (HCV) for Patients at Risk (PQRS #400)
Hepatitis C: Discussion and Shared Decision Making Surrounding Treatment Options (PQRS #390)
Annual Hepatitis C Virus (HCV) Screening for Patients who are Active Injection Drug Users (eMeasure)
Appropriate Screening Follow-up for Patients Identified with Hepatitis C Virus (HCV) Infection (eMeasure)

17. C3: Additional Measures Proposed
Hepatitis A Vaccination (NQF 0399)
Hepatitis B Vaccination (NQF 0400)

18. D1: Pediatric Primary Care
Childhood Immunization Status (CIS) (IT-12.9)
Non-recommended Cervical Cancer Screening in Adolescent Females (NCQA HEDIS)
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (IT-1.29)
HbA1c Testing for Pediatric Patients
Children & Adolescents’ Access to Primary Care Practitioners
Tdap/TD and MCV immunizations for Adolescents
Chlamydia Screening and Follow-Up
Appropriate Treatment for Children with Upper Respiratory Infection (URI)
Appropriate Testing for Children With Pharyngitis (IT-1.34)
Developmental Screening in the First Three Years of Life (IT-8.20)
Well-Child Visits in the First 15 Months of Life (6 or more visits) (IT-8.21)
Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life (IT-8.22)
Adolescent Well-Care Visits
HPV Vaccine for Female Adolescents
Acute Otitis Externa: Systemic Antimicrobial Therapy – Avoidance of Inappropriate Use
Audiological Evaluation no later than 3 months of age

19. D1: Additional Measures Proposed
Depression Remission at 6 and 12 Months for ages 12 years and older (NQF 0710)
Behavioral Health Counselling for Childhood Obesity

20. D2: Pediatric Access to Specialty Care
Third next available appointment (IT-1.1)
Functional Outcome Assessment (New)
Audiological Evaluation no later than 3 months of age
Improvement in Quality of Life (Quality of Life Assessment Tool: PedsQL or AQoL) (IT-10.1a)

21. D2: Additional Measures Proposed
PedsQL Arthritis Module
PedsQL Asthma Module
PedsQL Brain Tumor Module
PedsQL Cardiac Module
PedsQL Cancer Module
PedsQL Cerebral Palsy Module
PedsQL Cognitive Functioning Scale
PedsQL Diabetes Module
PedsQL Duchenne Muscular Dystrophy Module
PedsQL End Stage Renal Module
PedsQL Eosinophilic Esophagitis Module
PedsQL Gastrointestinal Symptoms Module
PedsQL Neuromuscular Module
PedsQL Sickle Cell Module
PedsQL Rheumatology Module
PedsQL Stem Cell Transplant Module
PedsQL Transplant Module

22. D3: Pediatric Hospital Safety
National Healthcare Safety Network (NHSN) Central line-associated Bloodstream Infection (CLABSI) Outcome Measure (IT-4.2 For Pediatric Age Range)
Pediatric CLABSI (New)
Pediatric CAUTI (New)
Pediatric Falls (New)
Pediatric Surgical site infections (SSI) (New)
Pediatric Adverse Drug Events (New)
Pediatric Pressure Injuries (New)
Pediatric Venous Thromboembolism (New)

23. D3: Additional Measures Proposed
Newborn ventilator associated PNA (NQF 0140)

24. D4: Pediatric Chronic Disease Management: Asthma
Asthma in Younger Adults Admission Rate (PQI15-AD)
Medication Management for People with Asthma (IT-1.31)
Asthma Medication Ratio (New)
Asthma Percent of Opportunity Achieved (IT-1.22)

25. D4: Additional Measures Proposed
Asthma: Pharmacologic Therapy for Persistent Asthma (NQF 0047)
Asthma pediatric quality of life survey

26. D5: Pediatric Chronic Disease Management: Diabetes
Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) (Modified for a pediatric population) IT-1.10 (Pediatric)
Diabetes Care: HbA1c Control < 8.0%
Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents
Hemoglobin A1c (HbA1c) Testing for Pediatric Patients
Reduce Emergency Department visits for Diabetes

27. D5: Additional Measures Proposed
Pediatric quality of life survey - Diabetes

28. E1: Improved Maternal Care
Screening for Clinical Depression and Follow-Up Plan (CDF-AD) (IT-1.8)
Elective Delivery (Patients with elective vaginal deliveries or elective cesarean) (IT-8.3)
Cesarean Section (Nulliparous women with a term, singleton baby in a vertex position delivered by cesarean section) (IT-8.6)
Antenatal Steroids (IT-8.4)
Exclusive Breast Milk Feeding (IT-8.18)
Frequency of Ongoing Prenatal Care (IT-8.5)
Contraceptive Care – Postpartum Women Ages 15–44 (CCP-AD)*
Preventative Care & Screening: Tobacco Use: Screening & Cessation Intervention (NQF 0028)
Controlling High Blood Pressure (NQF 0018)
Timeliness of Prenatal/Postnatal Care (IT-8.1)
Percentage of Low Birth- weight births (IT-8.2)
Pre-term birth rate (IT-8.12)
Post-Partum Follow-Up and Care Coordination (PQRS #336) (IT-8.19)
Behavioral Health Risk Assessment (for Pregnant Women) (BHRA-CH) (IT-8.27)
Timeliness of Prenatal Care (PPC-CH) (New)
Maternity Care: Elective Delivery or Early Induction Without Medical Indication at >= 37 and < 39 Weeks (Overuse) (PQRS #335 )
Medical Assistance with Smoking & Tobacco Use Cessation (modified denominator) (NQF 0027 modified)

29. E1: Additional Measures Proposed
Incidence of Episiotomy (NQF 0470)
Appropriate Prophylactic Antibiotic Received Within One Hour Prior to Surgical Incision – Cesarean section (NQF 0472)
Unexpected complications of term newborns (NQF 0716)
Contraceptive Care - Most & Moderately Effective Methods (NQF 2903)
Contraceptive Care - Access to LARC (NQF 2904)

30. F1: Improved Access to Adult Dental Care
Chronic Disease Patients Accessing Dental Services (IT-7.8)
Cavities: Adults (IT-7.10)
Reduce Emergency Department visits for Dental Conditions (IT-9.4.i)

31. F1: Additional Measures Proposed
Preventative Care & Screening: Tobacco Use: Screening & Cessation Intervention (NQF 0028)
Oral Evaluation: Adults
Pain Assessment and Follow-up (IT-1.27)
Preventative Care & Screening: Oral Cancer Screening

32. F2: Pediatric Dental Dental Sealant: Children (IT-7.1)
Cavities: Children (IT-7.2)
Utilization of Services: Children (IT-7.11)
Oral Evaluation: Children (IT-7.12)
Prevention: Topical Fluoride Intensity for Children at Elevated Caries Risk (IT-7.15)
Preventive Services for Children at Elevated Caries Risk (IT-7.16)
Per Member Per Month Cost of Clinical Services (PMPM Cost): Children (IT-7.20)
Prevention: Dental Sealants for 6-9 Year-Old Children at Elevated Caries Risk (IT-7.13)
Percentage of Eligibles Who Received Preventive Dental Services (PDENT-CH)

33. F2: Additional Measures Proposed
Preventative Care & Screening: Tobacco Use
Pain Assessment and Follow-Up
Preventative Care & Screening: Oral Cancer Screening

34. G1: Palliative Care
Hospice and Palliative Care – Pain assessment (IT-13.1)
Hospice and Palliative Care – Treatment Preferences (IT-13.2)
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)
Palliative Care: Percent of patients who have documentation in the medical record that an interdisciplinary family meeting was conducted on or before day five of ICU admission (IT-13.6)
Proportion of patients who died from cancer receiving chemotherapy in the last 14 days of life
Proportion of patients who died from cancer with more than one emergency department visit in the last 30 days of life (IT-13.3)
Proportion of patients who died from cancer admitted to the ICU in the last 30 days of life (IT-13.4)
Proportion of patients who died from cancer not admitted to hospice
Proportion of patients who died from cancer admitted to hospice for less than 3 days
Advance Care Plan (NQF 0326)

35. G1: Additional Measures Proposed
Patients Treated with an Opioid who are Given a Bowel Regimen (NQF 1617)
Hospice and Palliative Care - Dyspnea Treatment (NQF 1638)
Hospice and Palliative Care - Dyspnea Screening (NQF 1639)
Patients with Advanced Cancer Screened for Pain at Outpatient Visits (NQF 1628)
Documentation of emotional or psychosocial needs
Social Work Psychosocial Assessment
Screen for Complicated Grief and Bereavement
Screen for Anxiety and Depression
Proportion not admitted to hospice - NQF 0215
Comfortable Dying: Pain Brought to a Comfortable Level within 48 hours of Initial Assessment (NQF 0209)
Hospice and Palliative Care-- Pain Screening (NQF 1634)
Hospitalized Patients Who Die and Expected Death with an ICD that has Been Deactivated (NQF 1625)
Inclusion of symptoms beyond pain

36. H1: Integration of Behavioral Health in a Primary Care Setting
Depression Remission at 12 Months (IT-1.9)
Depression Response at Twelve Months- Progress Towards Remission
Depression Remission at Six Months
Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention NQF#0028
Screening for Clinical Depression and Follow-Up Plan (CDF-AD) NQF#0418
Substance Use Screening and Intervention Composite
Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling
Depression Utilization of the PHQ-9 Tool (eMeasure)
Medical Assistance with Smoking and Tobacco Use Cessation (MSC) - Modified Denominator NQF#0027 (Modified)

37. H1: Additional Measures Proposed
Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication (ADD-CH) (NQF 0108)
Gains in Patient Activation (PAM) Scores at 12 Months (NQF 2483)
Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (NQF 1932)
Use of First-Line Psychosocial Care for Children and Adolescents on Antipsychotics (APP-CH)* (NQF 2801)
Adherence to chronic medications (NQF 0542)
Annual Physical Exam for Persons with Mental Illness

38. H2: Behavioral Health and Appropriate Utilization
Follow-Up After Hospitalization for Mental Illness (IT-1.18)
Adherence to Antipsychotics for Individuals with Schizophrenia (SAA-AD) (IT-11.5)
Diabetes Screening for People With Schizophrenia or Bipolar Disorder Who Are Using Antipsychotic Medications (SSD-AD) (IT-11.10)
Follow-Up After Discharge from the Emergency Department for Mental Health or Alcohol or Other Drug Dependence (FUA-AD)*
Diabetes Care for People with Serious Mental Illness: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) (HPCMI-AD)*
Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons (IT-9.1)
Cardiovascular monitoring for people with cardiovascular disease and schizophrenia (SMC) (IT-11.12)
Assignment of Primary Care Physician to Individuals with Schizophrenia (IT-11.13)
Annual Physical Exam for Persons with Mental Illness (IT-11.14)
Housing Assessment for Individuals with Schizophrenia (IT-11.28)
Independent Living Skills Assessment for Individuals with Schizophrenia (IT-11.29)
Alcohol Screening and Follow-up for People with Serious Mental Illness
Adult Major Depressive Disorder (MDD): Suicide Risk Assessment (eMeasure)
Reduce low acuity ED Visits
Risk Adjusted Behavioral Health/ Substance Abuse 30-Day Readmission Rate

39. H2: Additional Measures Proposed
Follow-Up After Hospitalization for Mental Illness: Ages 6 to 20 (FUH-CH) (NQF 0576)
Child and Adolescent Major Depressive Disorder (MDD): Suicide Risk Assessment (SRA-CH) (NQF 1365)

40. H3: Chronic Non-Malignant Pain Management
Care Planning for Dual Diagnosis (IT-11.9)
Documentation of Current Medications in the Medical Record
Pain Assessment and Follow-up (IT-1.27)
Risk Adjusted Behavioral Health/Substance Abuse 30-Day Readmission Rate
Reduce Emergency Department Visits for Behavioral Health/Substance Abuse
Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (IET) (IT-11.8)
Use of Opioids at High Dosage – modified denominator
Initiation of Depression Treatment (IT-11.7)
Hospice and Palliative Care – Pain Assessment (NQF 1637)

41. H3: Additional Measures Proposed
No additional measures have been proposed thus far.

42. I1: Access to Specialty Care
Third next available appointment (IT-
Functional Outcome Assessment
Improvement in Quality of Life (Quality of Life Assessment Tool: PedsQL or AQoL)

43. I1: Additional Measures Proposed
Communication between Primary Care and Specialty Provider
Language Services: Percent of Patients served (NQF 1821)

44. J1: Hospital Safety
Central line-associated bloodstream infections (CLABSI) rates (IT-4.2)
Catheter-associated Urinary Tract Infections (CAUTI) rates (IT-4.3)
Surgical site infections (SSI) rates (IT-4.4)
Patient Fall Rate (IT-4.5)
Severe Sepsis and Septic Shock: Management Bundle (IT-4.10)
Falls: Screening, Risk-Assessment, and Plan of Care to Prevent Future Falls (IT-4.19)

45. J1: Additional Measures Proposed
NQF List of Serious Reportable Events (SREs)
Clostridium Difficile Infection (CDI)- NQF1717
Methicillin Resistant Staphylococcus Aureus (MRSA)- NQF0147,1716
Acute Myocardial Infarction (AMI) Mortality Rate- NQF0730
Pneumonia Mortality Rate (PN)- NQF0231
PSI 6- Iatrogenic Pneumothorax- NQF0346
PSI 9- Perioperative Hemorrhage- NQF2909
PSI 11- Post Operative Respiratory Rate- NQF Perioperative PE or DVT- NQF0450
PSI 14- Perioperative Wound Dehiscence- NQF NQF 1821 (L2: Patients Receiving Language Services Supported by Qualified Language Services Providers)

46. K1: Rural Hospital 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

47. K1: Additional Measures Proposed
Documentation of Current Medications in the Medical Record
Admit Decision Time to ED Departure Time for Admitted Patients
Falls: Screening, Risk-Assessment, and Plan of Care to Prevent Future Falls
HCAHPS (Care transitions and communications)
Preventive Care and Screening: Influenza Immunization
Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention
Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented
Health Literacy
Emergency Department Communication
Maternal Depression Screening
Preventive Care and Screening: Screening for Clinical Depression and Follow-Up Plan