Swope Health Services - Quality Measures

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Quality Measures

Clinical Measures	Goal
Diabetes Measures
Average HbA1C	< 7.0
Patients with 2 HbA1C’s at least 91 days apart	> 90%
Documentation of Self–Management Goal	> 70%
Cardiac Risk Option 1: ACE or ARB	> 75%
Cardiac Risk Option 2: Statins	> 60%
Patients with BP < 130/80	> 40%
Dental Exam in Last Year	> 70%
Patients with LDL < 100	> 70%
Foot Exam in Past Year (CDC Measure)	> 79%
Flu Immunization in Past Year (CDC Measure)	> 40%
Pneumonia Immunization Ever (CDC Measure)	> 60%
Dilated Retinal Exam in Last Year (CDC Measure)	> 48%
Cardio Vascular Disease Measures
Patients with Hypertension BP < 140/90	> 50 %
Patients with 2 BPs in Last Year at least 3 months a part	> 90%
Patients with Fasting Lipid Profile Documented	> 80%
LDL Cholesterol < 100 (CAD or DM)	> 60 %
Documentation of Self–Management Goal	> 70 %
Aspirin or other antithrombotic agent use (CAD)	> 90 %
Asthma Measures
Current Severity Assessment	> 90 %
Appropriate treatment with anti-inflammatory medication	> 95 %
Current Self Management Goal	> 70 %
Number of Symptom – Free days in Previous two weeks	> 10 days

Clinical Measures

Goal

Diabetes Measures

Average HbA1C

< 7.0

Patients with 2 HbA1C’s at least 91 days apart

> 90%

Documentation of Self–Management Goal

> 70%

Cardiac Risk Option 1: ACE or ARB

> 75%

Cardiac Risk Option 2: Statins

> 60%

Patients with BP < 130/80

> 40%

Dental Exam in Last Year

> 70%

Patients with LDL < 100

> 70%

Foot Exam in Past Year (CDC Measure)

> 79%

Flu Immunization in Past Year (CDC Measure)

> 40%

Pneumonia Immunization Ever (CDC Measure)

> 60%

Dilated Retinal Exam in Last Year (CDC Measure)

> 48%

Cardio Vascular Disease Measures

Patients with Hypertension BP < 140/90

> 50 %

Patients with 2 BPs in Last Year at least 3 months a part

> 90%

Patients with Fasting Lipid Profile Documented

> 80%

LDL Cholesterol < 100 (CAD or DM)

> 60 %

Documentation of Self–Management Goal

> 70 %

Aspirin or other antithrombotic agent use (CAD)

> 90 %

Asthma Measures

Current Severity Assessment

> 90 %

Appropriate treatment with anti-inflammatory medication

> 95 %

Current Self Management Goal

> 70 %

Number of Symptom – Free days in Previous two weeks

> 10 days

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Life Cycle	Measures
Perinatal	Percentage of pregnant women with prenatal care by end of first trimester.
Percentage of women, who had a postpartum visit within 42 days after delivery.
Percentage of newborns, who had a follow-up visit within 14 days of birth.
Child	Percentage of children 5 through 18 years of age diagnosed with “persistent” asthma, who were prescribed appropriate medications.
Adolescent	Percentage of adolescents, with both a documented Behavioral Risk Assessment and who had a related counseling visit.
Adult	Percentage of adults diagnosed with an abnormal lipid profile, whose levels are under control.
Percentage of adults diagnosed with hypertension, whose blood pressure is under control.
Percentage of adults with type 1 or type 2 diabetes, whose last HbA1c < 7 %.
Percentage of adults, who are tobacco users, who have received counseling and/or a treatment plan to quit.
Oral	Percentage of dental patients, with a comprehensive oral exam and a treatment plan completed within a 12 month period.
Mental Health	a. Percentage of all adult patients, with screening for depression OR b. Percentage of patients with major depression, who have a 50% decrease in depression severity score.
All Life Cycles	Percentage of patients (a-children OR b- adolescent OR c-adult OR d-geriatric OR e-HIV/AIDS), with appropriate immunizations.
All Life Cycles	Percentage of patients (a-children & adolescents OR b-adults) with a Body Mass Index indicating overweight or obesity, who have received healthy weight counseling and/or other related interventions or treatment.

Life Cycle

Measures

Perinatal

Percentage of pregnant women with prenatal care by end of first trimester.

Percentage of women, who had a postpartum visit within 42 days after delivery.

Percentage of newborns, who had a follow-up visit within 14 days of birth.

Child

Percentage of children 5 through 18 years of age diagnosed with “persistent” asthma, who were prescribed appropriate medications.

Adolescent

Percentage of adolescents, with both a documented Behavioral Risk Assessment and who had a related counseling visit.

Adult

Percentage of adults diagnosed with an abnormal lipid profile, whose levels are under control.

Percentage of adults diagnosed with hypertension, whose blood pressure is under control.

Percentage of adults with type 1 or type 2 diabetes, whose last HbA1c < 7 %.

Percentage of adults, who are tobacco users, who have received counseling and/or a treatment plan to quit.

Oral

Percentage of dental patients, with a comprehensive oral exam and a treatment plan completed within a 12 month period.

Mental Health

a. Percentage of all adult patients, with screening for depression OR
b. Percentage of patients with major depression, who have a 50% decrease in depression severity score.

All Life Cycles

Percentage of patients (a-children OR b- adolescent OR c-adult OR d-geriatric OR e-HIV/AIDS), with appropriate immunizations.

All Life Cycles

Percentage of patients (a-children & adolescents OR b-adults) with a Body Mass Index indicating overweight or obesity, who have received healthy weight counseling and/or other related interventions or treatment.

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