Quality Id

Measure Name

High Priority

Measure Type

Measure Description

128

Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

No

Process

Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter 

Normal Parameters: 

Age 18 years and older BMI ≥ 18.5 and < 25 kg/m2

130

Documentation of Current Medications in the Medical Record

Yes

Process

Percentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications’ name, dosage, frequency and route of administration

134

Preventive Care and Screening: Screening for Depression and Follow-Up Plan

No

Process

Percentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen

181

Elder Maltreatment Screen and Follow-Up Plan

Yes

Process

Percentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening Tool on the date of encounter AND a documented follow-up plan on the date of the positive screen

226

Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

No

Process

Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received tobacco cessation intervention if identified as a tobacco user

282

Dementia: Functional Status Assessment

No

Process

Percentage of patients with dementia for whom an assessment of functional status* was performed at least once in the last 12 months

283

Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management

No

Process

Percentage of patients with dementia for whom there was a documented symptoms screening* for behavioral and psychiatric symptoms, including depression, AND for whom, if symptoms screening was positive, there was also documentation of recommendations for symptoms management in the last 12 months

286

Dementia: Safety Concerns Screening and Mitigation Recommendations or Referral for Patients with Dementia

Yes

Process

Percentage of patients with dementia or their caregiver(s) for whom there was a documented safety concerns screening * in two domains of risk: 1) dangerousness to self or others and 2) environmental risks; and if safety concerns screening was positive in the last 12 months, there was documentation of mitigation recommendations, including but not limited to referral to other resources or orders for home safety evaluation

288

Dementia: Caregiver Education and Support

Yes

Process

Percentage of patients with dementia whose caregiver(s)* were provided with education** on dementia disease management and health behavior changes AND were referred to additional resources*** for support in the last 12 months

317

Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented

No

Process

Percentage of patients aged 18 years and older seen during the submitting period who were screened for high blood pressure AND a recommended follow-up plan is documented based on the current blood pressure (BP) reading as indicated

325

Adult Major Depressive Disorder (MDD): Coordination of Care of Patients with Specific Comorbid Conditions

Yes

Process

Percentage of medical records of patients aged 18 years and older with a diagnosis of major depressive disorder (MDD) and a specific diagnosed comorbid condition (diabetes, coronary artery disease, ischemic stroke, intracranial hemorrhage, chronic kidney disease [stages 4 or 5], End Stage Renal Disease [ESRD] or congestive heart failure) being treated by another clinician with communication to the clinician treating the comorbid condition

370

Depression Remission at Twelve Months

Yes

Outcome

The percentage of patients 18 years of age and or older with major depression or dysthymia who reached remission 12 months (+/- 30 days) after an index visit

374

Closing the Referral Loop: Receipt of Specialist Report

Yes

Process

Percentage of patients with referrals, regardless of age, for which the referring provider receives a report from the provider to whom the patient was referred

383

Adherence to Antipsychotic Medications For Individuals with Schizophrenia

Yes

Intermediate Outcome

Percentage of individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder who had at least two prescriptions filled for any antipsychotic medication and who had a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic medications during the measurement period (12 consecutive months)

391

Follow-Up After Hospitalization for Mental Illness (FUH)

Yes

Process

The percentage of discharges for patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had a follow-up visit with a mental health practitioner. Two rates are submitted: 
• The percentage of discharges for which the patient received follow-up within 30 days of discharge.
• The percentage of discharges for which the patient received follow-up within 7 days of discharge.

402

Tobacco Use and Help with Quitting Among Adolescents

No

Process

The percentage of adolescents 12 to 20 years of age with a primary care visit during the measurement year for whom tobacco use status was documented and received help with quitting if identified as a tobacco user

411

Depression Remission at Six Months

Yes

Outcome

The percentage of patients 18 years of age or older with major depression or dysthymia who reached remission six months (+/- 30 days) after an index visit

431

Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling

No

Process

Percentage of patients aged 18 years and older who were screened for unhealthy alcohol use using a systematic screening method at least once within the last 24 months AND who received brief counseling if identified as an unhealthy alcohol user