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

109

Osteoarthritis (OA): Function and Pain Assessment

Yes

Process

Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain

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

131

Pain Assessment and Follow-Up

Yes

Process

Percentage of visits for patients aged 18 years and older with documentation of a pain assessment using a standardized tool(s) on each visit AND documentation of a follow-up plan when pain is present

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

182

Functional Outcome Assessment

Yes

Process

Percentage of visits for patients aged 18 years and older with documentation of a current functional outcome assessment using a standardized functional outcome assessment tool on the date of the encounter AND documentation of a care plan based on identified functional outcome deficiencies on the date of the identified deficiencies

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

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

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

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