NQF# 2016 UDS Quality of Care, Health Outcomes and Disparities Measures CMS eCQM 2016 2016 PQRSCMS Quality

Payment Program (QPP)

2016 CMS ACO Quality

Measures

ACO/PCMH measures

(Consensus Core Set version

1.0)

0032 Cervical Cancer Screening (CCS) CMS 124v4 309 309 Yes

0038 Childhood Immunization Status CMS 117v4 240 240

0034 Colorectal Cancer Screening (COL) CMS 130v4 113 113 ACO 19 Yes

0059 Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%) CMS 122v4 001 001 ACO 27 Yes

0018 Controlling High Blood Pressure CMS 165v4 236 236 ACO 28 Yes

N/A Coronary Artery Disease (CAD): Lipid Therapy

2508 Dental Sealants for Children between 6-9 Years CMS 277v0

N/A Early Entry into Prenatal Care

N/A HIV Linkage to Care

0068 Ischemic vascular disease (IVD): Use of Aspirin or Another Antiplatelet CMS 164v4 204 204 ACO 30 ACO only

N/A Low Birth Weight

0028 Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention CMS 138v4 226 226 ACO 17 Yes

0421 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan CMS 69v4 128 128 ACO 16 Yes

0418 Preventive Care and Screening: Screening for Depression and Follow-Up Plan CMS 2v5.0 134 134 ACO 18

0036 Use of Appropriate Medications for Asthma CMS 126v4 311

N/A Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC) CMS 155v4 239 239

Sources:Uniform Data System (UDS) Reporting Instructions for 2016 Health Center DataNational Quality Forum (NQF) Quality Positioning System2016 CMS Physician Quality Reporting System (PQRS) Measure ListCMS eCQM library Annual Updates CMS Quality Payment program (QPP, aka. MACRA/MIPS)CMS Accountable Care Organization 2016 Program Quality Measure Narrative SpecificationsACO and PCMH/Primary Care Consensus Core Measure Set, Core Quality Measure Collaborative

December 2016

Uniform Data Set (UDS) Measure Crosswalk to Other Quality Reporting Programs

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U1RRH29052, Rural Quality Improvement Technical Assistance Cooperative Agreement, $500,000 (0% financed with nongovernmental sources). This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. Government.

2016 UDS Quality of Care, Health Outcomes and Disparities Measures Description

Cervical Cancer Screening (CCS) Percentage of women 21 - 64 years of age, who received one or more Pap tests to screen for cervical cancer

Childhood Immunization Status Percentage of children 2 yerars of age who received age appropriate vaccines by their 2nd birthday

Colorectal Cancer Screening (COL) Percentage of patients 50 through 75 years of age who had appropriate screening for colorectal cancer

Comprehensive Diabetes Care: Hemoglobin A1c (HbA1c) Poor Control (>9.0%)

Percentage of patients 18-75 years of age with diabetes who had hemoglobin A1c (HbA1c) greater than 9.0 percent during the measurement period

Controlling High Blood PressurePercentage of patients 18-85 years old who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (less than 140/90 mm Hg) during the measurement period

Coronary Artery Disease (CAD): Lipid Therapy Percentage of patients aged 18 or older with a diagnosis of CAD who were prescribed a lipid lowering therapy

Dental Sealants for Children between 6-9 Years Percentage of children aged 6 through 9 years, at moderate to high risk of caries who received a sealant on a first permanent molar

Early Entry into Prenatal Care Female patients beginning prenatal care at the health center or with the referred provider during their first trimester

HIV Linkage to CarePercentage of patients whose first ever HIV diagnosis was made by health center staff between October 1, of the prior year and September 30, of the measurement year and who were seen for follow-up treatment within 90 days of that first ever diagnosis

Ischemic vascular disease (IVD): Use of Aspirin or Another Antiplatelet Percentage of patients aged 18 and older with a diagnosis of IVD or AMI, CABG, or PCI procedure with aspirin or another antithrombotic therapy

Low Birth Weight Percentage of babies of health center prenatal care patients born whose birth weight was below normal (less than 2,500 grams)

Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention

Percentage of patients aged 18 years and older who (1) were screend for tobacco use one or more times within 24 months and if identified to be a tobacco user (2) received cessation counseling intervention

Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up Plan

Percentage of patients aged 18 and older with (1) BMI documented and (2) follow-up plan documented if MBI is outside normal parameters

Preventive Care and Screening: Screening for Depression and Follow-Up Plan

Percentage of patients aged 12 and older who were (1) screened for depression with a standardized tool and, if screening was positive, (2) had a follow-up plan documented

Use of Appropriate Medications for Asthma Percentage of patients aged 5 through 64 years of age identified as having persistent asthma and were appropriately prescribed medication during the measurement period

Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents (WCC)

Percentage of patients 3 - 17 years of age with a BMI percentile, and counseling on nutrition and physicial activity documented

Source:Uniform Data System (UDS) Reporting Instructions for 2016 Health Center Data

December 2016

This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U1RRH29052, Rural Quality Improvement Technical Assistance Cooperative Agreement, $500,000 (0% financed with nongovernmental sources). This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS, or the U.S. Government.