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Transcript
STARS Objectives for MAP Plans
The Metrics identified below represent the key Outcome and Process measures by which we and the MAP plans are measured. Please check to
ensure that we are successfully meeting the metrics each time your patient comes to the clinic for a visit.
Metric
High Risk Medication usage
Medication Reconciliation Post-Discharge
Controlling Blood Pressure in Hypertension
Medication Adherence for Diabetes Meds
Medication Adherence for Hypertention
Medication Adherence for Cholesterol
Diabetes Control
Breast Cancer Screening
Colorectal Cancer Screening
Adult BMI Assessment
Diabetes Eye Exam
Statin Therapy in Diabetics
Diabetes Hemoglobin A1C
Smoking History if current or prior smoker
Spirometry if current or former smoker
Depression screening
Vascular screening
Neuropathy screening
Chronic Kidney Disease
Parathyroid
Thrombocytopenia
Explanation
Avoid use of medications on CMS’ high risk medication list.
Follow up with patients 3 – 7 days post hospital d/c and reviewing
meds. CPT codes are one of following 99495, 99796, 1111F
Hypertensive patient BP <140/90
Patients need to fill 80% of their DM meds for the year
Patients need to fill 80% of their hypertensive meds for the year
Patients need to fill 80% of their Statin meds for the year
Patients b/n 18 & 75 need H A1C < 9.0
Females 50 – 74 need mammogram every 2 years
Patients 50 – 75 need FOBT every year or Colonoscopy every 10
years
BMI needs to be documented in chart
Patients 18 – 75 w/diabetes Dx need a diabetic eye exam every 2
years
Patients w/diabetes Dx need to be on a statin.
Order at least annually
Perform history annually if current or prior smoker
Perform annually if current or prior smoker or symptomatic
PHQ9 performed annually
Flochec every 2 years
DPN/Sudoscan every 2 years
Order GFR, Creatinine and Urine microalbumin/creat ratio
annually. If GFR and UMA abnormal, then repeat Urine
microalbumin/creat ratio.
Order iPTH, if GFR<60 or hospital stay > 14 days
Order repeat CBC if platelet count < 120
Target
Minimum
Optimum
< 3%
< 2%
>96%
>98%
>92%
>94%
>94%
>94%
>92%
>92%
>82%
>94%
>96%
>96%
>96%
>94%
>94%
>84%
>95%
>92%
>99%
>94%
>92%
>94%
ACO Objectives for Traditional Medicare Patients
The Metrics identified below represent the key Outcome and Process measures by which the ACO is measured. Please check to ensure that we
are successfully addressing these each time your patient comes to the clinic for a visit.
Measure Class
Patient/Caregiver Experience
These measures will be obtained through satisfaction
surveys mailed to patients
Care Coordination/Patient Safety
Preventative Health
As Risk Population – Diabetes
At Risk Population – Hypertension
At risk Population – IVD
At Risk Population – HF
At Risk Population – CAD
Measure
Getting Timely Care, Appointments and Information
How well your doctors communicate
Patients’ rating of doctor
Access to specialists
Health promotion and education
Shared decision making
Health status/functional status
Readmission (Risk Standardized)
ASC Admissions: COPD or Asthma in Older Adults
ASC Admission: Heart Failure
Percent of PCP’s who qualified for EHR incentive
Medication reconciliation
Screening for fall risk
Influenza immunization
Pneumococcal vaccination
Adult weight screening and follow up
Tobacco use assessment and cessation intervention
Depression screening
Colorectal cancer screening
Mammography screening
Proportion of adults with blood pressure screened in past 2 years
Hb A1c Control < 8%
LDL < 100
BP < 140/90
No tobacco use
Aspirin use
% with HbA1c in poor control (>9%)
% BP < 140/90
% LDL < 100
% on aspirin or other antithrombotic
Beta-Blocker for LVSD
Drug therapy for lowering LDL
ACE Inhibitor or ARB therapy for patients with CAD & Diabetes &/or LVSD