Percent of hospitalized patients who are screened during the hospital stay using Joint Chart/ Hospital/ Inpatient 9.1 64 1661 No Annual; April a validated screening Commission EHR Care questionnaire for unhealthy alcohol use Percent of patients aged 18 years and older with a diagnosis of current substance abuse or Not Chart/ DSRIP Network/ Annual; April 9.2 68 AMA-PCPI No dependence who were Found EHR Outpatient Care screened for depression within the 12 month reporting period Department/ Initiation of alcohol and 9.3 52 0004 NCQA MMIS Inpatient Care, P4P Annual; April 56 48.2 other drug treatment Outpatient Care Department/ Engagement of alcohol and Annual; April 9.4 38 0004 NCQA MMIS Inpatient Care, P4P 22 19 other drug treatment Outpatient Care Project 10 – Hospital Partners with Residential Treatment Facility to Offer Alternative Setting to Intoxicated Patients – Project was not selected Project 11 – Improve Overall Quality of Care for Patients Diagnosed with Diabetes Mellitus and Hypertension Not Chart/ DSRIP Network/ 11.1 Lipid Management 58 NCQA No Annual; April Found EHR Outpatient Care Not Chart/ DSRIP Network/ 11.2 Foot Examination 43 NCQA No Annual; April Found EHR Outpatient Care Chart/ DSRIP Network/ 11.3 Eye Examination 39 0055 NCQA No Annual; April EHR Outpatient Care Comprehensive Diabetes Department/ 11.4 Care (CDC): Hemoglobin A1C 29 0057 NCQA MMIS No Annual; April Outpatient Care (HbA1C) testing 0638 Uncontrolled Diabetes Department/ 11.5 81 (based AHRQ MMIS P4P Annual; April 0.041 0.041 Admission Rate (PQI 14) Inpatient Care on)
9.1 Percent of hospitalized patients who are screened during the hospital stay using a validated screening questionnaire for unhealthy alcohol use 64 1661 Joint Commission Chart/ EHR Hospital/ Inpatient Care No Annual; April 9.2 Percent of patients aged 18 years and older with a diagnosis of current substance abuse or dependence who were screened for depression within the 12 month reporting period 68 Not Found AMA-PCPI Chart/ EHR DSRIP Network/ Outpatient Care No Annual; April 9.3 Initiation of alcohol and other drug treatment 52 0004 NCQA MMIS Department/ Inpatient Care, Outpatient Care P4P Annual; April 56 48.2 9.4 Engagement of alcohol and other drug treatment 38 0004 NCQA MMIS Department/ Inpatient Care, Outpatient Care P4P Annual; April 22 19 Project 10 – Hospital Partners with Residential Treatment Facility to Offer Alternative Setting to Intoxicated Patients – Project was not selected Project 11 – Improve Overall Quality of Care for Patients Diagnosed with Diabetes Mellitus and Hypertension 11.1 Lipid Management 58 Not Found NCQA Chart/ EHR DSRIP Network/ Outpatient Care No Annual; April 11.2 Foot Examination 43 Not Found NCQA Chart/ EHR DSRIP Network/ Outpatient Care No Annual; April 11.3 Eye Examination 39 0055 NCQA Chart/ EHR DSRIP Network/ Outpatient Care No Annual; April 11.4 Comprehensive Diabetes Care (CDC): Hemoglobin A1C (HbA1C) testing 29 0057 NCQA MMIS Department/ Outpatient Care No Annual; April 11.5 Uncontrolled Diabetes Admission Rate (PQI 14) 81 0638 (based on) AHRQ MMIS Department/ Inpatient Care P4P Annual; April 0.041 0.041
Addendum%202_Stage%202%20Quality%20Improvement_Measures%20Catalogue_061318.docx