3.3 Diabetes screening for people with schizophrenia or bipolar disorder who are prescribed antipsychotic medications (SSD) 35 1932 NCQA MMIS Department/ Outpatient Care No Annual; April 3.4 Major Depressive Disorder (MDD): Suicide Risk Assessment 59 0104 AMA-PCPI Chart/ EHR DSRIP Network/ Outpatient Care No Annual; April 3.5 Mental Health Utilization 62 Not Found NCQA MMIS Department/ Inpatient Care Outpatient Care No Annual; April 3.6 Follow-up After Hospitalization for Mental Illness – 7 days post discharge 41 0576 NCQA MMIS Department/ Outpatient Care P4P Annual; April 77 70 3.7 Antidepressant Medication Management – Effective Acute Phase Treatment 11 0105 NCQA MMIS Department/ Outpatient Care P4P Annual; April 62 61 3.8 Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use 15 0110 CQAIMH Chart/ EHR DSRIP Network/ Outpatient Care P4P Annual; April 90 N/A 3.9 Depression Remission at 12 Months 33 0710 MNCM Chart/ EHR DSRIP Network/ Outpatient Care P4P Annual; April 13.62 N/A Substitution Diabetes Monitoring for People with Diabetes and Schizophrenia 92 1934 NCQA MMIS Department/ Outpatient Care P4P Annual; April 90 79.3 Project 4 – Day Program and School Support Expansion – Project was not selected Project 5 – Electronic Self-Assessment Decision Support Tool 5.1 Follow-up After Hospitalization for Mental Illness – 30 days post discharge 40 0576 NCQA MMIS Department/ Outpatient Care No Annual; April
5.2 Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use 15 0110 CQAIMH Chart/ EHR DSRIP Network/ Outpatient Care No Annual; April 5.3 Screening for Clinical Depression and Follow-up Plan 79 0418 CMS Chart/ EHR DSRIP Network/ Outpatient Care No Annual; April 5.4 Mental Health Utilization 62 Not Found NCQA MMIS Department/ Inpatient Care, Outpatient Care No Annual; April 5.5 Weight Assessment and Counseling for Nutrition and Physical Activity for Children/ Adolescents 87 0024 NCQA Chart/ EHR DSRIP Network/ Outpatient Care No Annual; April 5.6 Adult Body Mass Index (BMI) Assessment 7 Not Found NCQA MMIS Department/ Outpatient Care No Annual; April 5.7 Adolescent Well-Care Visit 5 N/A NCQA MMIS Department/ Outpatient Care No Annual; April 5.8 Follow-up After Hospitalization for Mental Illness – 7 days post discharge 41 0576 NCQA MMIS Department/ Outpatient Care P4P Annual; April 77 70 5.9 Depression Remission at 12 Months 33 0710 MNCM Chart/ EHR DSRIP Network/ Outpatient Care P4P Annual; April 13.62 N/A 5.10 Follow-up Care for Children Prescribed ADHD Medication (ADD) 42 0108 NCQA MMIS Department/ Outpatient Care P4P Annual; April 100 64 5.11 Antidepressant Medication Management – Effective Acute Phase Treatment 11 0105 NCQA MMIS Department/ Outpatient Care P4P Annual; April 62 61 Project 6 – Care Transitions Intervention Model to Reduce 30-Day Readmissions for Chronic Cardiac Conditions
8.2 Heart Failure: Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (inpatient setting) 9 0081 AMA-PCPI Chart/ EHR Hospital/ Inpatient Care No Annual; April 8.3 Controlling High Blood Pressure (CBP) 31 0018 NCQA Chart/ EHR DSRIP Network/ Outpatient Care No Annual; April 8.4 Post-Discharge Appointment for Heart Failure Patients 73 Not Found AMA-PCPI Chart/ EHR Hospital/ Inpatient Care No Annual; April 8.5 Medication Reconciliation 61 0097 (based on) NCQA Chart/ EHR DSRIP Network/ Outpatient Care No Annual; April 8.6 Removed 8.7 30-Day All-Cause Readmission Following Heart Failure (HF) Hospitalization 3 0330 (based on) CMS MMIS Department/ Inpatient Care P4P Annual; April 0 (non-risk adjusted) 24.6 (risk adjusted) 8.8 30-Day All-Cause Readmission Following Acute Myocardial Infarction (AMI) Hospitalization 1 0505 (based on) CMS MMIS Department/ Inpatient Care P4P Annual; April 0 (non-risk adjusted) 18.4 (risk adjusted) 8.9 Heart Failure Admission Rate 45 0277 (based n) AHRQ MMIS Department/ Inpatient Care P4P Annual; April 1.223 1.988 Substitution Preventive Care and Screening: Tobacco Use: Screening & Cessation Interventions 76 0028 AMA-PCPI Chart/ EHR DSRIP Network/ Outpatient Care P4P Annual; April 98 N/A Project 9 – Hospital-Wide Screening for Substance Use Disorder
9.1 Percent of hospitalized patients who are screened during the hospital stay using a validated screening questionnaire for unhealthy alcohol use 64 1661 Joint Commission Chart/ EHR Hospital/ Inpatient Care No Annual; April 9.2 Percent of patients aged 18 years and older with a diagnosis of current substance abuse or dependence who were screened for depression within the 12 month reporting period 68 Not Found AMA-PCPI Chart/ EHR DSRIP Network/ Outpatient Care No Annual; April 9.3 Initiation of alcohol and other drug treatment 52 0004 NCQA MMIS Department/ Inpatient Care, Outpatient Care P4P Annual; April 56 48.2 9.4 Engagement of alcohol and other drug treatment 38 0004 NCQA MMIS Department/ Inpatient Care, Outpatient Care P4P Annual; April 22 19 Project 10 – Hospital Partners with Residential Treatment Facility to Offer Alternative Setting to Intoxicated Patients – Project was not selected Project 11 – Improve Overall Quality of Care for Patients Diagnosed with Diabetes Mellitus and Hypertension 11.1 Lipid Management 58 Not Found NCQA Chart/ EHR DSRIP Network/ Outpatient Care No Annual; April 11.2 Foot Examination 43 Not Found NCQA Chart/ EHR DSRIP Network/ Outpatient Care No Annual; April 11.3 Eye Examination 39 0055 NCQA Chart/ EHR DSRIP Network/ Outpatient Care No Annual; April 11.4 Comprehensive Diabetes Care (CDC): Hemoglobin A1C (HbA1C) testing 29 0057 NCQA MMIS Department/ Outpatient Care No Annual; April 11.5 Uncontrolled Diabetes Admission Rate (PQI 14) 81 0638 (based on) AHRQ MMIS Department/ Inpatient Care P4P Annual; April 0.041 0.041