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Measure CountMeasure NameDSRIP #NQF#Measure StewardNJ Data SourceReporting Entity/ Setting of CareEligible for P4P?Reporting PeriodNJ ITGNational Benchmark Project 1 - Hospital-Based Educators Teach Optimal Asthma Care1.1CAC-1: Relievers for Inpatient Asthma170143Joint CommissionChart/ EHRHospital/ Inpatient CareNo1st SA = April2nd SA = October1.2CAC-2 systemic corticosteroids for Inpatient Asthma180144Joint CommissionChart/ EHRHospital/ Inpatient CareNo1st SA = April2nd SA = October1.3Use of Appropriate Medications for People with Asthma830036NCQAMMISDepartment/ Outpatient CareNoAnnual; April1.4Medication Management for People with Asthma – 75%601799NCQAMMISDepartment/ Outpatient CareP4PAnnual; April1.5Percent of patients who have had a visit to an Emergency Department for asthma in the past six months.66Not FoundHRSAMMISDepartment/ Emergency DepartmentP4P1st SA = April2nd SA = October1.6Adult Asthma Admission Rate60283AHRQMMISDepartment/ Inpatient CareP4P1st SA = April2nd SA = October1.7Asthma admission rate 13Not FoundAHRQMMISDepartment/ Inpatient CareP4P1st SA = April2nd SA = OctoberSubstitutionAsthma: Pharmacologic Therapy for Persistent Asthma890047AMA-PCPIChart/ EHRDSRIP Network/ Outpatient CareP4P Substitution1st SA = April2nd SA = OctoberSubstitutionAsthma Medication Ratio901800NCQAMMISDepartment/ Outpatient CareP4P SubstitutionAnnual; AprilProject 2 – Pediatric Asthma Case Management and Home Evaluations2.1CAC-1: Relievers for Inpatient Asthma170143Joint CommissionChart/ EHRHospital/ Inpatient CareNo1st SA = April2nd SA = October2.2CAC-2 systemic corticosteroids for Inpatient Asthma180144Joint CommissionChart/ EHRHospital/ Inpatient CareNo1st SA = April2nd SA = October2.3Use of Appropriate Medications for People with Asthma830036NCQAMMISDepartment/ Outpatient CareNoAnnual; April2.4Medication Management for People with Asthma – 75%601799NCQAMMISDepartment/ Outpatient CareP4PAnnual; April2.5Percent of patients who have had a visit to an Emergency Department for asthma in the past six months.66Not FoundHRSAMMISDepartment/ Emergency DepartmentP4P1st SA = April2nd SA = October2.6Percent of patients evaluated for environmental triggers other than environmental tobacco smoke (dust mites, cats, dogs, molds/fungi, cockroaches) either by history of exposure and/or by allergy testing.65Not FoundHRSAChart/ EHRDSRIP Network/ Outpatient CareP4P1st SA = April2nd SA = October2.7Asthma admission rate 13Not FoundAHRQMMISHospital/ Inpatient CareP4P1st SA = April2nd SA = OctoberSubstitutionAsthma: Pharmacologic Therapy for Persistent Asthma890047AMA-PCPIChart/ EHRDSRIP Network/ Outpatient CareP4P Substitution1st SA = April2nd SA = OctoberSubstitutionAsthma Medication Ratio901800NCQAMMISDepartment/ Outpatient CareP4P SubstitutionAnnual; AprilProject 3 – Integrated Health Home for the Seriously Mentally Ill (SMI)3.1Follow-up After Hospitalization for Mental Illness – 30 days post discharge400576NCQAMMISDepartment/ Outpatient CareNoAnnual; April3.2Antidepressant Medication Management – Effective Continuation Phase Treatment120105NCQAMMISDepartment/ Outpatient CareNoAnnual; April3.3Diabetes screening for people with schizophrenia or bipolar disorder who are prescribed antipsychotic medications (SSD)351932NCQAMMISDepartment/ Outpatient CareNoAnnual; April3.4Major Depressive Disorder (MDD): Suicide Risk Assessment590104AMA-PCPIChart/ EHRDSRIP Network/ Outpatient CareNo1st SA = April2nd SA = October3.5Mental Health Utilization62Not FoundNCQAMMISDepartment/ Inpatient Care, Outpatient CareNoAnnual; April3.6Follow-up After Hospitalization for Mental Illness – 7 days post discharge410576NCQAMMISDepartment/ Outpatient CareP4PAnnual; April3.7Antidepressant Medication Management – Effective Acute Phase Treatment110105NCQAMMISDepartment/ Outpatient CareP4PAnnual; April3.8Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use150110CQAIMHChart/ EHRDSRIP Network/ Outpatient CareP4PAnnual; April3.9Depression Remission at 12 Months330710MNCMChart/ EHRDSRIP Network/ Outpatient CareP4PAnnual; AprilSubstitutionCardiovascular health screening for people with schizophrenia or bipolar disorder who are prescribed antipsychotic medications941927NCQAChart/ EHRDSRIP Network/ Outpatient CareP4P SubstitutionAnnual; AprilSubstitutionAdherence to Antipsychotic Medications for Individuals with Schizophrenia911879CMSMMISDepartment/ Outpatient CareP4P SubstitutionAnnual; AprilSubstitutionCardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia931933NCQAMMISDepartment/ Outpatient CareP4P SubstitutionAnnual; AprilSubstitutionDiabetes Monitoring for People with Diabetes and Schizophrenia921934NCQAMMISDepartment/ Outpatient CareP4P SubstitutionAnnual; AprilProject 4 – Day Program and School Support Expansion – Project was not selectedProject 5 – Electronic Self-Assessment Decision Support Tool5.1Follow-up After Hospitalization for Mental Illness – 30 days post discharge400576NCQAMMISDepartment/ Outpatient CareNoAnnual; April5.2Bipolar Disorder and Major Depression: Appraisal for alcohol or chemical substance use150110CQAIMHChart/ EHRDSRIP Network/ Outpatient CareNoAnnual; April5.3Screening for Clinical Depression and Follow-up Plan790418CMSChart/ EHRDSRIP Network/ Outpatient CareNoAnnual; April5.4Mental Health Utilization62Not FoundNCQAMMISDepartment/ Inpatient Care, Outpatient CareNoAnnual; April5.5Weight Assessment and Counseling for Nutrition and Physical Activity for Children/ Adolescents870024NCQAChart/ EHR DSRIP Network/ Outpatient CareNoAnnual; April5.6Adult BMI Assessment7Not FoundNCQAMMISDepartment/ Outpatient CareNoAnnual; April5.7Adolescent Well-Care Visit5Not FoundNCQAMMISDepartment/ Outpatient CareNoAnnual; April5.8Follow-up After Hospitalization for Mental Illness – 7 days post discharge410576NCQAMMISDepartment/ Outpatient CareP4PAnnual; April5.9Depression Remission at 12 Months330710MNCMChart/ EHRDSRIP Network/ Outpatient CareP4PAnnual; April5.10Follow-up Care for Children Prescribed ADHD Medication (ADD)420108NCQAMMISDepartment/ Outpatient CareP4PAnnual; April5.11Antidepressant Medication Management – Effective Acute Phase Treatment110105NCQAMMISDepartment/ Outpatient CareP4PAnnual; AprilSubstitutionCardiovascular health screening for people with schizophrenia or bipolar disorder who are prescribed antipsychotic medications941927NCQAChart/ EHRDSRIP Network/ Outpatient CareP4P SubstitutionAnnual; AprilSubstitutionAdherence to Antipsychotic Medications for Individuals with Schizophrenia911879CMSMMISDepartment/ Outpatient CareP4P SubstitutionAnnual; AprilSubstitutionCardiovascular Monitoring for People with Cardiovascular Disease and Schizophrenia931933NCQAMMISDepartment/ Outpatient CareP4P SubstitutionAnnual; AprilSubstitutionDiabetes Monitoring for People with Diabetes and Schizophrenia921934NCQAMMISDepartment/ Outpatient CareP4P SubstitutionAnnual; AprilProject 6 – Care Transitions Intervention Model to Reduce 30-Day Readmissions for Chronic Cardiac Conditions6.1Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction90081AMA-PCPIChart/ EHRHospital/ Inpatient CareNoAnnual; April6.2Controlling High Blood Pressure310018NCQAChart/ EHRDSRIP Network/ Outpatient CareNoAnnual; April6.3Post-Discharge Appointment for Heart Failure Patients73Not FoundAMA-PCPIChart/ EHRHospital/ Inpatient CareNo1st SA = April2nd SA = October6.4Medication Reconciliation610097NCQAChart/ EHRDSRIP Network/ Outpatient CareNoAnnual; April6.5Removed6.630-Day All-Cause Readmission Following Heart Failure (HF) Hospitalization30330CMSMMISDepartment/ Inpatient CareP4PAnnual; April6.730-Day All-Cause Readmission Following Acute Myocardial Infarction (AMI) Hospitalization10505CMSMMISDepartment/ Inpatient CareP4PAnnual; April6.8Heart Failure Admission Rate450277AHRQMMISDepartment/ Inpatient CareP4PAnnual; April6.9Timely Transmission of Transition Record800648AMA-PCPIChart/ EHRHospital/ Inpatient CareP4P1st SA = April2nd SA = OctoberSubstitutionIschemic Vascular Disease (IVD): Complete Lipid Profile and LDL-C Control <100mg/dL550075CMSChart/ EHRDSRIP Network/ Outpatient CareP4P Substitution Annual; AprilSubstitutionIschemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic560068NCQAChart/ EHRDSRIP Network/ Primary CareP4P SubstitutionAnnual; AprilSubstitutionPreventive Care and Screening: High Blood Pressure75Not FoundAMA-PCPIChart/ EHRDSRIP Network/ Outpatient CareP4P SubstitutionAnnual; AprilSubstitutionPreventive Care and Screening: Tobacco Use: Screening & Cessation Interventions760028AMA-PCPIChart/ EHRDSRIP Network/ Outpatient CareP4P SubstitutionAnnual; AprilProject 7 – Extensive Patient CHF-Focused Multi-Therapeutic Model7.1Left Ventricular Ejection Fraction (LVEF) Assessment570079AMA-PCPIChart/ EHRDSRIP Network/ Outpatient CareNoAnnual; April7.2Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction90081AMA-PCPIChart/ EHRHospital/ Inpatient CareNoAnnual; April7.3Controlling High Blood Pressure310018NCQAChart/ EHRDSRIP Network/ Outpatient CareNoAnnual; April7.4Post-Discharge Appointment for Heart Failure Patients73Not FoundAMA-PCPIChart/ EHRHospital/ Inpatient CareNo1st SA = April2nd SA = October7.5Medication Reconciliation610097NCQAChart/ EHRDSRIP Network/ Outpatient CareNoAnnual; April7.6Removed7.730-Day All-Cause Readmission Following Heart Failure (HF) Hospitalization30330CMSMMISDepartment/ Inpatient CareP4PAnnual; April7.830-Day All-Cause Readmission Following Acute Myocardial Infarction (AMI) Hospitalization10505CMSMMISDepartment/ Inpatient CareP4PAnnual; April7.9Heart Failure Admission Rate450277AHRQMMISDepartment/ Inpatient CareP4PAnnual; April SubstitutionIschemic Vascular Disease (IVD): Complete Lipid Profile and LDL-C Control <100mg/dL550075CMSChart/ EHRDSRIP Network/ Outpatient CareP4P Substitution Annual; AprilSubstitutionIschemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic560068NCQAChart/ EHRDSRIP Network/ Outpatient CareP4P SubstitutionAnnual; AprilSubstitutionPreventive Care and Screening: High Blood Pressure75Not FoundAMA-PCPIChart/ EHRDSRIP Network/ Outpatient CareP4P SubstitutionAnnual; AprilSubstitutionPreventive Care and Screening: Tobacco Use: Screening & Cessation Interventions760028AMA-PCPIChart/ EHRDSRIP Network/ Outpatient CareP4P SubstitutionAnnual; AprilProject 8 – The Congestive Heart Failure Transition Program (CHF-TP)8.1Left Ventricular Ejection Fraction (LVEF) Assessment570079AMA-PCPIChart/ EHRDSRIP Network/ Outpatient CareNoAnnual; April8.2Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction90081AMA-PCPIChart/ EHRHospital/ Inpatient CareNoAnnual; April8.3Controlling High Blood Pressure310018NCQAChart/ EHRDSRIP Network/ Outpatient CareNoAnnual; April8.4Post-Discharge Appointment for Heart Failure Patients73Not FoundAMA-PCPIChart/ EHRHospital/ Inpatient CareNo1st SA = April2nd SA = October8.5Medication Reconciliation610097NCQAChart/ EHRDSRIP Network/ Outpatient CareNoAnnual; April8.6Removed8.730-Day All-Cause Readmission Following Heart Failure (HF) Hospitalization30330CMSMMISDepartment/ Inpatient CareP4PAnnual; April8.830-Day All-Cause Readmission Following Acute Myocardial Infarction (AMI) Hospitalization10505CMSMMISDepartment/ Inpatient CareP4PAnnual; April8.9Heart Failure Admission Rate450277AHRQMMISDepartment/ Inpatient CareP4PAnnual; AprilSubstitutionIschemic Vascular Disease (IVD): Complete Lipid Profile and LDL-C Control <100mg/dL550075CMSChart/ EHRDSRIP Network/ Outpatient CareP4P Substitution Annual; AprilSubstitutionIschemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic560068NCQAChart/ EHRDSRIP Network/ Outpatient CareP4P SubstitutionAnnual; AprilSubstitutionPreventive Care and Screening: High Blood Pressure75Not FoundAMA-PCPIChart/ EHRDSRIP Network/ Outpatient CareP4P SubstitutionAnnual; AprilSubstitutionPreventive Care and Screening: Tobacco Use: Screening & Cessation Interventions760028AMA-PCPIChart/ EHRDSRIP Network/ Outpatient CareP4P SubstitutionAnnual; AprilProject 9 – Hospital-Wide Screening for Substance Use Disorder9.1Percent of hospitalized patients who are screened during the hospital stay using a validated screening questionnaire for unhealthy alcohol use64Not FoundJoint CommissionChart/ EHRHospital/ Inpatient CareNo1st SA = April2nd SA = October9.2Percent 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 period68Not FoundAMA-PCPIChart/ EHRDSRIP Network/ Outpatient CareNoAnnual; April9.3Initiation of alcohol and other drug treatment520004NCQAMMISDepartment/ Inpatient Care, Outpatient CareP4PAnnual; April9.4Engagement of alcohol and other drug treatment380004NCQAMMISDepartment/ Inpatient Care, Outpatient CareP4PAnnual; AprilSubstitutionSubstance use disorders: percentage of patients aged 18 years and older with a diagnosis of current alcohol dependence who were counseled regarding psychosocial AND pharmacologic treatment options for alcohol dependence within the 12 month reporting period.95Not FoundAMA-PCPIChart/ EHRDSRIP Network/ Outpatient CareP4P SubstitutionAnnual; AprilProject 10 – Hospital Partners with Residential Treatment Facility to Offer Alternative Setting to Intoxicated Patients – Project was not selectedProject 11 – Improve Overall Quality of Care for Patients Diagnosed with Diabetes Mellitus and Hypertension11.1Lipid Management58Not FoundAMA-PCPIChart/ EHRDSRIP Network/ Outpatient CareNoAnnual; April11.2Foot Examination43Not FoundAMA-PCPIChart/ EHRDSRIP Network/ Outpatient CareNoAnnual; April11.3Eye Examination39Not FoundAMA-PCPIChart/ EHRDSRIP Network/ Outpatient CareNoAnnual; April11.4Comprehensive Diabetes Care (CDC): Hemoglobin A1C (HbA1C) testing290057NCQAMMISDepartment/ Outpatient CareNoAnnual; April11.5Uncontrolled Diabetes Admission Rate (PQI 14)810638AHRQMMISDepartment/ Inpatient CareP4PAnnual; April11.6Diabetes Short-Term Complications Admission Rate (PQI 1)360272AHRQMMISDepartment/ Inpatient CareP4PAnnual; April11.7Hypertension Admission Rate48Not FoundAHRQMMISDepartment/ Inpatient CareP4PAnnual; April11.8Controlling High Blood Pressure310018NCQAChart/ EHRDSRIP Network/ Outpatient CareP4PAnnual; April11.9Diabetes Long-Term Complications Admission Rate (PQI 3)340274AHRQMMISDepartment/ Inpatient CareP4PAnnual; April SubstitutionDiabetes Mellitus: Daily Aspirin or Antiplatelet Medication Use for Patients with Diabetes and Ischemic Vascular Disease1000729CMSChart/ EHRDSRIP Network/ Outpatient CareP4P SubstitutionAnnual; AprilSubstitutionMedical attention for nephropathy980062NCQAChart/ EHRDSRIP Network/ Outpatient CareP4P SubstitutionAnnual; AprilSubstitutionAdherence to Chronic Medications for People with Diabetes Mellitus: Hypoglycemic agents970545CMSMMISDepartment/ Outpatient CareP4P SubstitutionAnnual; AprilSubstitutionAdherence to Chronic Medications for People with Diabetes Mellitus: Statins960545CMSMMISDepartment/ Outpatient CareP4P SubstitutionAnnual; AprilProject 12 – Diabetes Group Visits for Patients and Community Education12.1Lipid Management58Not FoundAMA-PCPIChart/ EHRDSRIP Network/ Outpatient CareNoAnnual; April12.2Foot Examination43Not FoundAMA-PCPIChart/ EHRDSRIP Network/ Outpatient CareNoAnnual; April12.3Eye Examination39Not FoundAMA-PCPIChart/ EHRDSRIP Network/ Outpatient CareNoAnnual; April12.4Comprehensive Diabetes Care (CDC) : Hemoglobin A1C (HbA1C) testing290057NCQAMMISDepartment/ Outpatient CareNoAnnual; April12.5Hemoglobin A1c (HbA1c) Testing for Pediatric Patients460060NCQAMMISDepartment/ Outpatient CareNoAnnual; April12.6Controlling High Blood Pressure310018NCQAChart/ EHRDSRIP Network/ Outpatient CareP4PAnnual; April12.7Diabetes Short-Term Complications Admission Rate (PQI 1)360272AHRQMMISDepartment/ Inpatient CareP4PAnnual; April12.8Uncontrolled Diabetes Admission Rate (PQI 14)810638AHRQMMISDepartment/ Inpatient CareP4PAnnual; April12.9Diabetes Long-Term Complications Admission Rate (PQI 3)340274AHRQMMISDepartment/ Inpatient CareP4PAnnual; AprilSubstitutionDiabetes Mellitus: Daily Aspirin or Antiplatelet Medication Use for Patients with Diabetes and Ischemic Vascular Disease1000729CMSChart/ EHRDSRIP Network/ Outpatient CareP4P SubstitutionAnnual; AprilSubstitutionMedical attention for nephropathy980062NCQAChart/ EHRDSRIP Network/ Outpatient CareP4P SubstitutionAnnual; AprilSubstitutionAdherence to Chronic Medications for People with Diabetes Mellitus: Hypoglycemic agents970545CMSMMISDepartment/ Outpatient CareP4P SubstitutionAnnual; AprilSubstitutionAdherence to Chronic Medications for People with Diabetes Mellitus: Statins960545CMSMMISDepartment/ Outpatient CareP4P SubstitutionAnnual; AprilProject 13 – Develop Intensive Case Management for Medically Complex High Cost Patient – Project not selectedDepartment/ Primary CAreCareProject 14 – Patient Centered Medical Home for Patients with HIV/ AIDS – Project not selectedProject 15 – After-School Obesity Program15.1Percentage of patients with BMI greater than or equal to 25 who set an individualized goal along with target date for reduction in BMI.710421CMSChart/ EHRDSRIP Network/ Outpatient CareNoAnnual; April15.2Children and Adolescents’ Access to Primary Care Practitioners27Not FoundNCQAMMISDepartment/ Outpatient CareNoAnnual; April15.3Weight Assessment and Counseling for Nutrition and Physical Activity for Children/ Adolescents870024NCQAChart/ EHRDSRIP Network/ Outpatient CareP4PAnnual; April15.4Children Age 6-17 Years who Engage in Weekly Physical Activity261348HRSAChart/ EHRDSRIP Network/ Outpatient CareP4P1st SA = April2nd SA = OctoberProject 16 – Wellness Program for Parents and Preschoolers – Project not selectedProject 17 – Patients Receive Recommended Care for Community-Acquired Pneumonia17.1Percentage of patients aged greater than or equal to 18 years diagnosed with community-acquired bacterial pneumonia who had a chest x-ray performed70Not FoundAMA-PCPIChart/ EHR Hospital/ Inpatient CareNo1st SA = April2nd SA = October17.2Percentage of patients aged greater than or equal to 18 years diagnosed with community-acquired bacterial pneumonia for whom mental status is assessed69Not FoundAMA-PCPIChart/ EHR Hospital/ Inpatient CareNoAnnual; April17.3Initial antibiotic selection for community-acquired pneumonia (CAP) in immunocompetent patients – Non-Intensive Care Unit 50Not FoundJoint CommissionChart/ EHRHospital/ Inpatient CareNo1st SA = April2nd SA = October17.4Initial antibiotic selection for community-acquired pneumonia (CAP) in immunocompetent patients –Intensive Care Unit (ICU)49Not FoundJoint CommissionChart/ EHRHospital/ Inpatient CareNo1st SA = April2nd SA = October17.5Initial antibiotic selection for community-acquired pneumonia (CAP) in immunocompetent patients510147CMSChart/ EHRHospital/ Inpatient CareP4PAnnual; April17.630-Day All-Cause Readmission Following Pneumonia (PN) Hospitalization40506CMSMMISDepartment/ Inpatient CareP4PAnnual; AprilSubstitutionEmergency Medicine: Community-Acquired Bacterial Pneumonia (CAP): Empiric Antibiotic1010096AMA-PCPIChart/ EHRHospital/ Inpatient CareP4P SubstitutionAnnual; AprilDefinition Key:Department – Refers to the New Jersey Department of HealthDSRIP Network – Refers to the DSRIP hospital’s outpatient (non-ED, non-inpatient) reporting entities. This may include the hospital-based clinic (as identified through hospital billing practices), a community-based reporting partner, or a combination of the two.Hospital – Refers to the participating DSRIP hospitalInpatient Care – Refers to the setting where care is received as a result of an admission order to a hospital.Outpatient Care – Refers to outpatient, (non-ED, non-inpatient) ambulatory care. This may include physical health or behavioral health care.Acronym Key:AHRQ – Agency for Healthcare Research and QualityAMA – American Medical AssociationAMA- PCPI – American Medical Association – Physician Consortium for Performance ImprovementCDC – Centers for Disease Control and PreventionCMS – Centers for Medicare & Medicaid Services CQAIHM – Center for Quality Assessment and Improvement in Mental HealthEHR – Electronic Health RecordHAB – HIV/AIDS BureauHRSA – Health Resources and Services AdministrationICSI – Institute for Clinical Systems ImprovementMCHB – Maternal and Child Health BureauMNCM – Minnesota Community MeasurementMMIS – Medicaid Management Information SystemNCQA – National Committee for Quality AssuranceP4P – Pay for Performance ................
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