stroke core measures 2021

To submit a research proposal for the Get With The Guidelines- Stroke program, email a completed Get With The Guidelines Data Request Form (download) to [emailprotected]. Applications are available at the American Medical Association Web site, www.ama- assn.org/go/cpt. Severity Measurement Performed for SAH and ICH Patients (Overall Rate), Rate of Rapid Effective Reperfusion From Skin Puncture. Set expectations for your organization's performance that are reasonable, achievable and survey-able. Arrhythmia means that the heart's normal beating rhythm is interrupted. Comprehensive Stroke (CSTK) (v2021A1) Home Comprehensive Stroke (CSTK) Comprehensive Stroke (CSTK) On this page: Comprehensive Stroke (CSTK) Initial Patient Population Monthly Sampling Sample Size Examples Set Measures General Data Elements Algorithm Output Data Elements Measure Set Specific Data Elements To begin, I will clarify the two Measure Stewards we are reviewing today (there are many other Measure Stewards out there). License to use CPT for any use not authorized herein must be obtained through the American Medical Association, Intellectual Property Services, AMA Plaza, 330 North Wabash Avenue, Suite 39300, Chicago, Illinois 60611-5885. ) These measures include aggressive use of medications, such as antithrombotics, anticoagulation therapy, deep vein thrombosis prophylaxis, cholesterol-reducing drugs and smoking cessation, all aimed at reducing death and disability and improving the lives of stroke patients. These Stroke chart abstracted measures were developed in collaboration with the American Heart Association (AHA)/American Stroke Association (ASA)/Brain Attack Coalition (BAC). This means the patient passed every measure they qualified for. Using the quarterly sampling table for the ischemic stroke with IV t-PA, IA t-PA or MER subpopulation, the sample size is less than the minimum required quarterly sample size, so 100% of the subpopulation or all 19 cases are sampled. An antithrombotic agent is a drug that reduces the formation of blood clots. Below are the list of Stroke measures by Certification Program. Using the monthly sampling table for the ischemic stroke subpopulation, the sample size required is 20% of this subpopulation or 26 cases for the month (20% of 129 equals 25.8 rounded to the next highest whole number equals 26). The required quarterly sample size would be 100% of the patient population or 5 cases for the quarter, No sampling; 100% Initial Patient Population required. This post is a guide to understanding the differences between the five major stroke measure sets. 7272 Greenville Ave. Assemble your multidisciplinary team to determine roles and processes for entering patient data. Neurology. There are no Stroke eCQMs applicable or available for Certification purposes. lock stream Find the exact resources you need to succeed in your accreditation journey. A hospitals ischemic stroke patient population size is 37 cases during the second quarter. Part 1: A review of the different stroke measure sets. The annual Acute Care Hospital Quality Improvement Program Measures reference guide provides a comparison of measures for five Centers for Medicare & Medicaid Services (CMS) acute care hospital quality improvement programs, including the: Hospital IQR Program Hospital Value-Based Purchasing (VBP) Program Promoting Interoperability Program All Records, Optional for HBIPS-2 and HBIPS-3, No sampling; 100% Patient Population required, ICD-10-PCS Principal or Other Procedure Codes. Hospitals whose Initial Patient Population size is less than the minimum number of cases per quarter/month for the sub-population cannot sample that sub-population. 671 0 obj <>/Filter/FlateDecode/ID[<8968A4F338E55446928FCF4A155C4BC8>]/Index[646 45]/Info 645 0 R/Length 114/Prev 86415/Root 647 0 R/Size 691/Type/XRef/W[1 2 1]>>stream If the Principal Diagnosis code falls on Table 8.1 it will be placed in the Ischemic Stroke, or sub-pop 1 and if it has a Principal Diagnosis code that falls on Table 8.2, then it will be placed in the Hemorrhagic Stroke or sub-pop-2. CSTK-02 Modified Rankin Score (mRS at 90 Days)3. This section includes the measure type (inpatient vs outpatient), the number of measures in the set, which certification the measure set is a part of, a list of the measures in the set and the associated algorithm. Calculate Patient Age. STK-6 Discharged on Statin Medication9. Hospitals will receive a score for their performance on 10 Claims-Based measures in four categories: patient safety, mortality, coordination of care and payment. A hospitals ischemic stroke patient population size is 295 cases during March. CMS will use these mortality measures, which it reports under the Clinical Care domain, in the FY 2019 program. Submission of aggregate data is still required. You acknowledge that the American Medical Association (AMA) holds all copyright, trademark and other rights in CPT. Sometimes, TPA can be given up to 4.5 hours after stroke symptoms started. This measure set is applicable to patients with diagnoses of ischemic stroke and hemorrhagic stroke, and TIA. The DDS platform is where hospitals submit performance measurement data to The Joint Commissions to meet ORYX reporting requirements. Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size is less than the minimum required monthly sample size, so 100% of the subpopulation or all 17 cases are sampled. For the purposes of this blog, since we are focusing specifically on stroke measures, there is only one stroke measure that is used for Accreditation purposes by both CMS and TJC: OP-23. Program details are found in Part 2. CSTK-04 Procoagulant Reversal Agent Initiation for Intracerebral Hemorrhage (ICH )4. You acknowledge that the American Medical Association (AMA) holds all copyright, trademark and other rights in CPT. The following are the list of required chart-abstracted stroke measures for each certification program. The two Measure Stewards (CMS and TJC) require hospitals to submit their chart-abstracted data in two different ways. https:// {8Dm.;JHTBXEXh^^^.Y)oH 6K;ANf!;*#.\1\c"1cKE. Family/caregivers will also need guidance in planning effective and realistic care strategies appropriate to the patient's prognosis and potential for rehabilitation. means youve safely connected to the .gov website. Chart-abstracted measures specificationsScreen Reader Text. Suspected stroke symptoms can be confounded by medications, metabolic encephalopathy, and comorbid conditions. Once a patient is qualified, he/she moves to the second part of the algorithm which tells you which sub-population he/she falls into. Appointments at Mayo Clinic Mayo Clinic offers appointments in Arizona, Florida and Minnesota and at Mayo Clinic Health System locations. %PDF-1.5 R,A`=N T$gZq,AW@0H#`.K#AJk_~}~Dc7?o=0T,qp{"+&y8N^-9yG-W +~ZY(DA[xvc2EGJv;P.Q12`3'o0f}ahq+ci;")i EmNW`0}d\K?QD-ki'e1ACa%i^\|.I$a-4>b(L x\_s6fE4f+[Itd2)Q" 2tIB.|Qe{r?);|_gb-rv>XS?m>`_\WNO>(b\@~f'4( L`yXS7?b!0@qp) Monday - Friday: 7 a.m. 7 p.m. CT TJC Comprehensive Stroke Performance Measures HOS-Sanford Medical Center Fargo Annual summaries for 2020 through 2022 Updated: 2/2023 3. Statin drugs are medications used to reduce serum level of lipids such as cholesterol. <>/Font<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 612 792] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> The measure set contains two independent sub-populations: Ischemic STK patients and Hemorrhagic STK patients. CSTK-10a Functional Status Prior to Stroke-Independent: IV Alteplase Only2. If the Patient Age is less than 18 years, the patient is not in the STK Initial Patient Population and is not eligible to be sampled for the STK measure set. Here is a diagram that outlines the submission differences. 2021; 97: . . Here are some resources to help you get started: JoAnne Marino is a Registered Nurse that is currently working as a Senior Clinical Consultant for Medisolv helping clients with the ENCOR Hospital Abstracted Measures. Stay up to date with all the latest Joint Commission news, blog posts, webinars, and communications. Closed on Sundays. The coalition was convened in 2015 by Americas Health Insurance Providers (AHIP) and the Centers for Medicare & Medicaid Services (CMS) and is housed at the National Quality Forum (NQF). The change in the performance measure requirements for Acute Stroke Ready Hospitals, (i.e., STK-OP-1 replacing ASR-OP-2 effective with discharges on and after July 1, 2021) can be found in several places. STK-3 Anticoagulation Therapy for Atrial Fibrillation/Flutter14. Using the quarterly sampling table for the ischemic stroke subpopulation, the sample size required is 84 cases for the quarter. <> Any use not authorized herein is prohibited, including by way of illustration and not by way of limitation, making copies of CPT for resale and/or license, transferring copies of CPT to any party not bound by this Agreement, creating any modified or derivative work of CPT, or making any commercial use of CPT. Get more information about cookies and how you can refuse them by clicking on the learn more button below. A hospitals hemorrhagic stroke patient population size is 795 cases during the second quarter. Using the monthly sampling table for the hemorrhagic stroke subpopulation, the sample size required is 20% of this subpopulation or 26 cases for the month (20% of 129 equals 25.8 rounded to the next highest whole number equals 26). STK-5 Antithrombotic Therapy By End of Hospital Day Two16. Medisolv can help you along the way. Find more information on our content editorial process. Mayo Clinic is a nonprofit organization and proceeds from Web advertising help support our mission. % Measure Type: OutpatientNumber of Measures Included: There are five process measures (youll see one additional measure listed below that is not reported and one additional measure that is retired starting with July 1, 2021 discharges). Using the notice and public comment rule-making process, CMS also intends to implement new core measures across applicable Medicare quality programs as appropriate, while eliminating redundant measures that are not part of the core set. By not making a selection you will be agreeing to the use of our cookies. For information concerning how to perform sampling, refer to the Population and Sampling Specifications section in this manual. Patients admitted to the hospital for inpatient acute care are included in the CSTK-2 Ischemic Stroke With IV t-PA, IA t-PA, or MER subpopulation sampling group if they have: ICD-10-CM Principal Diagnosis Code as defined in Appendix A, Table 8.1 AND ICD-10-PCS Principal or Other Procedure Codes as defined in Appendix A, Table 8.1a OR Table 8.1b, a Patient Age (Admission Date Birthdate) 18 years and a Length of Stay (Discharge Date - Admission Date) 120 days. ruTv?U J4lUBex(a8{g$CHj ~>-z I&8:+hlvM(XdvY;D|BOl,Yu'D> YR9Gbl6GrJ8'},^V)\i/0 Gg:} >!81I88{'swe )I6v#{$&YymLyn\tl S3r6.o?x@q$_1A=U$H3%QUx . Heres a link to TJCs full program comparison sheet with guidelines of certification requirements. We consistently hear from our clients that the biggest differentiator between Medisolv and other vendors is the level of one-of-one support. CSTK-08 Thrombolysis in Cerebral Infarction (TICI Post-Treatment Reperfusion Grade)5. Learn about the "gold standard" in quality. Honestly though Stroke Outpatient versus Outpatient Stroke. CMS is already using measures from the each of the core sets. STK-OP-1a Overall Rate (Not Reported2. CSM . <>>> Especially if you use an EHR vendor right now, youll notice a huge difference. Claims-Based Measures by Category Claims-Based Patient Safety Measures for 2022 Claims-Based Mortality Measures for 2022 Claims-Based Coordination of Care Measures for 2022 STK-4 Thrombolytic Therapy10. The following are Stroke eCQMs used by The Joint Commission. 10960 Grantchester Way, Suite 520Columbia, MD 21044. CMS will go through a public notice and comment rule-making for implementation of these core sets and looks forward to public input on the measures included in these core measure sets. Nineteen (19) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. /'6sh]l{;VSCe}>j}1#R/E5SzOOl%5-Ybh_+/y}V4jru*nvJ_VRF|8w^5 @/K6jPw*sfoqW}"3v}qCmqytT_.NnwT*_kL?hokU^dU2h=>tLi Using the quarterly sampling table for the hemorrhagic stroke subpopulation, the sample size is less than the minimum required quarterly sample size, so 100% of the subpopulation or all 67 cases are sampled. Measure requirements are often not aligned among payers, which has resulted in confusion and complexity for reporting providers. ASR-IP-1: Thrombolytic Therapy (IV alteplase initiated in the ED followed by inpatient admission to the ASRH)2. ASR-OP-2a Door to Transfer to Another Hospital Overall Rate2. Each measure includes patients from one or more categories. CSTK-10d Functional Status Prior to Stroke-Dependent: MER Therapy, 9. Fifty (50) ischemic stroke cases had IV or IA thrombolysis or a mechanical clot removal procedure during the second quarter. 2011-2021 6.7L Ford Power Stroke; 2008-2010 6.4L Ford Power Stroke; 2003-2007 6.0L Ford Power Stroke; . Saturday: 9 a.m. - 5 p.m. CT Set the Initial Patient Population Reject Case Flag to equal No. Core measures are based on the most common condition's hospitals see, such as acute myocardial infarction (AMI), heart failure (HF), pneumonia, surgical care, children's asthma care, venous thromboembolism (VTE), stroke, and more. CSTK-05a: Hemorrhagic Transformation for Patients Treated with Intravenous (IV) Thrombolytic (t-PA) Therapy Only2. Use the PMT benchmarking reports to identify areas for improvement and refine processes and protocols to ensure they are in line with the guidelines. License to use CPT for any use not authorized herein must be obtained through the American Medical Association, Intellectual Property Services, AMA Plaza, 330 North Wabash Avenue, Suite 39300, Chicago, Illinois 60611-5885.