Measure Definition Source Population(s) expected Total health care cost per person Aggregate payments/person HSCRC Total Cost Report All population for covered zips, high utilization set, target population if different, , each by race/ethnicity ED visits per capita Encounters per thousand HSCRC Casemix Data All population for covered zips, high utilization set, target population if different, , each by race/ethnicity Potentially avoidable utilization (see HSCRC specifications) PAU Patient Level Reports High utilization set, target population if different, each by race/ethnicity Total hospital admits per capita Admits per thousand HSCRC Casemix Data All population for covered zips, high utilization set, target population if different, each by race/ethnicity Increased Number of Shared Care Profiles Number of Practices within the One Health Quality Alliance receiving Shared Care Profiles on patients from CRISP One Health Quality Alliance Patient population covered by the One Health Quality Alliance’s 43 practices % of Practices achieving Meaningful Use Stage 2 HIE metric Number of Practices within the One Health Quality Alliance that successfully meet the CMS Stage 2 MU guideline under the Health Information Exchange measure One Health Quality Alliance This metric will cover the 450 providers in the One Health Quality Alliance, and measure the P2P communication between those providers Patient Satisfaction with Care Coordination and Physician/Hospital Communication Patient Satisfaction scores on an administered CAHPS survey under the domain areas of Care Coordination and Communication One Health Quality Alliance results on the CAHPS surveys Patient populations covered by the One Health Quality Alliance
Diabetes Testing Measure The percentage of members years of age diagnosed with diabetes (type 1 and type 2) who had HbA1c testing in measurement year One Health Quality Alliance Patient populations covered by the One Health Quality Alliance and MidAtlantic ACO Diabetes Control Measure The percentage of members 18–75 years of age with diabetes whose most recent HbA1c level (during measurement year) is >9% One Health Quality Alliance Patient populations covered by the One Health Quality Alliance and MidAtlantic ACO Depression Screening Measure Percentage of patients aged 18 years & older screened for clinical depression on using appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screen One Health Quality Alliance Patient populations covered by the One Health Quality Alliance and MidAtlantic ACO Post-Partum Depression Screening Measure The percentage of postpartum patients screened for clinical depression using depression screen within 3 months of delivery One Health Quality Alliance Patient populations covered by the One Health Quality Alliance Smoking Screening/Cessation Education Measure Percentage of members 18 years of age and older who were current smokers or tobacco users & who were recommended cessation medications during the measurement year. One Health Quality Alliance Patient populations covered by the One Health Quality Alliance and MidAtlantic ACO Breast Cancer Screening Measure Breast cancer screening: percentage of women 50 to 74 years of age who had a mammogram to One Health Quality Alliance Patient populations covered by the One Health Quality Alliance and
screen for breast cancer any time on/between October 1-2 years prior to the measurement year and December 31 of the measurement year MidAtlantic ACO Pediatric BMI screening measure Percentage of members 3–17 years of age who had an OP visit with a PCP or OB/GYN and who had evidence of the following during the measurement year. +BMI percentile documentation + Counseling for nutrition + Counseling for physical activity One Health Quality Alliance Patient populations covered by the One Health Quality Alliance Total hospital admits per capita Admits per thousand HSCRC Casemix Data All population for covered zips, high utilization set, target population if different, each by race/ethnicity