1. Category C
Outcome Bundles for Hospitals, Clinics and Physician Practices
PROPOSED
June 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 - No points associated with this measure
Yellow Text - Required Measure
White Text – Points associated with this measure

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

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

6. B1: Care Transitions & Hospital Readmissions 6 pts
B Medication Reconciliation Post-Discharge (NQF 0097)
B 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)
B Risk Adjusted All-Cause Readmission (IT-3.22)
B INR Monitoring for Individuals on warfarin after hospital discharge
B 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)
B 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)
B Documentation of Current Medications in the Medical Record

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

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

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

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

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

12. D2: Pediatric Access to Specialty Care
REMOVED

13. D3: Pediatric Hospital Safety 6 pts
D Pediatric CLABSI
D Pediatric CAUTI
D Pediatric Surgical site infections (SSI)
D Pediatric Adverse Drug Events
D Pediatric Pressure Injuries

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

15. D5: Pediatric Chronic Disease Management: Diabetes
REMOVED

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

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

18. F2: Pediatric Dental 2 pts
F Dental Sealant: Children (IT-7.1)
F Dental Caries: Children
F Oral Evaluation: Children (IT-7.12)
F Preventive Services for Children at Elevated Caries Risk (IT-7.16)

19. G1: Palliative Care 6 pts
G Hospice and Palliative Care – Pain assessment (IT-13.1)
G Hospice and Palliative Care – Treatment Preferences (IT-13.2)
G 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)
G Advance Care Plan (NQF 0326)
G Patients Treated with an Opioid who are Given a Bowel Regimen (NQF 1617)
G Hospice and Palliative Care - Dyspnea Treatment (NQF 1638)
G Hospice and Palliative Care - Dyspnea Screening (NQF 1639)
G Patients with advanced Cancer screened for pain at outpatient visits

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

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

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

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

24. I1: Specialty Care 2 pts
I Assessment of Functional Status or QoL (Modified from NQF )
I Improvement in Functional Status or QoL (modified from PQRS 435)

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

26. 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

27. 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