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ACO Measures and Workflows

The following information contains details on the various ACO measures and their required workflows. Each measure will specify in detail what is being measured and how to meet it. In the appendix you will find additional information about our QM Smart Text, Depression Screening and Fall Risk workflows.

ACO 12 - Medication Reconciliation

a. Measure Specification- The percentage of patients aged 65 years and older discharged from any inpatient facility (e.g., hospital, skilled nursing facility, or rehabilitation facility) and seen within 30 days following discharge in the office by the physician providing ongoing care who had a reconciliation of the discharge medications with the current medication list in the outpatient medical record documented.

b. Workflow- Mark the patient’s medication list as reviewed in the Medications activity or the Medication Documentation navigator section.

ACO 13 - Falls: Screening for Fall Risk

a. Measure Specification- Percentage of patients aged 65 years and older who were screened for future fall risk at least once within 12 months.

b. Workflow- Please reference the Fall Risk tips notated in the appendix below. ACO 14 – Preventive Care and Screening: Influenza Immunization

a. Measure Specification- Percentage of patients aged 6 months and older seen for a visit between October 1 and March 31 who received an influenza immunization OR who reported previous receipt of an influenza immunization.

b. Workflow- Follow the workflow to order and administer an influenza immunization. i. If you did not administer the influenza vaccine, use SmartText QM: PREVENTIVE CARE

SCREENING: INFLUENZA IMMUNIZATION in the progress note or document in the Allergy activity to document why.

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ACO 15 - Preventive Care and Screening: Pneumonia Vaccination for Patients 65 Years and Older

a. Measure Specification - Percentage of patients aged 65 years and older who have ever received a pneumococcal vaccine.

b. Workflow- Follow the workflow to order and administer a pneumococcal immunization. i. Use SmartText QM: PREVENTIVE CARE SCREENING: PNEUMONIA VACCINATION in the

progress note or document in the Allergy activity if the procedure cannot be performed for a valid reason.

ACO 16 - Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up

a. Measure Specification - Percentage of patients aged 18 years and older with a calculated BMI in the past six months or during the current visit documented in the medical record AND if the most recent BMI is outside of normal parameters, a follow-up plan is documented within the past six months or during the current visit.

b. Workflow - Document both height and weight for the patient during a visit. The system will calculate BMI based on this information. If the system could not document the patient’s BMI, document why using SmartText QM: BMI SCREENING – UNABLE TO PERFORM. If the BMI is elevated, document a follow up plan with the SmartText QM: BMI ELEVATED – FOLLOW UP PLAN.



ACO 17 - Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention

a. Measure Specification - The percentage of patients aged 18 and older who were screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.

b. Workflow - During visits with current tobacco users, document patient counseling by completing the “Counseling Given” question in the Vitals navigator section, History navigator section, or History activity.

i. Prescribe the appropriate management of the patients tobacco use for patients ready to quit.

ACO 18 - Preventive Care and Screening: Screening for Clinical Depression and Follow-up Plan

a. Measure Specification - Percentage of patients aged 12 and older screened for clinical depression during the measurement period using an age-appropriate standardized screening tool AND, if positive, a follow-up plan is documented on the date of the positive screen.

b. Workflow – Please reference the Depression Screening Tip Sheet located in the appendix below. ACO 19 - Preventive Care and Screening: Colorectal Cancer Screening

a. Measure Specification - Percentage of patients aged 50 through 75 years who received the appropriate colorectal cancer screening.

b. Workflow - Review if the patient is due for a colorectal cancer screening in Health Maintenance. If needed order the test and later review the results in the InBasket.



ACO 20 – Preventive Care and Screening: Breast Cancer Screening a. Measure Specification - Percentage of women aged 40 through 69 years who had a mammogram

to screen for breast cancer within 24 months. b. Workflow - Review if the patient has received a mammogram within the past 24 months. If needed

order a mammogram and later review the results in the InBasket. i. Overriding the Health Maintenance without a corresponding result will not allow for meeting the

measure. ii. To document an external Breast Cancer Screening simply hit the Ext Result button from

Enter/Edit Results as shown below



ACO 21 - Preventive Care and Screening: Screening for High Blood Pressure and Follow-up Documented

a. Measure Specification - Percentage of patients aged 18 and older seen during the measurement period who are screened for high blood pressure (BP) AND a recommended follow-up plan is documented based on the current blood pressure reading as indicated.

b. Workflow - When a patient without known hypertension is seen, a nurse records the patient’s blood pressure in the Vitals navigator section. Follow-Up plans can be documented using the QM Smart Tool: BP Elevated Follow Up Plan. This tool is detailed in the appendix.

ACO 22 - Composite (All or Nothing Scoring): Diabetes Mellitus: Hemoglobin A1c Control

a. Measure Specification - Percentage of patients aged 18 to 75 years of age with diabetes mellitus who had HbA1c < 8.0 percent.

b. Workflow – When ordering and resulting a Hemoglobin A1c test the results are entered with discrete values. This numeric value needs to be attached to the order by entering it in the Enter/Edit Results field.

i. Note that attaching a scanned result will not count for the measure. The numeric value needs to be entered in the system discretely.

ACO 23 - Composite (All or Nothing Scoring): Diabetes Mellitus: Low Density Lipoprotein (LDL-C)

Control

a. Measure Specification - Percentage of patients ages 18 to 75 years of age with diabetes mellitus who had LDL-C < 100 mg/dL.

b. Workflow – When a diabetes patient aged 18 through 75 years is seen, the clinician orders an LDL cholesterol test. A lab technician enters results for the LDL-C result component.

i. Alternatively, a nurse or other clinical user enters the results using Enter/Edit Results. This needs to be completed in the event that a result comes back via fax or paper.

ACO 24 - Composite (All or Nothing Scoring): Diabetes Mellitus: High Blood Pressure Control

a. Measure Specification - Percentage of patients ages 18 to 75 years of age with diabetes mellitus who had a blood pressure < 140/90 mmHg.

b. Workflow – The patient’s blood pressure is entered into the vitals section.



ACO 25 - Composite (All or Nothing Scoring): Diabetes Mellitus: Tobacco Non-Use

a. Measure Specification - Percentage of patients ages 18 to 75 years of age with a diagnosis of diabetes who indicated they were tobacco non-users.

b. Workflow – During visits with diabetic patients, document tobacco use in the Vitals navigator section, History navigator section, or History activity.

ACO 26 - Composite (All or Nothing Scoring): Diabetes Mellitus: Daily Aspirin or Antiplatelet Medication

Use for Patients with Diabetes and Ischemic Vascular Disease

a. Measure Specification - Percentage of patients ages 18 to 75 years of age with diabetes mellitus and ischemic vascular disease with documented daily aspirin or antiplatelet medication use during the measurement year unless contraindicated.

b. Workflow – During visits with diabetic patients, document the appropriate diagnoses. Additionally it is important to mark any aspirin use in the Home Medications section.



ACO 27 - Diabetes Mellitus: Hemoglobin A1c Poor Control

a. Measure Specification - Percentage of patients aged 18 through 75 years with diabetes mellitus who had most recent hemoglobin A1c greater than 9.0%.

b. Workflow – When ordering and resulting a Hemoglobin A1c test the results are entered with discrete values. This numeric value needs to be attached to the order by entering it in the Enter/Edit Results field.

i. Note that attaching a scanned result will not count for the measure. The numeric value needs to be entered in the system discretely.

ACO 28 - Hypertension (HTN): Controlling High Blood Pressure

a. Measure Specification - Percentage of patients aged 18 through 85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (< 140/90 mmHg) during the measurement year.

b. Workflow – When a patient arrives for the visit the appropriate diagnoses are made to document hypertension. Additionally the patient’s blood pressure is documented in the vitals section.



ACO 29 - Ischemic Vascular Disease (IVD): Complete Lipid Profile and Low Density Lipoprotein (LDL-C)

a. Measure Specification - Percentage of patients aged 18 years and older with ischemic vascular disease (IVD) who received at least one lipid profile within 12 months and whose most recent LDL-C level was in control (less than 100 mg/dL).

b. Workflow – When a patient with IVD is seen, a clinician ensures that IVD is on the patient’s active problem list. If it isn’t, the clinician adds it to the patient’s problem list (and records IVD as an encounter diagnosis, if appropriate). You also can order an LDL cholesterol lab test or a full lipid panel if one has not been ordered recently.

i. Note that if the result is returned via paper or fax it must be additionally entered into the order via the enter/edit results section.

ACO 30 - Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic

a. Measure Specification - Percentage of patients aged 18 years and older with ischemic vascular disease (IVD) with documented use of aspirin or other antithrombotic.

b. Workflow – When a patient with IVD is seen, document IVD as an encounter diagnosis. If the patient is not currently taking aspirin or another antithrombotic medication, order one of these medications.

ACO 31 - Heart Failure: Beta- Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD)

a. Measure Specification - Percentage of patients aged 18 years and older with a diagnosis of heart failure (HF) with a current or prior left ventricular ejection fraction (LVEF) < 40% who were prescribed beta-blocker therapy either within a 12 month period when seen in the outpatient setting OR at each hospital discharge.

b. Workflow – Using Enter/Edit results, discretely document a patient’s Left Ventricular Ejection Fraction when performing an echo. For patients with an LVEF less than 40%, prescribe a beta-blocker.



ACO 32 - Composite (All or Nothing Scoring): Coronary Artery Disease (CAD): Lipid Control

a. Measure Specification - Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who have a LDL-C result < 100 mg/dL OR patients who have a LDL-C result ≥ 100 mg/dL and have a documented plan of care to achieve LDL-C < 100 mg/dL, including at the minimum the prescription of a statin.

b. Workflow – Order lipid lowering therapy during visits with patients with coronary artery disease. i. Use SmartText QM: CAD: DRUG THERAPY FOR LOWERING LDL-C in the progress note or

document in the Allergy activity if the order should not be placed for a valid reason. ACO 33 - Composite (All or Nothing Scoring): Coronary Artery Disease (CAD) Angiotensin-Converting

Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy – Diabetes or Left Ventricular Left Ventricular Systolic Dysfunction (LVEF < 40%)

a. Measure Specification - Percentage of patients aged 18 years and older with a diagnosis of coronary artery disease seen within a 12 month period who also have diabetes OR a current or prior Left Ventricular Ejection Fraction (LVEF) < 40% who were prescribed ACE inhibitor or ARB therapy.

b. Workflow – Order an echocardiogram during a visit with a patient with CAD but without a recent LVEF result. Discretely document the results of the test using Enter/Edit results. For patients with an LVEF less than 40%, prescribe an ACE inhibitor or ARB therapy.

i. Use a result component that contains a % in the units column. Appendix QM Smart Tool: You can use the QM Smart Tool shown below to track many of your quality measures. All of the QM SmartText items that are referenced in this tip sheet are housed in this tool. Simply call it up in a note using .QM. You can also bring up each individual item by the id in the Insert Smart Text field.



Depression Screening Workflow All patients age 65 and over will display a Health Maintenance alert for annual depression screenings if not performed in the past year. 1. The Best Practice Advisory for overdue depression screening will display when the office visit encounter

is opened.

2. Click Depression on the navigator to open the section then click on the New Reading button.

3. Select the appropriate choices for the two items listed in PHQ-2. A score of 3 or higher will expand the

PHQ-9 questionnaire. Close this section after all items are completed.



4. If the PHQ-2 score is less than 3, or the PHQ-9 score is less than 5, the MA will see a second BPA with instructions to complete the documentation for a negative depression screening. Click the Accept button to open the Smartset, then select the appropriate check boxes. If the PHQ-9 is performed, “Annual Depression Screening (G0444)” should be selected for billing purposes. The correct diagnosis will automatically associate with each order selected.

5. If the PHQ-9 score is 5 or greater, the provider will see a BPA with instructions to complete the

documentation for a positive depression screening. a. When the provider opens the office visit encounter from a secured workstation, click on the highlighted

BestPractice section. Open SmartSet will be checked on.

b. When the provider opens the office visit encounter from the schedule, the BestPractice Advisory will

display. Open SmartSet will be checked on.



Click on the Accept button above to open the CHP ACO Screening SmartSet.

6. To document the follow-up plan, “Depression Screening Note” may be selected to automatically add a

documentation SmartPhrase to the Progress Note. Clicking on the word “edit” allows for the SmartLists in the note to be completed by the provider. Alternatively, the provider may use the SmartPhrase, .ACOPLANDEPRESSION to manually insert this note into the Assessment/Plan, or may create his/her own note to document the follow-up plan.

7. Click on the Sign button when all SmartSet selections are complete. The office visit navigator now

includes the Progress Note (when selected), the Visit Diagnosis and Procedure ordered in the SmartSet. Continue the workflow for this office visit.



Fall Risk Screening Workflow All patients age 65 and over will display a Health Maintenance alert for annual Fall Risk screenings if not performed in the past year. 1. The Best Practice Advisory for overdue fall risk screening will display when the office visit encounter is

opened. Click on the Accept button.

2. Click Fall Risk on the navigator to open the section with two assessment questions. Answer yes or no,

then add comments as needed by clicking on the small paper icon.

3. After closing the Fall Risk section, the related BPA will display. Click on the Accept button.



4. The negative or positive Fall Risk SmartSet with Fall Risk Screening orders will display. Click in the checkbox for HM Fall Risk procedure order. The appropriate diagnosis will automatically associate with the order based on the assessment. Click on the Sign button.

NOTE: When more than one Diagnoses is listed, the Primary diagnosis is the first one listed. This can be changed by clicking under the P column for another diagnosis to be designated Primary.

5. If the clinician is not an Authorizing Provider, the pop-up screen below will appear. Select the correct

provider for procedures, then click on the Accept button.



6. The office visit navigator now includes the Visit Diagnosis and Procedure ordered in the SmartSet. Continue the workflow for this office visit.

7. To document the follow-up plan, “CHP FALL RISK PLAN” may be selected to automatically add a

documentation SmartPhrase to the Progress Note. Clicking on the word “edit” allows for the SmartLists in the note to be completed by the provider. Alternatively, the provider may use the SmartPhrase, .FALLSRISKPLAN to manually insert this note into the Assessment/Plan, or may create his/her own note to document the follow-up plan.

8. Click on the Sign button when all SmartSet selections are complete. The office visit navigator now

includes the Progress Note (when selected), the Visit Diagnosis and Procedure ordered in the SmartSet. Continue the workflow for this office visit.


Documents

ACO Measures and Workflows - summalearner.comsummalearner.com/assets/aco-measures-and-workflows-bulletin... · ACO Measures and Workflows ... ACO Measures and Workflows ACO 21 - Preventive