Quality Id

Measure Name

High Priority

Measure Type

Measure Description

047

Care Plan

Yes

Process

Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record that an advance care plan was discussed but the patient did not wish or was not able to name a surrogate decision maker or provide an advance care plan

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

154

Falls: Risk Assessment

Yes

Process

Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months

155

Falls: Plan of Care

Yes

Process

Percentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 months

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

268

Epilepsy: Counseling for Women of Childbearing Potential with Epilepsy

No

Process

All female patients of childbearing potential (12 - 44 years old) diagnosed with epilepsy who were counseled or referred for counseling for how epilepsy and its treatment may affect contraception OR pregnancy at least once a year

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

290

Parkinson’s Disease: Psychiatric Symptoms Assessment for Patients with Parkinson’s Disease

No

Process

Percentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed* for psychiatric symptoms** in the past 12 months

291

Parkinson’s Disease: Cognitive Impairment or Dysfunction Assessment

No

Process

Percentage of all patients with a diagnosis of Parkinson’s Disease [PD] who were assessed* for cognitive impairment or dysfunction in the past 12 months

293

Parkinson’s Disease: Rehabilitative Therapy Options

Yes

Process

Percentage of all patients with a diagnosis of Parkinson’s Disease (or caregiver(s), as appropriate) who had rehabilitative therapy options (e.g., physical, occupational, or speech therapy) discussed in the past 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

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

386

Amyotrophic Lateral Sclerosis (ALS) Patient Care Preferences

Yes

Process

Percentage of patients diagnosed with Amyotrophic Lateral Sclerosis (ALS) who were offered assistance in planning for end of life issues (e.g. advance directives, invasive ventilation, hospice) at least once annually

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

408

Opioid Therapy Follow-up Evaluation

No

Process

All patients 18 and older prescribed opiates for longer than six weeks duration who had a follow-up evaluation conducted at least every three months during Opioid Therapy documented in the medical record

412

Documentation of Signed Opioid Treatment Agreement

No

Process

All patients 18 and older prescribed opiates for longer than six weeks duration who signed an opioid treatment agreement at least once during Opioid Therapy documented in the medical record

414

Evaluation or Interview for Risk of Opioid Misuse

No

Process

All patients 18 and older prescribed opiates for longer than six weeks duration evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record

419

Overuse Of Neuroimaging For Patients With Primary Headache And A Normal Neurological Examination

No

Efficiency

Percentage of patients with a diagnosis of primary headache disorder whom advanced brain imaging was not ordered

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

435

Quality of Life Assessment For Patients With Primary Headache Disorders

Yes

Outcome

Percentage of patients with a diagnosis of primary headache disorder whose health related quality of life (HRQoL) was assessed with a tool(s) during at least two visits during the 12 month measurement period AND whose health related quality of life score stayed the same or improved