PT/OT/Orthopedics Quality QCDR Measures: 2021

Quality IdMeasure NameHigh PriorityMeasure TypeMeasure Descriptionhf:tax:specialty_measure_setshf:tax:collection_types
MBHR03Pain Interference Response utilizing PROMISyesPatient Reported OutcomeThe percentage of adult patients (18 years of age or older) who report pain issues and demonstrated a response to treatment at one month from the index scoreDetails
HM04Functional Status Change for Patients With Upper-limb Functional Status DeficityesPatient Reported OutcomePercentage of patients aged 13 years or older with a functional deficit related to the upper-limb who achieve a Minimal Clinically Important Difference (MCID) in QuickDASH or equivalent score that indicates a functional improvement greater than zero. Two rates will be reported:
• The overall proportion of patients achieving an MCID in QuickDASH change score.
• The Risk-Adjusted MCID proportional difference where the difference between the risk adjusted predicted MCID and the observed MCID (measured via QuickDASH or equivalent tool) proportion is greater than zero.

The measure contains two goals: 1) for patients to achieve an unadjusted MCID greater than zero and, 2) for patients to achieve a risk adjusted MCID where the difference between the risk adjusted predicted MCID and the observed MCID proportion will be greater than zero. The measure is adjusted to patient characteristics known to be associated with functional status and quality of life outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality.
Details
HM05Functional Status Change for Patients With Neck Functional Status DeficityesPatient Reported OutcomePercentage of patients aged 18 years or older with a functional deficit related to the neck who achieve a Minimal Clinically Important Difference (MCID) in the Neck Disability Index (NDI) or equivalent score that indicates a functional improvement greater than zero. Two rates will be reported:
• The overall proportion of patients achieving an MCID in NDI change score.
• The Risk-Adjusted MCID proportional difference where the difference between the risk adjusted predicted MCID and the observed MCID (measured via NDI or equivalent tool) proportion is greater than zero.

The measure contains two goals: 1) for patients to achieve an unadjusted MCID greater than zero and, 2) for patients to achieve a risk adjusted MCID where the difference between the risk adjusted predicted MCID and the observed MCID proportion will be greater than zero. The measure is adjusted to patient characteristics known to be associated with functional status and quality of life outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality.
Details
HM06Functional Status Change for Patients With Low Back Functional Status DeficityesPatient Reported OutcomePercentage of patients aged 18 years or older with a functional deficit related to the low back who achieve a Minimal Clinically Important Difference (MCID) in the Modified Oswestry Low Back Pain Questionnaire (ODI) or equivalent score that indicates a functional improvement greater than zero. Two rates will be reported:
• The overall proportion of patients achieving an MCID in NDI change score.
• The Risk-Adjusted MCID proportional difference where the difference between the risk adjusted predicted MCID and the observed MCID (measured via NDI or equivalent tool) proportion is greater than zero.

The measure contains two goals: 1) for patients to achieve an unadjusted MCID greater than zero and, 2) for patients to achieve a risk adjusted MCID where the difference between the risk adjusted predicted MCID and the observed MCID proportion will be greater than zero. The measure is adjusted to patient characteristics known to be associated with functional status and quality of life outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality.
Details
HM07Functional Status Change for Patients with Vestibular DysfunctionyesPatient Reported OutcomePercentage of patients aged 14 years and older diagnosed with vestibular dysfunction who achieve a Minimal Clinically Important Difference (MCID) as measured via the validated Dizziness Handicap Inventory or equivalent instrument to indicate functional, emotional, and physical improvement
• Submission Age Criteria 1: Patients aged 14-17 years of age
• Submission Age Criteria 2: Patients aged 18-64 years of age
• Submission Age Criteria 3: Patients aged 65 years and older
• Submission Criteria 4: Overall total rate of patients aged 14 years and older
The measure is adjusted to patient characteristics known to be associated with functional status and quality of life outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician, and at the clinic level to assess quality.
Details
HM08Functional Status Change for Patients With Lower Extremity Functional Status DeficityesPatient Reported OutcomePercentage of patients aged 18 years or older with a functional deficit related to the lower extremity who achieve a Minimal Clinically Important Difference (MCID) in Lower Extremity Functional Scale (LEFS) score that indicates a functional improvement greater than zero. Two rates will be reported:
• The overall proportion of patients achieving an MCID in LEFS change score.
• The Risk-Adjusted MCID proportional difference where the difference between the risk adjusted predicted MCID and the observed MCID (measured via LEFS) proportion is greater than zero.

The measure contains two goals: 1) for patients to achieve an unadjusted MCID greater than zero and, 2) for patients to achieve a risk adjusted MCID where the difference between the risk adjusted predicted MCID and the observed MCID proportion will be greater than zero. The measure is adjusted to patient characteristics known to be associated with functional status and quality of life outcomes (risk adjusted) and used as a performance measure at the patient level, at the individual clinician level, and at the clinic level to assess quality.
Details
126Diabetes Mellitus: Diabetic Foot and Ankle Care, Peripheral Neuropathy – Neurological EvaluationnoProcessPercentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who had a neurological examination of their lower extremities within 12 monthsDetails
127Diabetes Mellitus: Diabetic Foot and Ankle Care, Ulcer Prevention – Evaluation of FootwearnoProcessPercentage of patients aged 18 years and older with a diagnosis of diabetes mellitus who were evaluated for proper footwear and sizingDetails
128Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-Up PlannoProcessPercentage of patients aged 18 years and older with a BMI documented during the current encounter or during the previous twelve months AND with a BMI outside of normal parameters, a follow-up plan is documented during the encounter or during the previous twelve months of the current encounter

Normal Parameters: Age 18 years and older BMI => 18.5 and < 25 kg/m2
Details
130Documentation of Current Medications in the Medical RecordyesProcessPercentage of visits for patients aged 18 years and older for which the eligible professional or eligible clinician attests to documenting a list of current medications using all immediate resources available on the date of the encounter. This list must include ALL known prescriptions, over-the-counters, herbals, and vitamin/mineral/dietary (nutritional) supplements AND must contain the medications' name, dosage, frequency and route of administrationDetails
134Preventive Care and Screening: Screening for Depression and Follow-Up PlannoeCQM/CQMPercentage of patients aged 12 years and older screened for depression on the date of the encounter using an age appropriate standardized depression screening tool AND if positive, a follow-up plan is documented on the date of the positive screenDetails
154Falls: Risk AssessmentyesProcessPercentage of patients aged 65 years and older with a history of falls that had a risk assessment for falls completed within 12 monthsDetails
155Falls: Plan of CareyesProcessPercentage of patients aged 65 years and older with a history of falls that had a plan of care for falls documented within 12 monthsDetails
181Elder Maltreatment Screen and Follow-Up PlanyesProcessPercentage of patients aged 65 years and older with a documented elder maltreatment screen using an Elder Maltreatment Screening tool on the date of encounter AND a documented follow-up plan on the date of the positive screenDetails