1. Redwood Community Care Organization Data Capture for ACO Quality Measures

2. Essential Resources http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO-NarrativeMeasures- Specs.pdf http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/sharedsavingsprogram/Downloads/ACO-NarrativeMeasures- Specs.pdf http://www.rchc.net/download/ecw-aco-quick-reference-setup-guide-november-2013/

3. ACO 1-7 CAHPS https://cahps.ahrq.gov/

4. ACO 8-11 – Claims Data

5. ACO 12 – Medication Reconciliation Denominator: All ACO patients discharged from inpatient facility within 30 days of the visit Numerator: Medications reconciled Exclusions: psych admits, rehab admits & AMA

6. ACO 12 – Medication Reconciliation

7. ACO 13 – Fall Risk Assessment Denominator: All ACO Patients > 65 yoa with an office visit in the reporting year Numerator: Structured data fall screening completed Exclusions: not ambulatory (use CPT code 3288F with 1P)

8. Future Integration of fall risk assessment Smartform ($5000) eClincalform ($1500) Structured data (free)

9. ACO 14 – Influenza Vaccine Denominator: ACO patients > 6 months of age with an office visit between 10/1 – 3/31 Numerator: Patients who received a flu vaccine (CVX codes must be correct) Exclusions: contraindications (V15.03 or 4037F-2P)

10. ACO 15 – Pneumonia Vaccine Denominator: All ACO Patients > 65 yoa Numerator: Patients who have ever received a penumococcal vaccine (CVX codes must be correct) Exclusions: Contraindications documented with CPT code 4040F-1P

11. ACO 16 – BMI Measurement & f/u Denominator: All ACO Patients > 18 yoa Numerator: Patients with a documented BMI and follow-up plan if the BMI is abnormal Exclusions: Palliative care, pregnancy (V66.5 or any pregnancy ICD code) BMI normal? Included in numerator f/u docume nted? Included in numerator Not included in numerator Yes No

12. ACO 16 – BMI Measurement & f/u

13. ACO 17 – Tobacco Screening and cessation counseling Denominator: All ACO Patients > 18 yoa Numerator: Patients who have been screened for tobacco use and if they do use tobacco have received cessation counseling or prescription for tobacco cessation medication Exclusions: none Tobacco Use? Included in numerator Documented counseling or med RX? Included in numerator Not included in numerator No Yes No

14. ACO 17 – Tobacco Screening and cessation counseling

16. ACO 18 – Depression Screening and follow-up Denominator: All ACO Patients > 18 yoa Numerator: Patients who have been screened for depression and have had follow up documented or medication rx for those who screen positive Exclusions: depression/bipolar codes for those not screened Pos depressi on screen? Included in numerator Documented f/u or med RX? Included in numerator Not included in numerator No Yes No

17. ACO 18 – Depression Screening and follow-up

20. ACO 19 – Colon Cancer Screening Denominator: All ACO Patients 50 – 75 yoa Numerator: Patients who have been screened for colon cancer by colonoscopy, sigmoidoscopy or FOBT test. Exclusions: colectomy (by icd code)

21. ACO 19 – Colon Cancer Screening

22. ACO 20 – Breast Cancer Screening Denominator: All ACO female patients 40 – 69 yoa Numerator: Patients who have been screened for breast cancer with mammography Exclusions: mastectomy (by icd code)

23. ACO 21 – Blood Pressure Screening and follow-up Denominator: All ACO patients > 18 yoa Numerator: Patients who have been screened for high blood pressure and for those with prehypertension or new hypertension have a documented follow-up plan. Exclusions: diagnosis of hypertension if not screened (by icd code) BP normal? Included in numerator f/u plan or med Rx documente d? Included in numerator Not included in numerator Yes No (prehypertension or HTN values) No

24. ACO 21 – Blood Pressure Screening and follow-up

26. ACO 22 – 26 – Diabetic all or nothing Denominator: All ACO patients 18 – 75 yoa with a diagnosis of DM that have been seen twice during the reporting year Numerator: A1c <8.0 (Loinc code) LDL <100 (Loinc code) BP < 140/90 (Vitals) Not a tobacco user (Structured data) Aspirin use (Medication class antiplatelet) Exclusions: pregnancy, polycystic ovaries, gestational DM, steroid induced DM (by icd code) – for the asa measure also exclude (GI bleed, on warfarin)

27. ACO 22 – 26 – Diabetic all or nothing

31. Any Antiplatelet Rx meets the requirement for the numerator

32. ACO 27 – Diabetes Control of A1c Denominator: All ACO patients 18 – 75 yoa with a diagnosis of DM Numerator: Patients who’s last A1c was >9.0% Exclusions: pregnancy, polycystic ovaries, gestational DM, steroid induced DM (by icd code)

33. ACO 28 – Controlling High Blood Pressure Denominator: All ACO patients 18 – 84 yoa with a diagnosis of HTN Numerator: Patients who’s most recent BP was <140/90 Exclusions: pregnancy, ESRD (by icd code)

34. ACO 29 – IVD Lipid panel and control Denominator: All ACO patients > 18 yoa, with the diagnosis of ischemic vascular disease, h/o MI, PCI or CABG (by ICD code) Numerator: Patients who’s BOTH received a lipid panel (complete panel) in the measurement year and who’s most recent LDL was < 100 Exclusions: none *LOINC codes must be correct

35. ACO 30 – IVD use of aspirin or other antithrombotic Denominator: All ACO patients > 18 yoa, with the diagnosis of ischemic vascular disease, h/o MI, PCI or CABG (by ICD code) Numerator: Patients who are taking aspirin or antithrombotic medication Exclusions: GI bleed, on warfarin Any Antiplatelet Rx meets the requirement for the numerator

36. ACO 31 – CHF use of beta blocker Denominator: All ACO patients > 18 yoa, with the diagnosis of heart failure (ICD code) or documentation of LVEF <40% (structured data) Numerator: Patients who are taking beta blocker (medication) Exclusions: Arrhythmia, hypotension, asthma, AV block, pacemaker (by ICD code)

37. ACO 32 – CAD Lipid Control Denominator: All ACO patients > 18 yoa, with the diagnosis of CAD (by ICD code) Numerator: Patients who either have a documented LDL <100 during the reporting period OR are taking a statin (medication) Exclusions: statin not indicated (CPT code 4013-1P) *LOINC codes must be correct

38. ACO 33 – ACE for CHF or DM/CAD Denominator: All ACO patients > 18 yoa, with the diagnosis of CAD (ICD code) and documentation of LVEF <40% (structured data) OR with diagnosis of CAD and DM. Seen within the reporting period. Numerator: Patients who are prescribed ACE inhibitor (medication) Exclusions: Allergy, Intolerance, CKD any stage, acute renal failure, pregnancy, rheumatic heart disease, (by ICD code)

39. Thank You! Danielle Oryn DO MPH CMIO Redwood Community Health doryn@rchc.net