MBHR14 Sleep Quality Response at 3-months

Measure Title
Sleep Quality Response at 3-months

Measure Description
Percentage of patients 18 years and older who reported sleep quality concerns (e.g., insomnia) with documentation of a standardized tool AND demonstrated a response to treatment at three months (+/- 60 days) after index visit.

Denominator

DENOMINATOR:

Patients aged >= 18 years of age

AND
Patient Encounter CPT codes:
0362T, 0373T, 90785, 90791, 90792, 90832,90833, 90834, 90836, 90837, 90838, 90839, 90840, 90845, 90846, 90847, 90849, 90853, 90863, 90875, 90876, 96110, 96112, 96113, 96116, 96121, 96127, 96130, 96131, 96132, 96133, 96136, 96137, 96138, 96139, 96146, 96156, 96158, 96159, 96164, 96165, 96167, 96170, 96171, 96178, 97129, 97130, 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 98966, 98967, 98968, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215,99354, 99355, 99406, 99407, 99408, 99409, 99446, 99447, 99448, 99449, 99484, 99492, 99493, 99494, G2011, G2061, G2062, G2063, G0396, G0397, G0402, G0438, G0439

AND
Index Event Date: Initial (Index) Insomnia Severity Index (ISI) score of 15 or higher
AND
Follow Up Event Date: A Follow Up Insomnia Severity Index (ISI) score

Numerator

Patients 18 years and older who reported sleep quality concerns (e.g., insomnia) and an initial (index) Insomnia Severity Index (ISI) score of 15 or higher and reduction of 5 points or greater from the index score, three months (+/- 60 days) after index date.

Denominator Exclusions
• Patients who die OR
• Are enrolled in hospice in the measurement year (PRO2014.1Y1 ) OR
• Are unable to complete the Insomnia Severity Index (ISI) at follow-up due to cognitive deficit, visual deficit, motor deficit, language barrier, or low reading level, AND a suitable recorder (e.g., advocate) is not available (PRO2014.1Y2)

Denominator Exceptions (PRO2014.8Y )
• Patient refused to complete the Insomnia Severity Index (ISI) at follow-up OR
• Ongoing care not indicated (e.g., referred to another provider or facility, consultation only) OR
• Patient self-discharged early (e.g., financial or insurance reasons, transportation problems, or reason unknown) OR
• Medical reasons (e.g., scheduled for surgery or hospitalized)

NQS Domain

Effective Clinical Care

NQF Number

N/A

High Priority

Yes

High Priority Type

Outcome

Measure Type

Patient Reported Outcome (PRO)

Meaningful Measure Area

Functional Outcomes

Inverse Measure

No

Proportional Measure

Yes

Continuous Variable Measure

No

Ratio Measure

No

Number of performance rates to be submitted

1

 Overall Performance Rate

1st performance rate

Measure Risk-Adjusted?

No

Care Setting

Ambulatory Care: Clinician Office/Clinic, Ambulatory Care: Hospital, Home Care, Hospital, Hospital Inpatient, Hospital Outpatient, Long Term Care, Nursing Home, Outpatient Services, Rehabilitation Facility, Rehabilitation Facility: Inpatient

Includes Telehealth?    

Yes