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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