Measures in PRIME - Prime Registry

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PRIME ID	NQF#	QPP CQM#	eCQM#	MEASURE TITLE	DESCRIPTION	Type	High Priority	Status
12		369	158	Pregnant women that had HBsAg testing	This measure identifies pregnant women who had a HBsAg (hepatitis B) test during their pregnancy.	Process	No	Active
35		66	146	Appropriate Testing for Children with Pharyngitis	Percentage of children 3-18 years of age who were diagnosed with pharyngitis, ordered an antibiotic and received a group A streptococcus (strep) test for the episode.	Process	Yes	Active
36		236	165	Controlling High Blood Pressure	Percentage of patients 18-85 years of age who had a diagnosis of hypertension and whose blood pressure was adequately controlled (<140/90mmHg) during the measurement period.	Outcome	Yes	Active
37	22	238	156	Use of High-Risk Medications in the Elderly	Percentage of patients 65 years of age and older who were ordered high-risk medications. Two rates are submitted. 1) Percentage of patients who were ordered at least one high-risk medication. 2) Percentage of patients who were ordered at least two of the same high-risk medication	Process	Yes	Active
38		239	155	Weight Assessment and Counseling for Nutrition and Physical Activity for Children and Adolescents	Percentage of patients 3-17 years of age who had an outpatient visit with a Primary Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had evidence of the following during the measurement period. Three rates are reported -Percentage of patients with height, weight, and body mass index (BMI) percentile documentation -Percentage of patients with counseling for nutrition -Percentage of patients with counseling for physical activity.	Process	No	Active
39	28	226	138	Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention	Percentage of patients aged 18 years and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.	Process	No	Active
40	2.372	112	125	Breast Cancer Screening	Percentage of women 50-74 years of age who had a mammogram to screen for breast cancer	Process	No	Active
41		309	124	Cervical Cancer Screening	Percentage of women 21-64 years of age who were screened for cervical cancer using either of the following criteria: * Women age 21-64 who had cervical cytology performed every 3 years * Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years	Process	No	Active
42		310	153	Chlamydia Screening for Women	Percentage of women 16-24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period	Process	No	Active
43	34	113	130	Colorectal Cancer Screening	Percentage of adults 50-75 years of age who had appropriate screening for colorectal cancer.	Process	No	Active
44		311	126	Use of Appropriate Medications for Asthma	Percentage of patients 5-64 years of age who were identified as having persistent asthma and were appropriately ordered medication during the measurement period	Process	No	Active
45		240	117	Childhood Immunization Status	Percentage of children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella (MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday	Process	No	Active
46	41	110	147	Preventive Care and Screening: Influenza Immunization	Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization.	Process	No	Active
47		111	127	Pneumococcal Vaccination Status for Older Adults	Percentage of patients 65 years of age and older who have ever received a pneumococcal vaccine	Process	No	Active
48		312	166	Use of Imaging Studies for Low Back Pain	Percentage of patients 18-50 years of age with a diagnosis of low back pain who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days of the diagnosis.	Process	Yes	Active
49	55	117	131	Diabetes: Eye Exam	Percentage of patients 18-75 years of age with diabetes who had a retinal or dilated eye exam by an eye care professional during the measurement period or a negative retinal exam (no evidence of retinopathy) in the 12 months prior to the measurement period	Process	No	Active
50		163	123	Diabetes: Foot Exam	The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection and sensory exam with mono filament and a pulse exam) during the measurement year	Process	No	Active
51	59	1	122	Diabetes: Hemoglobin A1c (HbA1c) Poor Control (> 9%)	Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period.	Outcome	Yes	Active
53	62	119	134	Diabetes: Medical Attention for Nephropathy	The percentage of patients 18-75 years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period.	Process	No	Active
54		2	163	Diabetes: Low Density Lipoprotein (LDL-C) Control (< 100 mg/dL)	Percentage of patients 18-75 years of age with diabetes whose LDL-C was adequately controlled (<100 mg/dL) during the measurement period.	Outcome	No	Active
55		204	164	Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antiplatelet	The percentage of patients 18 years of age and older who were discharged from an inpatient setting with an acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary intervention (PCI) during the 12 months prior to the measurement year, or who had a diagnosis of ischemic vascular disease (IVD) during the measurement year and the year prior to the measurement year and who had documentation of routine use of aspirin or another antiplatelet during the measurement year.	Process	No	Active
56	69	65	154	Appropriate Treatment for Children with Upper Respiratory Infection (URI)	Percentage of children 3 months-18 years of age who were diagnosed with upper respiratory infection (URI) and were not dispensed an antibiotic prescription on or three days after the episode.	Process	Yes	Active
57	70	7	145	Coronary Artery Disease (CAD): Beta-Blocker Therapy-Prior Myocardial Infarction (MI) or Left Ventricular Systolic Dysfunction (LVEF <40%)	Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have a prior MI or a current or prior LVEF <40% who were prescribed beta-blocker therapy.	Process	No	Active
58		241	182	Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL-C Control (<100 mg/dL)	Percentage of patients 18 years of age and older who were discharged alive for acute myocardial infarction (AMI), coronary artery bypass graft (CABG) or percutaneous coronary interventions (PCI) in the 12 months prior to the measurement period, or who had an active diagnosis of ischemic vascular disease (IVD) during the measurement period, and who had each of the following during the measurement period: a complete lipid profile and LDL-C was adequately controlled (< 100 mg/dL).	Process	No	Active
59	81	5	135	Heart Failure (HF): Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD)	Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy either within a 12-month period when seen in the outpatient setting OR at each hospital discharge	Process	No	Active
60	83	8	144	Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)	Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge	Process	No	Active
61	101	318	139	Falls: Screening for Future Fall Risk	Percentage of patients 65 years of age and older who were screened for future fall risk during the measurement period	Process	Yes	Active
64		366	136	ADHD: Follow-Up Care for Children Prescribed Attention-Deficit/Hyperactivity Disorder (ADHD) Medication	Percentage of children 6-12 years of age and newly dispensed a medication for attention-deficit/hyperactivity disorder (ADHD) who had appropriate follow-up care. Two rates are reported. a. Percentage of children who had one follow-up visit with a pract	Process	No	Active
65		134	2	Preventive Care and Screening: Screening for Depression and Follow-Up Plan	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.	Process	No	Active
66	419	130	68	Documentation of Current Medications in the Medical Record	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 administrationroute of administration.	Process	Yes	Active
67		128	69	Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan	Percentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous 12 months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous 12 months of the current encounter Normal Parameters: Age 18 years and older BMI => 18.5 and < 25 kg/m2	Process	No	Active
69		371	160	Depression Utilization of the PHQ-9 Tool	Patients age 18 and older with the diagnosis of major depression or dysthymia who have a Patient Health Questionnaire (PHQ-9) tool administered at least once during a 4-month period in which there was a qualifying visit.	Process	No	Active
72		316	61	Preventive Care and Screening: Cholesterol - Fasting Low Density Lipoprotein (LDL-C) Test Performed	Percentage of patients aged 20 through 79 years whose risk factors have been assessed and a fasting LDL-C test has been performed.	Process	No	Active
73		281	149	Dementia: Cognitive Assessment	Percentage of patients, regardless of age, with a diagnosis of dementia for whom an assessment of cognition is performed and the results reviewed at least once within a 12 month period	Process	No	Active
75		317	22	Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented	Percentage of patients aged 18 years and older seen during the reporting 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.	Process	No	Active
76		372	82	Maternal Depression Screening	The percentage of children who turned 6 months of age during the measurement year, who had a face-to-face visit between the clinician and the child during child's first 6 months, and who had a maternal depression screening for the mother at least once between 0 and 6 months of life.	Process	No	Active
80		0	0	Comprehensive Diabetes Care: Blood Pressure Control (<140/90 mm Hg)	The percentage of patients 18-75 years of age with diabetes (type 1 and type 2) whose most recent blood pressure level taken during the measurement year is <140/90 mm Hg.	Outcome	No	Active
82		0	179	ADE Prevention and Monitoring: Warfarin Time in Therapeutic Range	Average percentage of time in which patients aged 18 and older with atrial fibrillation who are on chronic warfarin therapy have International Normalized Ratio (INR) test results within the therapeutic range (i.e., TTR) during the measurement period.	Outcome	No	Active
85		373	65	Hypertension: Improvement in Blood Pressure	Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period.	Outcome	Yes	Active
86		23	0	Perioperative Care: Venous Thromboembolism (VTE) Prophylaxis (When Indicated in ALL Patients)	Percentage of surgical patients aged 18 years and older undergoing procedures for which venous thromboembolism (VTE) prophylaxis is indicated in all patients, who had an order for Low Molecular Weight Heparin(LMWH), Low- Dose Unfractionated Heparin(LDUH),	Process	Yes	Active
87		438	347	Statin Therapy for the Prevention and Treatment of Cardiovascular Disease	Percentage of the following patients - all considered at high risk of cardiovascular events - who were prescribed or were on statin therapy during the measurement period: Adults aged >= 21 years who were previously diagnosed with or currently have an active diagnosis of clinical atherosclerotic cardiovascular disease (ASCVD); OR Adults aged >= 21 years who have ever had a fasting or direct low-density lipoprotein cholesterol (LDL-C) level >= 190 mg/dL or were previously diagnosed with or currently have an active diagnosis of familial or pure hypercholesterolemia; OR *Adults aged 40-75 years with a diagnosis of diabetes with a fasting or direct LDL-C level of 70-189 mg/dL	Process	No	Active
88		305	137	Initiation and Engagement of Alcohol and Other Drug Dependence Treatment	Percentage of patients 13 years of age and older with a new episode of alcohol and other drug (AOD) dependence who received the following. Two rates are reported. a. Percentage of patients who initiated treatment within 14 days of the diagnosis. b. Percentage of patients who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit	Process	No	Active
89	710	370	159	Depression Remission at Twelve Months	Patients age 18 and older with major depression or dysthymia and an initial Patient Health Questionnaire (PHQ-9) score greater than nine who demonstrate remission at twelve months (+/- 30 days after an index visit) defined as a PHQ-9 score less than five.	Outcome	Yes	Active
90		374	50	Closing the Referral Loop: Receipt of Specialist Report	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.	Process	Yes	Active
91	2.803	402	0	Tobacco Use and Help with Quitting Among Adolescents	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.	Process	No	Active
92	2.152	431	0	Preventive Care and Screening: Unhealthy Alcohol Use: Screening & Brief Counseling	Percentage of patients aged 18 years and older who were screened at least once within the last 24 months for unhealthy alcohol use using a systematic screening method AND who received brief counseling if identified as an unhealthy alcohol user.	Process	No	Active
93		316	64	Preventive Care and Screening: Risk-Stratified Cholesterol -Fasting Low Density Lipoprotein (LDL-C)	Percentage of patients aged 20 through 79 years who had a fasting LDL-C test performed and whose risk-stratified fasting LDL-C is at or below the recommended LDL-C goal.	Process	No	Active
94		0	0	Well Child Visits in the first 15 months of life	The percentage of children 15 months old who had the recommended number of well-child visits with a PCP during their first 15 months of life.	Process	No	Active
95		0	0	Well Child Visits in 3rd, 4th, 5th, and 6th yrs of life	The percentage of children 3-6 years of age who had one or more well-child visits with a PCP during the measurement year.	Process	No	Active
96		0	0	Adolescent Well Care Visits	Percentage of adolescents ages 12 to 21 who had at least one comprehensive well-care visit with a primary care practitioner (PCP) or an obstetric/gynecologic (OB/GYN) practitioner during the measurement year.	Process	No	Active
97		394	0	Immunizations for Adolescents	The percentage of adolescents 13 years of age who had the recommended immunizations by their 13th birthday	Process	No	Active
99		53	0	Pharmacologic Therapy for Persistent Asthma	Percentage of patients aged 5 years and older with a diagnosis of persistent asthma who were prescribed long-term control medication	Process	No	Active
100		0	0	Measuring the Value-Functions of Primary Care: Provider Level Continuity Measure	Bice-Boxerman Continuity of Care Primary Care Physician Measure (BB-COC-PC). At a patient-level, BB-COC is a measure that considers the dispersion of primary care visits across providers, such that patients with higher scores have most of their primary care visits to the same provider or a small number of providers while those lower scores see a larger number providers.	Structure	Yes	Active
101		0	0	Pain Brought Under Control within the first three visits	Percent of patients 18 and older who report being uncomfortable because of pain at the initial palliative care assessment who report pain was brought to a comfortable level (e.g. “Comfortable? Yes/No”, “mild” or pain score < 4) within the first three visits	Outcome	Yes	Active
102		0	0	Palliative Care—Treatment Preferences	The percentage of adult patients 18 and older with documentation of preferences for life-sustaining treatments within the first three visits	Process	Yes	Active
103		0	0	Palliative Care– Spiritual Assessment	Percentage of adult patients 18 and older and/or their caregiver receiving a palliative care visit with documentation of a discussion of spiritual/religious concerns or documentation that the they did not want to discuss during the first three visits	Process	Yes	Active
104		0	0	Palliative Care Timely Dyspnea Screening & Treatment	Percentage of palliative care adult patients 18 years and older who were screened for dyspnea during the initial palliative care encounter or documentation that a screening was attempted AND for those with moderate/severe dyspnea or who are uncomfortable	Process	Yes	Active
105		0	0	Patients Treated with an Opioid Who Are Given a Bowel Regimen	Percentage of adults 18 and older treated with an opioid that are offered/prescribed a bowel regimen during the same visit or documentation of reason for why this was not needed	Process	Yes	Active
106		0	0	All Patients Who Die an Expected Death with an ICD that Has Been Deactivated	Percentage of adult 18 and older patients in any care setting who die an expected death from cancer or other terminal illness and who have an implantable cardioverter-defibrillator (ICD) in place at the time of death that was deactivated prior to death or	Process	Yes	Active
107		0	0	Patients Admitted to ICU who Have Care Preferences Documented	Percentage of adult 18 and older patients admitted to ICU who receive palliative care and survive at least 2 days who have their care preferences documented within 2 days OR documentation as to why this was not done.	Process	Yes	Active
108		0	0	Patients with Advanced Cancer Screened for Pain at Outpatient Visits	Adult patients with advanced cancer who are screened for pain with a standardized quantitative tool at each outpatient visit	Process	No	Active
109		0	0	Palliative Care Initial Encounter Pain Screening	The percentage of palliative care adult patients 18 and older who were screened for pain during the initial palliative care encounter or documentation that a screening was attempted	Process	No	Active
110		377	90	Functional Status Assessments for Congestive Heart Failure	Percentage of patients 65 years of age and older with congestive heart failure who completed initial and follow-up patient-reported functional status assessments	Process	Yes	Active
111		379	74	Primary Caries Prevention Intervention as Offered by Primary Care Providers, including Dentists	Percentage of children, age 0-20 years, who received a fluoride varnish application during the measurement period.	Process	No	Active
112		109	0	Osteoarthritis (OA): Function and Pain Assessment	Percentage of patient visits for patients aged 21 years and older with a diagnosis of osteoarthritis (OA) with assessment for function and pain	Process	Yes	Active
113		24	0	Communication with the Physician or Other Clinician Managing On-going Care Post-Fracture for Men and Women Aged 50 Years and Older	Percentage of patients aged 50 years and older treated for a fracture with documentation of communication, between the physician treating the fracture and the physician or other clinician managing the patient's on-going care, that a fracture occurred and	Process	Yes	Active
114	53	418	0	Osteoporosis Management in Women who have had a fracture	The percentage of women age 50-85 who suffered a fracture and who either had a bone mineral density test or received a prescription for a drug to treat osteoporosis in the six months after the fracture	Process	No	Active
115	46	39	0	Screening for Osteoporosis for Women Aged 65-85 Years of Age	Percentage of female patients aged 65-85 years of age who ever had a central dual-energy X-ray absorptiometry (DXA) to check for osteoporosis	Process	No	Active
116		131	0	Pain assessment and follow-up	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	Process	Yes	Active
117		182	0	Functional Outcome Assessment	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	Process	Yes	Active
118		181	0	Elder Maltreatment Screen and Follow-Up Plan	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	Process	Yes	Active
119		282	0	Dementia: Functional Status Assessment	Percentage of patients with dementia for whom an assessment of functional status* was performed at least once in the last 12 months	Process	No	Active
120		286	0	Dementia: Safety Concerns Screening and Mitigation Recommendations or Referral for Patients with Dementia	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	Process	Yes	Active
121		283	0	Dementia Associated Behavioral and Psychiatric Symptoms Screening and Management	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	Process	No	Active
122		217	0	Functional Status Change for Patients with Knee Impairments	A self-report measure of change in functional status for patients 14 year+ with knee impairments. The change in functional status (FS) assessed using FOTO's (knee ) PROM (patient-reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality	Outcome	Yes	Active
123		218	0	Functional Status Change for Patients with Hip Impairments	A self-report measure of change in functional status (FS) for patients 14 years+ with hip impairments. The change in functional status (FS) assessed using FOTO's (hip) PROM (patient- reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality	Outcome	Yes	Active
124		219	0	Functional Status Change for Patients with Foot or Ankle Impairments	A self-report measure of change in functional status (FS) for patients 14 years+ with foot and ankle impairments. The change in functional status (FS) assessed using FOTO's (foot and ankle) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality	Outcome	Yes	Active
125		220	0	Functional Status Change for Patients with Lumbar Impairments	A self-report outcome measure of change in functional status for patients 14 years+ with lumbar impairments. The change in functional status (FS) assessed using FOTO (lumbar) PROM (patient reported outcome measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level by to assess quality	Outcome	Yes	Active
126		221	0	Functional Status Change for Patients with Shoulder Impairments	A self-report outcome measure of change in functional status (FS) for patients 14 years+ with shoulder impairments. The change in functional status (FS) assessed using FOTO's (shoulder) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality	Outcome	Yes	Active
127		222	0	Functional Status Change for Patients with Elbow, Wrist or Hand Impairments	A self-report outcome measure of functional status (FS) for patients 14 years+ with elbow, wrist or hand impairments. The change in FS assessed using FOTO (elbow, wrist and hand) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality	Outcome	Yes	Active
128		223	0	Functional Status Change for Patients with Other General Orthopaedic Impairments	A self-report outcome measure of functional status (FS) for patients 14 years+ with general orthopaedic impairments (neck, cranium, mandible, thoracic spine, ribs or other general orthopaedic impairment). The change in FS assessed using FOTO (general orthopaedic) PROM (patient reported outcomes measure) is adjusted to patient characteristics known to be associated with FS outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level by to assess quality	Outcome	Yes	Active
129	268	21	0	Perioperative Care: Selection of prophylactic antibiotic – first or second generation cephalosporin	Percentage of surgical patients aged 18 years and older undergoing procedures with the indications for a first OR second generation cephalosporin prophylactic antibiotic, who had an order for a first OR second generation cephalosporin for antimicrobial prophylaxis	Process	Yes	Active
130	1.525	326	0	Atrial Fibrillation and Atrial Flutter: Chronic Anticoagulation Therapy	Percentage of patients aged 18 years and older with nonvalvular atrial fibrillation (AF) or atrial flutter who were prescribed warfarin OR another FDA-approved oral anticoagulant drug that for the prevention of thromboembolism during the measurement period.	Process	No	Active
131		288	288	Dementia/l Caregiver Education and Support	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	Process	No	Active
132		467	0	Developmental Screening 0-3yo	The percentage of children screened for risk of developmental, behavioral, and social delays using a standardized screening tool in the first three years of life. This is a measure of screening in the first three years of life that includes three, age-specific indicators assessing whether children are screened by 12 months of age, by 24 months of age and by 36 months of age.	Process	No	Active
133		483	0	Person-Centered Primary Care Measure Performance Measure (PCPCM-PM)	The Person-Centered Primary Care Measure Performance Measure (PCPCM-PM) utilizes the PCPCM (a comprehensive and parsimonious set of 11 patient-reported items) to assess the broad scope of primary care. PCPCM PROM 1. My practice makes it easy for me to get care. Definitely Mostly Somewhat Not at all 2. My practice is able to provide most of my care. Definitely Mostly Somewhat Not at all 3. In caring for me, my doctor considers all the factors that affect my health. Definitely Mostly Somewhat Not at all 4. My practice coordinates the care I get from multiple places. Definitely Mostly Somewhat Not at all 5. My doctor or practice knows me as a person. Definitely Mostly Somewhat Not at all 6. My doctor and I have been through a lot together. Definitely Mostly Somewhat Not at all 7. My doctor or practice stands up for me. Definitely Mostly Somewhat Not at all 8. The care I get takes into account knowledge of my family. Definitely Mostly Somewhat Not at all 9. The care I get in this practice is informed by knowledge of my community. Definitely Mostly Somewhat Not at all 10. Over time, my practice helps me to stay healthy. Definitely Mostly Somewhat Not at all 11. Over time, my practice helps me to meet my goals. Definitely Mostly Somewhat Not at all	Patient Reported Outcome (PRO)	Yes	Active
134		0	0	The Patient-Enablement Index (PEI)	The Patient-Enablement Index (PEI) is a brief set of 6 patient-report items that assess patient’s ability to understand and cope with their health issues as a result of the care received.	0	0	Inactive
135		0	0	Tamiflu - Number of beneficiaries who received Tamiflu and respiratory antibiotics on the same day (PCMH)	Percentage of benificiaries 1-18 years of age who received Tamiflu and respiratory antibiotics on the same day	0	0	Active
136		0	0	Pharmacotherapy Management of COPD Exacerbation	The percentage of COPD exacerbations for members 40 years of ge and older who had an acute inpatient discharge or ED visit on or between January 1 - Novermber 30 of the measurement year and who were dispensed approprate medications. Two rates reported: 1. Dispensed a systematic corticosteroid (or there was evidence of an active prescription) within 14 days of the event. 2. Dispensed a bronchodilator (or there as evidence of an active prescription within 30 days of the event.	0	0	Active
137		442	0	Persistent of Beta Blocker treatment after heart attack	The percentage of members 18 years of age and older during the measurement year who were hospitalized and discharged from July 1 of the year prior to the measurement year to June 30 of the measurement year with a diagnosis of AMI and who received persistent beta-blocker treatment for six months after discharge.	Process	No	Active
138		0	0	Plan All Cause Readmissions (PCR)	For members 18 years of age and older, the number of acute inpatient stays during the measurement year that were followed by an unplanned acute readmission for any diagnosis within 30 days and the predicted probability of an acure readmission. Data are reported in the follwoing categories: 1. Count of index hospital stays (IHS) (denominator) 2. Count of observed 30-day readmissions (numerator) 3. Count of expected 30-day readmissions. Note: For commercial and Medicaid, report only members 18-64 years of age.	Process	0	Active
139		48	0	Urinary Incontinence: Assessment of Presence or Absence of Urinary Incontinence in Women Aged 65 Years and Older	Percentage of female patients aged 65 years and older who were assessed for the presence or absence of urinary incontinence within 12 months	Process	No	Active
140		46	0	Medication Reconciliation Post-Discharge	The percentage of discharges from any inpatient facility (e.g. hospital, skilled nursing facility, or rehabilitation facility) for patients 18 years of age and older seen within 30 days following discharge in the office by the physician, prescribing practitioner, registered nurse, or clinical pharmacist providing on-going care for whom the discharge medication list was reconciled with the current medication list in the outpatient medical record This measure is submitted as three rates stratified by age group: Submission Criteria 1: 18-64 years of age. Submission Criteria 2: 65 years and older. Total Rate: All patients 18 years of age and older.	Process	0	Active
141		0	0	AHRQ: Death from suicide	Patient with a diagnosis of major depression or dysthmia who died from suicide, reported in 12 month intervals	0	0	Active
142		0	0	AHRQ: Improvement in Depressive Symptoms - Remission	Patient age 18 or older with a diagnosis of major depression or dysthmia and an initial PHQ-9 socre > 9 who demonstrates remission defined as a PHQ-9 score less than 5.	0	0	Active
143		0	0	AHRQ: Improvement in Depressive Symptoms - Response	Patient age 18 or older with a diagnosis of major depression or dysthmia and an initial PHQ-9 socre > 9 who demonstrates a response to treatment defined as a PHQ-9 score that is reduced by 50% or greater from the initial PHQ-9 score.	0	0	Active
144		0	0	AHRQ: Improvement in Depressive Symptoms - Recurrence	Patient age 18 or older with a diagnosis of major depression or dysthmia and an initial PHQ-9 socre > 9 who demonstrates remission (fdefined as a PHQ-9 score <5) of at least two months' duration and subsequently expereinces a recurrence of a depressive episode, defined as a 50% increase in PHQ-9 score or defined as a PHQ-9 score > 9 OR hospitalization for depression or suicidality.	0	0	Active
145		0	0	AHRQ: Adverse Events	Depression treatment-related adverse events. Use of a brief, publicly available, validated measurement toll to capture adverse events is recommended. Reported in 12-month intervals.	0	0	Active
146		0	0	AHRQ: Suicide ideation and behavior	Selection of 'several days', 'more than half the days', or 'nearly every day' option on PHQ-9 item 9 ("Thoughts that you would be better off dead or of hurting yourself in some way").	0	0	Active
147	326	47	0	Advance Care Plan	Percentage of patients aged 65 years and older who have an advance care plan or surrogate decision maker documented in the medical record or documentation 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	Process	Yes	Active
151	101	154	0	Falls: Risk Assessment	Percentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 months	Process	Yes	Active
152	101	155	0	Falls: Plan of Care	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	Process	Yes	Active
153	0	50	0	Urinary Incontinence: Plan of Care for Urinary Incontinence in Women Aged 65 Years and Older	Percentage of female patients aged 65 years and older with a diagnosis of urinary incontinence with a documented plan of care for urinary incontinence at least once within 12 months	Process	Yes	Active