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[]
[null,null,"Category 3 DY4 reporting Template"]
[]
[null,null,"Instructions"]
[]
[null,null,"1."]
[null,null,"2."]
[null,null,"3."]
[null,null,"4."]
[]
[null,null,"Progress Indicator",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"RHP",null,"TPI Count:",{"$f":"MAX('Providers List'!$I$2:$I$2171)","v":0},null,"Cat 1 or 2 Projects Count:",{"$f":"MAX('Providers List'!$L$2:$L$2171)","v":0}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"RHP 1"]
[null,null,"Contact Information:",null,{"$f":"IF(OR(D19=\"\",D20=\"\",D21=\"\"),\"Incomplete\",\"Complete\")","v":"Incomplete"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"RHP 2",null,1,{"$f":"IF($Y13=\"\",\"\",INDEX('Providers List'!$B$2:$B$2171,MATCH('Step 1'!$Y13,'Providers List'!$I$2:$I$2171,0)))","v":{"$error":"#N/A"}},null,1,{"$f":"IF($AB13=\"\",\"\",INDEX('Providers List'!$D$2:$D$2171,MATCH('Step 1'!$AB13,'Providers List'!$L$2:$L$2171,0)))","v":{"$error":"#N/A"}}]
[null,null,"RHP Region and TPI Input:",null,{"$f":"IF(OR(RHP=\"\",TPI=\"\"),\"Incomplete\",\"Complete\")","v":"Incomplete"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"RHP 3",null,{"$f":"IF($Y13<$Z$11,Y13+1,\"\")","v":""},{"$f":"IF($Y14=\"\",\"\",INDEX('Providers List'!$B$2:$B$2171,MATCH('Step 1'!$Y14,'Providers List'!$I$2:$I$2171,0)))","v":""},null,{"$f":"IF($AB13<$AC$11,AB13+1,\"\")","v":""},{"$f":"IF($AB14=\"\",\"\",INDEX('Providers List'!$D$2:$D$2171,MATCH('Step 1'!$AB14,'Providers List'!$L$2:$L$2171,0)))","v":""}]
[null,null,"Create Outcome Tabs:",null,"Incomplete",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"RHP 4",null,{"$f":"IF($Y14<$Z$11,Y14+1,\"\")","v":""},{"$f":"IF($Y15=\"\",\"\",INDEX('Providers List'!$B$2:$B$2171,MATCH('Step 1'!$Y15,'Providers List'!$I$2:$I$2171,0)))","v":""},null,{"$f":"IF($AB14<$AC$11,AB14+1,\"\")","v":""},{"$f":"IF($AB15=\"\",\"\",INDEX('Providers List'!$D$2:$D$2171,MATCH('Step 1'!$AB15,'Providers List'!$L$2:$L$2171,0)))","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"RHP 5",null,"",{"$f":"IF($Y16=\"\",\"\",INDEX('Providers List'!$B$2:$B$2171,MATCH('Step 1'!$Y16,'Providers List'!$I$2:$I$2171,0)))","v":""},null,"",{"$f":"IF($AB16=\"\",\"\",INDEX('Providers List'!$D$2:$D$2171,MATCH('Step 1'!$AB16,'Providers List'!$L$2:$L$2171,0)))","v":""}]
[null,null,"Please enter the name and contact information of the primary contact regarding information reported in this template:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"RHP 6",null,"",{"$f":"IF($Y17=\"\",\"\",INDEX('Providers List'!$B$2:$B$2171,MATCH('Step 1'!$Y17,'Providers List'!$I$2:$I$2171,0)))","v":""},null,"",{"$f":"IF($AB17=\"\",\"\",INDEX('Providers List'!$D$2:$D$2171,MATCH('Step 1'!$AB17,'Providers List'!$L$2:$L$2171,0)))","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"RHP 7",null,"",{"$f":"IF($Y18=\"\",\"\",INDEX('Providers List'!$B$2:$B$2171,MATCH('Step 1'!$Y18,'Providers List'!$I$2:$I$2171,0)))","v":""},null,"",{"$f":"IF($AB18=\"\",\"\",INDEX('Providers List'!$D$2:$D$2171,MATCH('Step 1'!$AB18,'Providers List'!$L$2:$L$2171,0)))","v":""}]
[null,null,"Contact Name:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"RHP 8",null,"",{"$f":"IF($Y19=\"\",\"\",INDEX('Providers List'!$B$2:$B$2171,MATCH('Step 1'!$Y19,'Providers List'!$I$2:$I$2171,0)))","v":""},null,"",{"$f":"IF($AB19=\"\",\"\",INDEX('Providers List'!$D$2:$D$2171,MATCH('Step 1'!$AB19,'Providers List'!$L$2:$L$2171,0)))","v":""}]
[null,null,"Email Address:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"RHP 9",null,"",{"$f":"IF($Y20=\"\",\"\",INDEX('Providers List'!$B$2:$B$2171,MATCH('Step 1'!$Y20,'Providers List'!$I$2:$I$2171,0)))","v":""},null,"",{"$f":"IF($AB20=\"\",\"\",INDEX('Providers List'!$D$2:$D$2171,MATCH('Step 1'!$AB20,'Providers List'!$L$2:$L$2171,0)))","v":""}]
[null,null,"Phone Number:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"RHP 10",null,"",{"$f":"IF($Y21=\"\",\"\",INDEX('Providers List'!$B$2:$B$2171,MATCH('Step 1'!$Y21,'Providers List'!$I$2:$I$2171,0)))","v":""},null,"",{"$f":"IF($AB21=\"\",\"\",INDEX('Providers List'!$D$2:$D$2171,MATCH('Step 1'!$AB21,'Providers List'!$L$2:$L$2171,0)))","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"RHP 11",null,"",{"$f":"IF($Y22=\"\",\"\",INDEX('Providers List'!$B$2:$B$2171,MATCH('Step 1'!$Y22,'Providers List'!$I$2:$I$2171,0)))","v":""},null,"",{"$f":"IF($AB22=\"\",\"\",INDEX('Providers List'!$D$2:$D$2171,MATCH('Step 1'!$AB22,'Providers List'!$L$2:$L$2171,0)))","v":""}]
[null,null,"Please select the provider's RHP and TPI reported in this template below:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"RHP 12",null,"",{"$f":"IF($Y23=\"\",\"\",INDEX('Providers List'!$B$2:$B$2171,MATCH('Step 1'!$Y23,'Providers List'!$I$2:$I$2171,0)))","v":""},null,"",{"$f":"IF($AB23=\"\",\"\",INDEX('Providers List'!$D$2:$D$2171,MATCH('Step 1'!$AB23,'Providers List'!$L$2:$L$2171,0)))","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"RHP 13",null,"",{"$f":"IF($Y24=\"\",\"\",INDEX('Providers List'!$B$2:$B$2171,MATCH('Step 1'!$Y24,'Providers List'!$I$2:$I$2171,0)))","v":""},null,"",{"$f":"IF($AB24=\"\",\"\",INDEX('Providers List'!$D$2:$D$2171,MATCH('Step 1'!$AB24,'Providers List'!$L$2:$L$2171,0)))","v":""}]
[null,null,"RHP region:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"RHP 14",null,"",{"$f":"IF($Y25=\"\",\"\",INDEX('Providers List'!$B$2:$B$2171,MATCH('Step 1'!$Y25,'Providers List'!$I$2:$I$2171,0)))","v":""},null,"",{"$f":"IF($AB25=\"\",\"\",INDEX('Providers List'!$D$2:$D$2171,MATCH('Step 1'!$AB25,'Providers List'!$L$2:$L$2171,0)))","v":""}]
[null,null,"TPI:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"RHP 15",null,"",{"$f":"IF($Y26=\"\",\"\",INDEX('Providers List'!$B$2:$B$2171,MATCH('Step 1'!$Y26,'Providers List'!$I$2:$I$2171,0)))","v":""},null,"",{"$f":"IF($AB26=\"\",\"\",INDEX('Providers List'!$D$2:$D$2171,MATCH('Step 1'!$AB26,'Providers List'!$L$2:$L$2171,0)))","v":""}]
[null,null,"Provider Name:",{"$f":"IF(TPI=\"\",\"\",INDEX('Providers List'!$C$2:$C$2171,MATCH(\"\"&RHP&\"_\"&TPI&\"\",'Providers List'!$H$2:$H$3000,0)))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"RHP 16",null,"",{"$f":"IF($Y27=\"\",\"\",INDEX('Providers List'!$B$2:$B$2171,MATCH('Step 1'!$Y27,'Providers List'!$I$2:$I$2171,0)))","v":""},null,"",{"$f":"IF($AB27=\"\",\"\",INDEX('Providers List'!$D$2:$D$2171,MATCH('Step 1'!$AB27,'Providers List'!$L$2:$L$2171,0)))","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"RHP 17",null,"",{"$f":"IF($Y28=\"\",\"\",INDEX('Providers List'!$B$2:$B$2171,MATCH('Step 1'!$Y28,'Providers List'!$I$2:$I$2171,0)))","v":""},null,"",{"$f":"IF($AB28=\"\",\"\",INDEX('Providers List'!$D$2:$D$2171,MATCH('Step 1'!$AB28,'Providers List'!$L$2:$L$2171,0)))","v":""}]
[null,null,"Create project specific tabs",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"RHP 18",null,"",{"$f":"IF($Y29=\"\",\"\",INDEX('Providers List'!$B$2:$B$2171,MATCH('Step 1'!$Y29,'Providers List'!$I$2:$I$2171,0)))","v":""},null,"",{"$f":"IF($AB29=\"\",\"\",INDEX('Providers List'!$D$2:$D$2171,MATCH('Step 1'!$AB29,'Providers List'!$L$2:$L$2171,0)))","v":""}]
[null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"RHP 19",null,"",{"$f":"IF($Y30=\"\",\"\",INDEX('Providers List'!$B$2:$B$2171,MATCH('Step 1'!$Y30,'Providers List'!$I$2:$I$2171,0)))","v":""},null,"",{"$f":"IF($AB30=\"\",\"\",INDEX('Providers List'!$D$2:$D$2171,MATCH('Step 1'!$AB30,'Providers List'!$L$2:$L$2171,0)))","v":""}]
[null,null,"Press this button only after the contact information, RHP region, and TPI inputs have been marked \"Complete\" in the progress indicator.",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"RHP 20",null,"",{"$f":"IF($Y31=\"\",\"\",INDEX('Providers List'!$B$2:$B$2171,MATCH('Step 1'!$Y31,'Providers List'!$I$2:$I$2171,0)))","v":""},null,"",{"$f":"IF($AB31=\"\",\"\",INDEX('Providers List'!$D$2:$D$2171,MATCH('Step 1'!$AB31,'Providers List'!$L$2:$L$2171,0)))","v":""}]
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[]
[null,null,null,null,"Certification"]
[false]
[null,null,null,null,"Please check the box to certify the statement below and insert your name, title and date in the boxes that follow"]
[]
[]
[]
[null,null,null,null,"Name:"]
[null,null,null,null,"Title:"]
[null,null,null,null,"Date:"]

{"sheet":"Cat 1 or 2 Project Specific 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[null,null,null,{"$f":"IF($F105=\"\",1,IF(OFFSET($A$26,($F105-1)*$A$13,0)=FALSE,1,0))","v":1},86,1,null,null,null,null,null,"Performance Reporting - Readiness:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F106=\"\",1,IF(OFFSET($A$26,($F106-1)*$A$13,0)=FALSE,1,0))","v":1},87,1,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F107=\"\",1,IF(OFFSET($A$26,($F107-1)*$A$13,0)=FALSE,1,0))","v":1},88,1,null,null,null,null,null,"Eligible to report in April DY4?",null,null,null,null,null,null,null,{"$f":"IF(F107=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$I$4:$I$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F107,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$I$4:$I$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F107,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$I$4:$I$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F107,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F108=\"\",1,IF(OFFSET($A$26,($F108-1)*$A$13,0)=FALSE,1,0))","v":1},89,1,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F109=\"\",1,IF(OFFSET($A$26,($F109-1)*$A$13,0)=FALSE,1,0))","v":1},90,1,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F110=\"\",1,IF(OFFSET($A$26,($F110-1)*$A$13,0),IF(T107=\"Eligible to Report in October DY4\",0,1),1))","v":1},91,1,null,null,null,null,null,"Outcome is eligible to be reported in October of DY4",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F111=\"\",1,IF(OFFSET($A$26,($F111-1)*$A$13,0)=FALSE,1,0))","v":1},92,1,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,{"$f":"CELL(\"Address\",T112)","v":"$T$112"},null,{"$f":"IF($F112=\"\",1,IF(OFFSET($T$107,($F112-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F112-1)*$A$13,0)=FALSE,1,0)))","v":1},93,1,null,null,null,null,null,"Are you ready to report this outcome with 12 months of data aligning with your DY4 measurement period?",null,null,null,null,null,null,null,null,null,"If not, within the online reporting system please include a progress update regarding the status of your performance.  If no updates to performance are available, please describe any salient updates to the measure collection process.  This progress update fulfills your semi-annual reporting requirement for this milestone. Please indicate that you will do this by selecting 'Yes' to the right",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T107<>\"Eligible to Report in April DY4\",0,IF(T112=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T107<>\"Eligible to Report in April DY4\",$T112=\"Yes\"),0,IF(AE112=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,94,1,null,null,null,null,null,"Provider intention to Carry forward",null,null,null,null,null,null,null,"NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,95,1,null,null,null,null,null,"Provider intention to report in October DY4",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,96,1,null,null,null,null,null,"Additional text boxes to use in October",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,97,1,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,98,1,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,99,1,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,100,1,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,101,1,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[{"$f":"CELL(\"Address\",T121)","v":"$T$121"},null,null,{"$f":"IF($F121=\"\",1,IF(OFFSET($T$107,($F121-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F121-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F121-1)*$A$13,0)=\"Yes\",0,1))))","v":1},102,1,null,null,null,null,null,"Are you reporting to approved measure specifications?  This includes numerator description, denominator description and any approved subsets",null,null,null,null,null,null,null,null,null,"Please describe any differences between specifications used to determine DY4 performance and the approved measure specifications:",null,null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T112<>\"Yes\",0,IF(T121=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,{"$f":"IF($T112<>\"Yes\",0,IF(AND(T121=\"No\",AE121=\"Free Text\"),1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0]
[{"$f":"CELL(\"Address\",T122)","v":"$T$122"},null,null,{"$f":"IF($F122=\"\",1,IF(OFFSET($T$107,($F122-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F122-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F122-1)*$A$13,0)=\"Yes\",0,1))))","v":1},103,1,null,null,null,null,null,"Are there any changes/improvements/clarifications to your data abstraction process for the performance reported in DY4 relative to how the baseline was described in the field above?",null,null,null,null,null,null,null,null,null,"Please describe the changes/improvements to your abstraction process",null,null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T112<>\"Yes\",0,IF(T122=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,{"$f":"IF($T112<>\"Yes\",0,IF(AND(T122=\"Yes\",AE122=\"Free Text\"),1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0]
[{"$f":"CELL(\"Address\",T123)","v":"$T$123"},null,null,{"$f":"IF($F123=\"\",1,IF(OFFSET($T$107,($F123-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F123-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F123-1)*$A$13,0)=\"Yes\",0,1))))","v":1},104,1,null,null,null,null,null,"Are there any changes or improvements to your tool administration process as reported at baseline?",null,null,null,null,null,null,null,null,null,"Please describe changes in tool/survey administration process",null,null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T112<>\"Yes\",0,IF(T123=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,{"$f":"IF($T112<>\"Yes\",0,IF(AND(T123=\"Yes\",AE123=\"Free Text\"),1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F124=\"\",1,IF(OR(OFFSET($T$107,($F124-1)*$A$13,0)<>\"Eligible to Report in April DY4\",$T124=\"\"),1,IF(OFFSET($A$26,($F124-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F124-1)*$A$13,0)=\"Yes\",0,1))))","v":1},105,1,null,null,null,null,null,"Risk Adjustment Type",null,null,null,null,null,null,null,{"$f":"IF(F123=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$EZ$4:$EZ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F123,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$EZ$4:$EZ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F123,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$EZ$4:$EZ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F123,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[{"$f":"CELL(\"Address\",T125)","v":"$T$125"},null,null,{"$f":"IF($F125=\"\",1,IF(OR(OFFSET($T$107,($F125-1)*$A$13,0)<>\"Eligible to Report in April DY4\",$T124=\"\"),1,IF(OFFSET($A$26,($F125-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F125-1)*$A$13,0)=\"Yes\",0,1))))","v":1},106,1,null,null,null,null,null,null,"Are there any changes or improvements to risk adjustment process?",null,null,null,null,null,null,null,null,"Please describe changes in risk adjustment process",null,null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T112<>\"Yes\",0,IF($T124=\"\",0,IF(T125=\"\",1,0)))","v":0},0,0,0,0,0,0,0,0,0,{"$f":"IF($T112<>\"Yes\",0,IF(AND(T125=\"Yes\",AE125=\"Free Text\"),1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F126=\"\",1,IF(OFFSET($T$107,($F126-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F126-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F126-1)*$A$13,0)=\"Yes\",IF(IF(F126=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F126,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F126,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F126,'Master Data Mock'!$FM$4:$FM$5000,0))))<>\"\",0,1),1))))","v":1},107,1,null,null,null,null,null,{"$f":"\"Provider used a proxy population to determine baseline performance described as:  \"&IF(F126=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F126,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F126,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F126,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":"Provider used a proxy population to determine baseline performance described as:  "},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F127=\"\",1,IF(OFFSET($T$107,($F127-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F127-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F127-1)*$A$13,0)=\"Yes\",IF(IF(F127=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F127,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F127,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F127,'Master Data Mock'!$FM$4:$FM$5000,0))))<>\"\",0,1),1))))","v":1},108,1,null,null,null,null,null,null,"Please describe the alignment (similarities and differences) between the proxy population reported for baseline and the cohort used for the DY4 measurement period",null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($D126=1,$T112<>\"Yes\"),0,IF(T127=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F128=\"\",1,IF(OFFSET($A$26,($F128-1)*$A$13,0)=FALSE,1,0))","v":1},109,1,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F129=\"\",1,IF(OFFSET($T$107,($F129-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F129-1)*$A$13,0)=FALSE,1,IF(OR(OFFSET($T$112,($F129-1)*$A$13,0)=\"Yes\",OFFSET($T$31,($F129-1)*$A$13,0)<>\"P4R\"),1,0))))","v":1},110,1,null,null,null,null,null,"Alternate Achievement Activity Status Update",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,111,1,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,112,1,null,null,null,null,null,"Alternate Achievement Activity:",null,null,null,null,null,null,null,{"$f":"IF(OR(ISERROR(INDEX('Master Data Mock'!$P$4:$P$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F131,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$P$4:$P$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F131,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$P$4:$P$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F131,'Master Data Mock'!$FM$4:$FM$5000,0)))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,113,1,null,null,null,null,null,"Alternative Achievement Activity Baseline Reported:",null,null,null,null,null,null,null,{"$f":"IF(LEFT(T131,2)=\"SA\",IF(OR(ISERROR(INDEX('Master Data Mock'!$EP$4:$EP$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F132,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$EP$4:$EP$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F132,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$EP$4:$EP$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F132,'Master Data Mock'!$FM$4:$FM$5000,0))),IF(OR(ISERROR(INDEX('Master Data Mock'!$EQ$4:$EQ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F132,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$EQ$4:$EQ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F132,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$EQ$4:$EQ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F132,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,114,1,null,null,null,null,null,"Please include an update for any activities to date related to the selected Stretch Activity above or performance in the PFP measure above. If baseline for this PFP measure has not yet been reported, please indicate when this will be submitted and which 12 month measurement period it will reflect (DY3 or DY4).  If ready to report PFP baseline now please complete the PFP Baseline form found here: http://www.hhsc.state.tx.us/1115-Waiver-Guideline.shtml ",null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T31<>\"P4R\",0,IF(T133=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,115,1,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F135=\"\",1,IF(OR(OFFSET($T$107,($F135-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F135-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F135-1)*$A$13,0)=FALSE,1,0)))","v":1},116,1,null,null,null,null,null,"Performance Reporting - Quantitative",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,117,1,null,null,null,null,null,null,null,null,null,null,{"$f":"IF($F136=\"\",\"\",1)","v":1},null,null,null,null,{"$f":"IF($F136=\"\",\"\",IF(Q136=\"\",\"\",IF(Q136+1>OFFSET($A$21,($F136-1)*$A$13,0),\"\",Q136+1)))","v":""},null,null,null,null,{"$f":"IF($F136=\"\",\"\",IF(V136=\"\",\"\",IF(V136+1>OFFSET($A$21,($F136-1)*$A$13,0),\"\",V136+1)))","v":""},null,null,null,null,{"$f":"IF($F136=\"\",\"\",IF(AA136=\"\",\"\",IF(AA136+1>OFFSET($A$21,($F136-1)*$A$13,0),\"\",AA136+1)))","v":""},null,null,null,null,{"$f":"IF($F136=\"\",\"\",IF(AF136=\"\",\"\",IF(AF136+1>OFFSET($A$21,($F136-1)*$A$13,0),\"\",AF136+1)))","v":""},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,118,1,null,null,null,null,null,null,null,null,null,null,"Metric 1",null,null,null,null,"Metric 2",null,null,null,null,"Metric 3",null,null,null,null,"Metric 4",null,null,null,null,"Metric 5",null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,119,1,null,null,null,null,null,"Milestone ID:",null,null,null,null,{"$f":"IF($F138=\"\",\"\",IF(Q136=\"\",\"\",\"AM-1.\"&Q136))","v":"AM-1.1"},null,null,null,null,{"$f":"IF($F138=\"\",\"\",IF(V136=\"\",\"\",\"AM-1.\"&V136))","v":""},null,null,null,null,{"$f":"IF($F138=\"\",\"\",IF(AA136=\"\",\"\",\"AM-1.\"&AA136))","v":""},null,null,null,null,{"$f":"IF($F138=\"\",\"\",IF(AF136=\"\",\"\",\"AM-1.\"&AF136))","v":""},null,null,null,null,{"$f":"IF($F138=\"\",\"\",IF(AK136=\"\",\"\",\"AM-1.\"&AK136))","v":""},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,120,1,null,null,null,null,null,"Milestone Description:",null,null,null,null,{"$f":"IF(Q136=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(Q136-1)*5),MATCH(Q138,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(Q136-1)*5),0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(Q136-1)*5),MATCH(Q138,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(Q136-1)*5),0))))","v":"Achievement of DY4 performance goal"},null,null,null,null,{"$f":"IF(V136=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(V136-1)*5),MATCH(V138,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(V136-1)*5),0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(V136-1)*5),MATCH(V138,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(V136-1)*5),0))))","v":""},null,null,null,null,{"$f":"IF(AA136=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AA136-1)*5),MATCH(AA138,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AA136-1)*5),0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AA136-1)*5),MATCH(AA138,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AA136-1)*5),0))))","v":""},null,null,null,null,{"$f":"IF(AF136=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AF136-1)*5),MATCH(AF138,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AF136-1)*5),0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AF136-1)*5),MATCH(AF138,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AF136-1)*5),0))))","v":""},null,null,null,null,{"$f":"IF(AK136=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AK136-1)*5),MATCH(AK138,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AK136-1)*5),0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AK136-1)*5),MATCH(AK138,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AK136-1)*5),0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,121,1,null,null,null,null,null,"Numerator Description:",null,null,null,null,{"$f":"IF(Q136=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(Q136-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F140,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(Q136-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F140,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,{"$f":"IF(V136=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(V136-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F140,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(V136-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F140,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,{"$f":"IF(AA136=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(AA136-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F140,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(AA136-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F140,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,{"$f":"IF(AF136=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(AF136-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F140,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(AF136-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F140,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,{"$f":"IF(AK136=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(AK136-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F140,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(AK136-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F140,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,122,1,null,null,null,null,null,"Numerator Value:",null,null,null,null,"Input",null,null,null,null,"Input",null,null,null,null,"Input",null,null,null,null,"Input",null,null,null,null,"Input",null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,{"$f":"IF(OR($T107<>\"Eligible to Report in April DY4\",$T112<>\"Yes\",Q136=\"\"),0,IF(Q141=\"Input\",1,0))","v":0},0,0,0,0,{"$f":"IF(OR($T107<>\"Eligible to Report in April DY4\",$T112<>\"Yes\",V136=\"\"),0,IF(V141=\"Input\",1,0))","v":0},0,0,0,0,{"$f":"IF(OR($T107<>\"Eligible to Report in April DY4\",$T112<>\"Yes\",AA136=\"\"),0,IF(AA141=\"Input\",1,0))","v":0},0,0,0,0,{"$f":"IF(OR($T107<>\"Eligible to Report in April DY4\",$T112<>\"Yes\",AF136=\"\"),0,IF(AF141=\"Input\",1,0))","v":0},0,0,0,0,{"$f":"IF(OR($T107<>\"Eligible to Report in April DY4\",$T112<>\"Yes\",AK136=\"\"),0,IF(AK141=\"Input\",1,0))","v":0},0,0,0,0,0]
[null,null,null,1,123,1,null,null,null,null,null,"Denominator Description:",null,null,null,null,{"$f":"IF(Q136=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(Q136-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F142,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(Q136-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F142,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,{"$f":"IF(V136=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(V136-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F142,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(V136-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F142,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,{"$f":"IF(AA136=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(AA136-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F142,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(AA136-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F142,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,{"$f":"IF(AF136=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(AF136-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F142,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(AF136-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F142,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,{"$f":"IF(AK136=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(AK136-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F142,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(AK136-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F142,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,124,1,null,null,null,null,null,"Denominator:",null,null,null,null,"Input",null,null,null,null,"Input",null,null,null,null,"Input",null,null,null,null,"Input",null,null,null,null,"Input",null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,{"$f":"IF(OR($T107<>\"Eligible to Report in April DY4\",$T112<>\"Yes\",Q136=\"\"),0,IF(Q143=\"Input\",1,0))","v":0},0,0,0,0,{"$f":"IF(OR($T107<>\"Eligible to Report in April DY4\",$T112<>\"Yes\",V136=\"\"),0,IF(V143=\"Input\",1,0))","v":0},0,0,0,0,{"$f":"IF(OR($T107<>\"Eligible to Report in April DY4\",$T112<>\"Yes\",AA136=\"\"),0,IF(AA143=\"Input\",1,0))","v":0},0,0,0,0,{"$f":"IF(OR($T107<>\"Eligible to Report in April DY4\",$T112<>\"Yes\",AF136=\"\"),0,IF(AF143=\"Input\",1,0))","v":0},0,0,0,0,{"$f":"IF(OR($T107<>\"Eligible to Report in April DY4\",$T112<>\"Yes\",AK136=\"\"),0,IF(AK143=\"Input\",1,0))","v":0},0,0,0,0,0]
[null,null,null,1,125,1,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,126,1,null,null,null,null,null,"Measurement Period Start:",null,null,null,null,"MM/DD/YYYY",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,{"$f":"IF(OR($T107<>\"Eligible to Report in April DY4\",$T112<>\"Yes\"),0,IF(Q145=\"MM/DD/YY\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,127,1,null,null,null,null,null,"Measurement Period End:",null,null,null,null,"MM/DD/YYYY",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,{"$f":"IF(OR($T107<>\"Eligible to Report in April DY4\",$T112<>\"Yes\"),0,IF(Q146=\"MM/DD/YY\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
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[null,null,null,1,129,1,null,null,null,null,null,"DY4 Performance Rate:",null,null,null,null,{"$f":"IF(ISERROR(Q141/Q143*IF(OFFSET($T$66,($F148-1)*$A$13+(Q136-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F148-1)*$A$13+(Q136-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F148-1)*$A$13+(Q136-1)*8,0)=\"per 1K\"),1000,1))),\"\",Q141/Q143*IF(OFFSET($T$66,($F148-1)*$A$13+(Q136-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F148-1)*$A$13+(Q136-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F148-1)*$A$13+(Q136-1)*8,0)=\"per 1K\"),1000,1)))","v":""},null,null,null,null,{"$f":"IF(ISERROR(V141/V143*IF(OFFSET($T$66,($F148-1)*$A$13+(V136-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F148-1)*$A$13+(V136-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F148-1)*$A$13+(V136-1)*8,0)=\"per 1K\"),1000,1))),\"\",V141/V143*IF(OFFSET($T$66,($F148-1)*$A$13+(V136-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F148-1)*$A$13+(V136-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F148-1)*$A$13+(V136-1)*8,0)=\"per 1K\"),1000,1)))","v":""},null,null,null,null,{"$f":"IF(ISERROR(AA141/AA143*IF(OFFSET($T$66,($F148-1)*$A$13+(AA136-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F148-1)*$A$13+(AA136-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F148-1)*$A$13+(AA136-1)*8,0)=\"per 1K\"),1000,1))),\"\",AA141/AA143*IF(OFFSET($T$66,($F148-1)*$A$13+(AA136-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F148-1)*$A$13+(AA136-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F148-1)*$A$13+(AA136-1)*8,0)=\"per 1K\"),1000,1)))","v":""},null,null,null,null,{"$f":"IF(ISERROR(AF141/AF143*IF(OFFSET($T$66,($F148-1)*$A$13+(AF136-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F148-1)*$A$13+(AF136-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F148-1)*$A$13+(AF136-1)*8,0)=\"per 1K\"),1000,1))),\"\",AF141/AF143*IF(OFFSET($T$66,($F148-1)*$A$13+(AF136-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F148-1)*$A$13+(AF136-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F148-1)*$A$13+(AF136-1)*8,0)=\"per 1K\"),1000,1)))","v":""},null,null,null,null,{"$f":"IF(ISERROR(AK141/AK143*IF(OFFSET($T$66,($F148-1)*$A$13+(AK136-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F148-1)*$A$13+(AK136-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F148-1)*$A$13+(AK136-1)*8,0)=\"per 1K\"),1000,1))),\"\",AK141/AK143*IF(OFFSET($T$66,($F148-1)*$A$13+(AK136-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F148-1)*$A$13+(AK136-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F148-1)*$A$13+(AK136-1)*8,0)=\"per 1K\"),1000,1)))","v":""},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
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[null,null,null,1,{"$f":"E151+1","v":133},1,null,null,null,null,null,null,null,null,null,null,"Metric 1",null,null,null,null,"Metric 2",null,null,null,null,"Metric 3",null,null,null,null,"Metric 4",null,null,null,null,"Metric 5",null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,134,1,null,null,null,null,null,"Percentage of Goal Achieved",null,null,null,null,{"$f":"IF(OR(Q136=\"\",Q148=\"\"),\"\",IF(ISERROR(MIN(MAX(ROUNDDOWN((Q148-OFFSET($T$68,($F153-1)*$A$13+(Q136-1)*8,0))/(OFFSET($AH$66,($F153-1)*$A$13+(Q136-1)*8,0)-OFFSET($T$68,($F153-1)*$A$13+(Q136-1)*8,0))*4,0)/4,0),1)),\"\",MIN(MAX(ROUNDDOWN((Q148-OFFSET($T$68,($F153-1)*$A$13+(Q136-1)*8,0))/(OFFSET($AH$66,($F153-1)*$A$13+(Q136-1)*8,0)-OFFSET($T$68,($F153-1)*$A$13+(Q136-1)*8,0))*4,0)/4,0),1)))","v":""},null,null,null,null,{"$f":"IF(OR(V136=\"\",V148=\"\"),\"\",MIN(MAX(ROUNDDOWN((V148-OFFSET($T$68,($F153-1)*$A$13+(V136-1)*8,0))/(OFFSET($AH$66,($F153-1)*$A$13+(V136-1)*8,0)-OFFSET($T$68,($F153-1)*$A$13+(V136-1)*8,0))*4,0)/4,0),1))","v":""},null,null,null,null,{"$f":"IF(OR(AA136=\"\",AA148=\"\"),\"\",MIN(MAX(ROUNDDOWN((AA148-OFFSET($T$68,($F153-1)*$A$13+(AA136-1)*8,0))/(OFFSET($AH$66,($F153-1)*$A$13+(AA136-1)*8,0)-OFFSET($T$68,($F153-1)*$A$13+(AA136-1)*8,0))*4,0)/4,0),1))","v":""},null,null,null,null,{"$f":"IF(OR(AF136=\"\",AF148=\"\"),\"\",MIN(MAX(ROUNDDOWN((AF148-OFFSET($T$68,($F153-1)*$A$13+(AF136-1)*8,0))/(OFFSET($AH$66,($F153-1)*$A$13+(AF136-1)*8,0)-OFFSET($T$68,($F153-1)*$A$13+(AF136-1)*8,0))*4,0)/4,0),1))","v":""},null,null,null,null,{"$f":"IF(OR(AK136=\"\",AK148=\"\"),\"\",MIN(MAX(ROUNDDOWN((AK148-OFFSET($T$68,($F153-1)*$A$13+(AK136-1)*8,0))/(OFFSET($AH$66,($F153-1)*$A$13+(AK136-1)*8,0)-OFFSET($T$68,($F153-1)*$A$13+(AK136-1)*8,0))*4,0)/4,0),1))","v":""},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,135,1,null,null,null,null,null,"Status",null,null,null,null,{"$f":"IF(Q153=\"\",\"\",IF(Q153<1,\"Partially Achieved\",\"Achieved\"))","v":""},null,null,null,null,{"$f":"IF(V153=\"\",\"\",IF(V153<1,\"Partially Achieved\",\"Achieved\"))","v":""},null,null,null,null,{"$f":"IF(AA153=\"\",\"\",IF(AA153<1,\"Partially Achieved\",\"Achieved\"))","v":""},null,null,null,null,{"$f":"IF(AF153=\"\",\"\",IF(AF153<1,\"Partially Achieved\",\"Achieved\"))","v":""},null,null,null,null,{"$f":"IF(AK153=\"\",\"\",IF(AK153<1,\"Partially Achieved\",\"Achieved\"))","v":""},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,136,1,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F156=\"\",1,IF(OR(OFFSET($T$31,($F156-1)*$A$13,0)=\"P4R\",OFFSET($T$107,($F156-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F156-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F156-1)*$A$13,0)=FALSE,1,0)))+IF(SUM(Q156:AO156)=0,0,1)","v":1},137,1,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,138,1,null,null,null,null,null,"Please explain why your achievement is less than expected.",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,{"$f":"IF(ISERROR(IF(OR(Q136=\"\",$D157=1,Q154<>\"Partially Achieved\"),0,IF(Q157=\"Free Text\",1,0))),0,IF(OR(Q136=\"\",$D157=1,Q154<>\"Partially Achieved\"),0,IF(Q157=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(V136=\"\",$D157=1,V154<>\"Partially Achieved\"),0,IF(V157=\"Free Text\",1,0))),0,IF(OR(V136=\"\",$D157=1,V154<>\"Partially Achieved\"),0,IF(V157=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AA136=\"\",$D157=1,AA154<>\"Partially Achieved\"),0,IF(AA157=\"Free Text\",1,0))),0,IF(OR(AA136=\"\",$D157=1,AA154<>\"Partially Achieved\"),0,IF(AA157=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AF136=\"\",$D157=1,AF154<>\"Partially Achieved\"),0,IF(AF157=\"Free Text\",1,0))),0,IF(OR(AF136=\"\",$D157=1,AF154<>\"Partially Achieved\"),0,IF(AF157=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AK136=\"\",$D157=1,AK154<>\"Partially Achieved\"),0,IF(AK157=\"Free Text\",1,0))),0,IF(OR(AK136=\"\",$D157=1,AK154<>\"Partially Achieved\"),0,IF(AK157=\"Free Text\",1,0)))","v":0},0,0,0,0,0]
[null,null,null,1,139,1,null,null,null,null,null,"What is your plan to improve performance by the end of the following DY?",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,{"$f":"IF(ISERROR(IF(OR(Q136=\"\",$D158=1,Q154<>\"Partially Achieved\"),0,IF(Q158=\"Free Text\",1,0))),0,IF(OR(Q136=\"\",$D158=1,Q154<>\"Partially Achieved\"),0,IF(Q158=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(V136=\"\",$D158=1,V154<>\"Partially Achieved\"),0,IF(V158=\"Free Text\",1,0))),0,IF(OR(V136=\"\",$D158=1,V154<>\"Partially Achieved\"),0,IF(V158=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AA136=\"\",$D158=1,AA154<>\"Partially Achieved\"),0,IF(AA158=\"Free Text\",1,0))),0,IF(OR(AA136=\"\",$D158=1,AA154<>\"Partially Achieved\"),0,IF(AA158=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AF136=\"\",$D158=1,AF154<>\"Partially Achieved\"),0,IF(AF158=\"Free Text\",1,0))),0,IF(OR(AF136=\"\",$D158=1,AF154<>\"Partially Achieved\"),0,IF(AF158=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AK136=\"\",$D158=1,AK154<>\"Partially Achieved\"),0,IF(AK158=\"Free Text\",1,0))),0,IF(OR(AK136=\"\",$D158=1,AK154<>\"Partially Achieved\"),0,IF(AK158=\"Free Text\",1,0)))","v":0},0,0,0,0,0]
[null,null,null,1,140,1,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,141,1,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F161=\"\",1,IF(OR(OFFSET($T$107,($F161-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F161-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F161-1)*$A$13,0)=FALSE,1,0)))","v":1},142,1,null,null,null,null,null,"Performance Reporting - Qualitative",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F162=\"\",1,IF(OR(OFFSET($T$107,($F162-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F162-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F162-1)*$A$13,0)=FALSE,1,0)))","v":1},143,1,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F163=\"\",1,IF(OR(OFFSET($T$107,($F163-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F163-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F163-1)*$A$13,0)=FALSE,1,0)))","v":1},144,1,null,null,null,null,null,"Please describe your interpretation of the rate above, including factors that may have caused a change in the rate (e.g. intervention, population shifts, system changes, etc.) as well as any trends identified within groups in your denominator (e.g. patient characteristics, seasonality, location of care, etc.)",null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T107<>\"Eligible to Report in April DY4\",$T112<>\"Yes\"),0,IF(T163=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F164=\"\",1,IF(OR(OFFSET($T$107,($F164-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F164-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F164-1)*$A$13,0)=FALSE,1,0)))","v":1},145,1,null,null,null,null,null,"Please estimate what percentage of your intervention population (QPI) is also represented by the denominator used to calculate your DY4 performance above",null,null,null,null,null,null,null,"Input",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T107<>\"Eligible to Report in April DY4\",$T112<>\"Yes\"),0,IF(T164=\"Input\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,{"$f":"CELL(\"Address\",T165)","v":"$T$165"},{"$f":"IF($F165=\"\",1,IF(OR(OFFSET($T$107,($F165-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F165-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F165-1)*$A$13,0)=FALSE,1,0)))","v":1},146,1,null,null,null,null,null,"Are you able to report performance in this outcome exclusively for the individuals receiving the intervention?",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T107<>\"Eligible to Report in April DY4\",$T112<>\"Yes\"),0,IF(T165=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F166=\"\",1,IF(OR(OFFSET($T$107,($F166-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F166-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F166-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$165,($F166-1)*$A$13,0)=\"Yes\",0,1))))","v":1},147,1,null,null,null,null,null,"Intervention Input",null,null,null,null,null,null,null,"Intervention Only Numerator:",null,"Input",null,null,null,"Intervention Only Denominator:",null,"Input",null,null,null,"Intervention Only Performance Rate:",null,null,null,null,null,{"$f":"IF(ISERROR(V166/AB166),\"\",V166/AB166)","v":""},null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T107<>\"Eligible to Report in April DY4\",$T112<>\"Yes\",$T165<>\"Yes\"),0,IF(V166=\"Input\",1,0))","v":0},0,0,0,0,0,{"$f":"IF(OR($T107<>\"Eligible to Report in April DY4\",$T112<>\"Yes\",$T165<>\"Yes\"),0,IF(AB166=\"Input\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F167=\"\",1,IF(OR(OFFSET($T$107,($F167-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F167-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F167-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$165,($F167-1)*$A$13,0)=\"Yes\",0,1))))","v":1},148,1,null,null,null,null,null,null,"Please describe your interpretation of the Intervention only performance rate including any factors contributing to this result",null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T107<>\"Eligible to Report in April DY4\",$T112<>\"Yes\",$T165<>\"Yes\"),0,IF(T167=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,{"$f":"CELL(\"Address\",T168)","v":"$T$168"},{"$f":"IF($F168=\"\",1,IF(OR(OFFSET($T$107,($F168-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F168-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F168-1)*$A$13,0)=FALSE,1,0)))","v":1},149,1,null,null,null,null,null,"Are you able to report performance in this outcome at a level broader than the denominator used to determine DY4 performance (i.e. system level performance)?",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T107<>\"Eligible to Report in April DY4\",$T112<>\"Yes\"),0,IF(T168=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F169=\"\",1,IF(OR(OFFSET($T$107,($F169-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F169-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F169-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$168,($F169-1)*$A$13,0)=\"Yes\",0,1))))","v":1},150,1,null,null,null,null,null,"System Level Input",null,null,null,null,null,null,null,"System Level Numerator:",null,"Input",null,null,null,"System Level Denominator:",null,"Input",null,null,null,"System Level Performance Rate:",null,null,null,null,null,{"$f":"IF(ISERROR(V169/AB169),\"\",V169/AB169)","v":""},null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T107<>\"Eligible to Report in April DY4\",$T112<>\"Yes\",$T168<>\"Yes\"),0,IF(V169=\"Input\",1,0))","v":0},0,0,0,0,0,{"$f":"IF(OR($T107<>\"Eligible to Report in April DY4\",$T112<>\"Yes\",$T168<>\"Yes\"),0,IF(AB169=\"Input\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F170=\"\",1,IF(OR(OFFSET($T$107,($F170-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F170-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F170-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$168,($F170-1)*$A$13,0)=\"Yes\",0,1))))","v":1},151,1,null,null,null,null,null,null,"Please describe your interpretation of the system level performance rate including any factors contributing to this result",null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T107<>\"Eligible to Report in April DY4\",$T112<>\"Yes\",$T168<>\"Yes\"),0,IF(T170=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F171=\"\",1,IF(OR(OFFSET($T$107,($F171-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F171-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F171-1)*$A$13,0)=FALSE,1,0)))","v":1},152,1,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F172=\"\",1,IF(OR(OFFSET($T$107,($F172-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F172-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F172-1)*$A$13,0)=FALSE,1,0)))","v":1},153,1,null,null,null,null,null,"Are there any other process or improvement outcomes, beyond the Category 3 outcomes associated with this project, that are being used to monitor intervention effects or impact?",null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T107<>\"Eligible to Report in April DY4\",$T112<>\"Yes\"),0,IF(T172=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F173=\"\",1,IF(OR(OFFSET($T$107,($F173-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F173-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F173-1)*$A$13,0)=FALSE,1,0)))","v":1},154,1,null,null,null,null,null,"Please Include any Additional Comments here:",null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T107<>\"Eligible to Report in April DY4\",$T112<>\"Yes\"),0,IF(T173=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F174=\"\",1,IF(OR(OFFSET($T$107,($F174-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F174-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F174-1)*$A$13,0)=FALSE,1,0)))","v":1},155,1,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
["#Metrics",null,null,{"$f":"IF($O$14=\"\",0,IF($F175=\"\",1,0))","v":0},{"$f":"E174+1","v":156},{"$f":"IF(F174=\"\",\"\",IF(G175=\"New\",IF(F174+1>$A$15,\"\",F174+1),F174))","v":2},"New",null,null,null,{"$f":"\"Outcome \"&$F175&\" Details\"","v":"Outcome 2 Details"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"X",{"$f":"K175","v":"Outcome 2 Details"}]
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["#Milestones",null,null,0,158,2,null,null,null,null,null,"Category 3 Outcome ID:",null,null,null,{"$f":"IF($F177=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$E$4:$E$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F177,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$E$4:$E$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F177,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$E$4:$E$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F177,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
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[null,null,null,{"$f":"IF($F260=\"\",1,IF(OFFSET($A$26,($F260-1)*$A$13,0)=FALSE,1,0))","v":1},241,2,null,null,null,null,null,"Performance Reporting - Readiness:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F261=\"\",1,IF(OFFSET($A$26,($F261-1)*$A$13,0)=FALSE,1,0))","v":1},242,2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F262=\"\",1,IF(OFFSET($A$26,($F262-1)*$A$13,0)=FALSE,1,0))","v":1},243,2,null,null,null,null,null,"Eligible to report in April DY4?",null,null,null,null,null,null,null,{"$f":"IF(F262=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$I$4:$I$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F262,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$I$4:$I$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F262,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$I$4:$I$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F262,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F263=\"\",1,IF(OFFSET($A$26,($F263-1)*$A$13,0)=FALSE,1,0))","v":1},244,2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F264=\"\",1,IF(OFFSET($A$26,($F264-1)*$A$13,0)=FALSE,1,0))","v":1},245,2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F265=\"\",1,IF(OFFSET($A$26,($F265-1)*$A$13,0),IF(T262=\"Eligible to Report in October DY4\",0,1),1))","v":1},246,2,null,null,null,null,null,"Outcome is eligible to be reported in October of DY4",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F266=\"\",1,IF(OFFSET($A$26,($F266-1)*$A$13,0)=FALSE,1,0))","v":1},{"$f":"E265+1","v":247},{"$f":"IF(F265=\"\",\"\",IF(G266=\"New\",IF(F265+1>$A$15,\"\",F265+1),F265))","v":2},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,{"$f":"CELL(\"Address\",T267)","v":"$T$267"},null,{"$f":"IF($F267=\"\",1,IF(OFFSET($T$107,($F267-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F267-1)*$A$13,0)=FALSE,1,0)))","v":1},248,2,null,null,null,null,null,"Are you ready to report this outcome with 12 months of data aligning with your DY4 measurement period?",null,null,null,null,null,null,null,null,null,"If not, within the online reporting system please include a progress update regarding the status of your performance.  If no updates to performance are available, please describe any salient updates to the measure collection process.  This progress update fulfills your semi-annual reporting requirement for this milestone. Please indicate that you will do this by selecting 'Yes' to the right",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T262<>\"Eligible to Report in April DY4\",0,IF(T267=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T262<>\"Eligible to Report in April DY4\",$T267=\"Yes\"),0,IF(AE267=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,249,2,null,null,null,null,null,"Provider intention to Carry forward",null,null,null,null,null,null,null,"NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,250,2,null,null,null,null,null,"Provider intention to report in October DY4",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,251,2,null,null,null,null,null,"Additional text boxes to use in October",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,252,2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,253,2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,254,2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,255,2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,256,2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[{"$f":"CELL(\"Address\",T276)","v":"$T$276"},null,null,{"$f":"IF($F276=\"\",1,IF(OFFSET($T$107,($F276-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F276-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F276-1)*$A$13,0)=\"Yes\",0,1))))","v":1},257,2,null,null,null,null,null,"Are you reporting to approved measure specifications?  This includes numerator description, denominator description and any approved subsets",null,null,null,null,null,null,null,null,null,"Please describe any differences between specifications used to determine DY4 performance and the approved measure specifications:",null,null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T267<>\"Yes\",0,IF(T276=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,{"$f":"IF($T267<>\"Yes\",0,IF(AND(T276=\"No\",AE276=\"Free Text\"),1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0]
[{"$f":"CELL(\"Address\",T277)","v":"$T$277"},null,null,{"$f":"IF($F277=\"\",1,IF(OFFSET($T$107,($F277-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F277-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F277-1)*$A$13,0)=\"Yes\",0,1))))","v":1},258,2,null,null,null,null,null,"Are there any changes/improvements/clarifications to your data abstraction process for the performance reported in DY4 relative to how the baseline was described in the field above?",null,null,null,null,null,null,null,null,null,"Please describe the changes/improvements to your abstraction process",null,null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T267<>\"Yes\",0,IF(T277=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,{"$f":"IF($T267<>\"Yes\",0,IF(AND(T277=\"Yes\",AE277=\"Free Text\"),1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0]
[{"$f":"CELL(\"Address\",T278)","v":"$T$278"},null,null,{"$f":"IF($F278=\"\",1,IF(OFFSET($T$107,($F278-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F278-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F278-1)*$A$13,0)=\"Yes\",0,1))))","v":1},259,2,null,null,null,null,null,"Are there any changes or improvements to your tool administration process as reported at baseline?",null,null,null,null,null,null,null,null,null,"Please describe changes in tool/survey administration process",null,null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T267<>\"Yes\",0,IF(T278=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,{"$f":"IF($T267<>\"Yes\",0,IF(AND(T278=\"Yes\",AE278=\"Free Text\"),1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F279=\"\",1,IF(OR(OFFSET($T$107,($F279-1)*$A$13,0)<>\"Eligible to Report in April DY4\",$T279=\"\"),1,IF(OFFSET($A$26,($F279-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F279-1)*$A$13,0)=\"Yes\",0,1))))","v":1},260,2,null,null,null,null,null,"Risk Adjustment Type",null,null,null,null,null,null,null,{"$f":"IF(F278=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$EZ$4:$EZ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F278,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$EZ$4:$EZ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F278,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$EZ$4:$EZ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F278,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[{"$f":"CELL(\"Address\",T280)","v":"$T$280"},null,null,{"$f":"IF($F280=\"\",1,IF(OR(OFFSET($T$107,($F280-1)*$A$13,0)<>\"Eligible to Report in April DY4\",$T279=\"\"),1,IF(OFFSET($A$26,($F280-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F280-1)*$A$13,0)=\"Yes\",0,1))))","v":1},261,2,null,null,null,null,null,null,"Are there any changes or improvements to risk adjustment process?",null,null,null,null,null,null,null,null,"Please describe changes in risk adjustment process",null,null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T267<>\"Yes\",0,IF($T279=\"\",0,IF(T280=\"\",1,0)))","v":0},0,0,0,0,0,0,0,0,0,{"$f":"IF($T267<>\"Yes\",0,IF(AND(T280=\"Yes\",AE280=\"Free Text\"),1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F281=\"\",1,IF(OFFSET($T$107,($F281-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F281-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F281-1)*$A$13,0)=\"Yes\",IF(IF(F281=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F281,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F281,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F281,'Master Data Mock'!$FM$4:$FM$5000,0))))<>\"\",0,1),1))))","v":1},262,2,null,null,null,null,null,{"$f":"\"Provider used a proxy population to determine baseline performance described as:  \"&IF(F281=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F281,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F281,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F281,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":"Provider used a proxy population to determine baseline performance described as:  "},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F282=\"\",1,IF(OFFSET($T$107,($F282-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F282-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F282-1)*$A$13,0)=\"Yes\",IF(IF(F282=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F282,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F282,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F282,'Master Data Mock'!$FM$4:$FM$5000,0))))<>\"\",0,1),1))))","v":1},263,2,null,null,null,null,null,null,"Please describe the alignment (similarities and differences) between the proxy population reported for baseline and the cohort used for the DY4 measurement period",null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($D281=1,$T267<>\"Yes\"),0,IF(T282=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F283=\"\",1,IF(OFFSET($A$26,($F283-1)*$A$13,0)=FALSE,1,0))","v":1},264,2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F284=\"\",1,IF(OFFSET($T$107,($F284-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F284-1)*$A$13,0)=FALSE,1,IF(OR(OFFSET($T$112,($F284-1)*$A$13,0)=\"Yes\",OFFSET($T$31,($F284-1)*$A$13,0)<>\"P4R\"),1,0))))","v":1},265,2,null,null,null,null,null,"Alternate Achievement Activity Status Update",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,266,2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,267,2,null,null,null,null,null,"Alternate Achievement Activity:",null,null,null,null,null,null,null,{"$f":"IF(OR(ISERROR(INDEX('Master Data Mock'!$P$4:$P$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F286,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$P$4:$P$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F286,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$P$4:$P$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F286,'Master Data Mock'!$FM$4:$FM$5000,0)))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,268,2,null,null,null,null,null,"Alternative Achievement Activity Baseline Reported:",null,null,null,null,null,null,null,{"$f":"IF(LEFT(T286,2)=\"SA\",IF(OR(ISERROR(INDEX('Master Data Mock'!$EP$4:$EP$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F287,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$EP$4:$EP$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F287,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$EP$4:$EP$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F287,'Master Data Mock'!$FM$4:$FM$5000,0))),IF(OR(ISERROR(INDEX('Master Data Mock'!$EQ$4:$EQ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F287,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$EQ$4:$EQ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F287,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$EQ$4:$EQ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F287,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,269,2,null,null,null,null,null,"Please include an update for any activities to date related to the selected Stretch Activity above or performance in the PFP measure above. If baseline for this PFP measure has not yet been reported, please indicate when this will be submitted and which 12 month measurement period it will reflect (DY3 or DY4).  If ready to report PFP baseline now please complete the PFP Baseline form found here: http://www.hhsc.state.tx.us/1115-Waiver-Guideline.shtml ",null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T186<>\"P4R\",0,IF(T288=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,270,2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F290=\"\",1,IF(OR(OFFSET($T$107,($F290-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F290-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F290-1)*$A$13,0)=FALSE,1,0)))","v":1},271,2,null,null,null,null,null,"Performance Reporting - Quantitative",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,272,2,null,null,null,null,null,null,null,null,null,null,{"$f":"IF($F291=\"\",\"\",1)","v":1},null,null,null,null,{"$f":"IF($F291=\"\",\"\",IF(Q291=\"\",\"\",IF(Q291+1>OFFSET($A$21,($F291-1)*$A$13,0),\"\",Q291+1)))","v":2},null,null,null,null,{"$f":"IF($F291=\"\",\"\",IF(V291=\"\",\"\",IF(V291+1>OFFSET($A$21,($F291-1)*$A$13,0),\"\",V291+1)))","v":3},null,null,null,null,{"$f":"IF($F291=\"\",\"\",IF(AA291=\"\",\"\",IF(AA291+1>OFFSET($A$21,($F291-1)*$A$13,0),\"\",AA291+1)))","v":4},null,null,null,null,{"$f":"IF($F291=\"\",\"\",IF(AF291=\"\",\"\",IF(AF291+1>OFFSET($A$21,($F291-1)*$A$13,0),\"\",AF291+1)))","v":5},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,273,2,null,null,null,null,null,null,null,null,null,null,"Metric 1",null,null,null,null,"Metric 2",null,null,null,null,"Metric 3",null,null,null,null,"Metric 4",null,null,null,null,"Metric 5",null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,274,2,null,null,null,null,null,"Milestone ID:",null,null,null,null,{"$f":"IF($F293=\"\",\"\",IF(Q291=\"\",\"\",\"AM-1.\"&Q291))","v":"AM-1.1"},null,null,null,null,{"$f":"IF($F293=\"\",\"\",IF(V291=\"\",\"\",\"AM-1.\"&V291))","v":"AM-1.2"},null,null,null,null,{"$f":"IF($F293=\"\",\"\",IF(AA291=\"\",\"\",\"AM-1.\"&AA291))","v":"AM-1.3"},null,null,null,null,{"$f":"IF($F293=\"\",\"\",IF(AF291=\"\",\"\",\"AM-1.\"&AF291))","v":"AM-1.4"},null,null,null,null,{"$f":"IF($F293=\"\",\"\",IF(AK291=\"\",\"\",\"AM-1.\"&AK291))","v":"AM-1.5"},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,275,2,null,null,null,null,null,"Milestone Description:",null,null,null,null,{"$f":"IF(Q291=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(Q291-1)*5),MATCH(Q293,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(Q291-1)*5),0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(Q291-1)*5),MATCH(Q293,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(Q291-1)*5),0))))","v":"Achievement of DY4 performance goal"},null,null,null,null,{"$f":"IF(V291=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(V291-1)*5),MATCH(V293,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(V291-1)*5),0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(V291-1)*5),MATCH(V293,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(V291-1)*5),0))))","v":"Achievement of DY4 performance goal- 30 day follow-up"},null,null,null,null,{"$f":"IF(AA291=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AA291-1)*5),MATCH(AA293,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AA291-1)*5),0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AA291-1)*5),MATCH(AA293,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AA291-1)*5),0))))","v":"Achievement of DY4 performance goal- Counseling for physical activity"},null,null,null,null,{"$f":"IF(AF291=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AF291-1)*5),MATCH(AF293,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AF291-1)*5),0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AF291-1)*5),MATCH(AF293,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AF291-1)*5),0))))","v":"Achievement of DY4 performance goal- GSMC"},null,null,null,null,{"$f":"IF(AK291=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AK291-1)*5),MATCH(AK293,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AK291-1)*5),0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AK291-1)*5),MATCH(AK293,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AK291-1)*5),0))))","v":"Achievement of DY4 performance goal- Mortality O/E"},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,276,2,null,null,null,null,null,"Numerator Description:",null,null,null,null,{"$f":"IF(Q291=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(Q291-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F295,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(Q291-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F295,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":{"$error":"#N/A"}},null,null,null,null,{"$f":"IF(V291=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(V291-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F295,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(V291-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F295,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":{"$error":"#N/A"}},null,null,null,null,{"$f":"IF(AA291=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(AA291-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F295,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(AA291-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F295,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":{"$error":"#N/A"}},null,null,null,null,{"$f":"IF(AF291=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(AF291-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F295,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(AF291-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F295,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":{"$error":"#N/A"}},null,null,null,null,{"$f":"IF(AK291=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(AK291-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F295,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(AK291-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F295,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":{"$error":"#N/A"}},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,277,2,null,null,null,null,null,"Numerator Value:",null,null,null,null,"Input",null,null,null,null,"Input",null,null,null,null,"Input",null,null,null,null,"Input",null,null,null,null,"Input",null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,{"$f":"IF(OR($T262<>\"Eligible to Report in April DY4\",$T267<>\"Yes\",Q291=\"\"),0,IF(Q296=\"Input\",1,0))","v":0},0,0,0,0,{"$f":"IF(OR($T262<>\"Eligible to Report in April DY4\",$T267<>\"Yes\",V291=\"\"),0,IF(V296=\"Input\",1,0))","v":0},0,0,0,0,{"$f":"IF(OR($T262<>\"Eligible to Report in April DY4\",$T267<>\"Yes\",AA291=\"\"),0,IF(AA296=\"Input\",1,0))","v":0},0,0,0,0,{"$f":"IF(OR($T262<>\"Eligible to Report in April DY4\",$T267<>\"Yes\",AF291=\"\"),0,IF(AF296=\"Input\",1,0))","v":0},0,0,0,0,{"$f":"IF(OR($T262<>\"Eligible to Report in April DY4\",$T267<>\"Yes\",AK291=\"\"),0,IF(AK296=\"Input\",1,0))","v":0},0,0,0,0,0]
[null,null,null,1,278,2,null,null,null,null,null,"Denominator Description:",null,null,null,null,{"$f":"IF(Q291=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(Q291-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F297,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(Q291-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F297,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":{"$error":"#N/A"}},null,null,null,null,{"$f":"IF(V291=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(V291-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F297,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(V291-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F297,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":{"$error":"#N/A"}},null,null,null,null,{"$f":"IF(AA291=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(AA291-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F297,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(AA291-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F297,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":{"$error":"#N/A"}},null,null,null,null,{"$f":"IF(AF291=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(AF291-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F297,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(AF291-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F297,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":{"$error":"#N/A"}},null,null,null,null,{"$f":"IF(AK291=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(AK291-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F297,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(AK291-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F297,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":{"$error":"#N/A"}},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,279,2,null,null,null,null,null,"Denominator:",null,null,null,null,"Input",null,null,null,null,"Input",null,null,null,null,"Input",null,null,null,null,"Input",null,null,null,null,"Input",null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,{"$f":"IF(OR($T262<>\"Eligible to Report in April DY4\",$T267<>\"Yes\",Q291=\"\"),0,IF(Q298=\"Input\",1,0))","v":0},0,0,0,0,{"$f":"IF(OR($T262<>\"Eligible to Report in April DY4\",$T267<>\"Yes\",V291=\"\"),0,IF(V298=\"Input\",1,0))","v":0},0,0,0,0,{"$f":"IF(OR($T262<>\"Eligible to Report in April DY4\",$T267<>\"Yes\",AA291=\"\"),0,IF(AA298=\"Input\",1,0))","v":0},0,0,0,0,{"$f":"IF(OR($T262<>\"Eligible to Report in April DY4\",$T267<>\"Yes\",AF291=\"\"),0,IF(AF298=\"Input\",1,0))","v":0},0,0,0,0,{"$f":"IF(OR($T262<>\"Eligible to Report in April DY4\",$T267<>\"Yes\",AK291=\"\"),0,IF(AK298=\"Input\",1,0))","v":0},0,0,0,0,0]
[null,null,null,1,280,2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,281,2,null,null,null,null,null,"Measurement Period Start:",null,null,null,null,"MM/DD/YYYY",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,{"$f":"IF(OR($T262<>\"Eligible to Report in April DY4\",$T267<>\"Yes\"),0,IF(Q300=\"MM/DD/YY\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,282,2,null,null,null,null,null,"Measurement Period End:",null,null,null,null,"MM/DD/YYYY",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,{"$f":"IF(OR($T262<>\"Eligible to Report in April DY4\",$T267<>\"Yes\"),0,IF(Q301=\"MM/DD/YY\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,283,2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,284,2,null,null,null,null,null,"DY4 Performance Rate:",null,null,null,null,{"$f":"IF(ISERROR(Q296/Q298*IF(OFFSET($T$66,($F303-1)*$A$13+(Q291-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F303-1)*$A$13+(Q291-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F303-1)*$A$13+(Q291-1)*8,0)=\"per 1K\"),1000,1))),\"\",Q296/Q298*IF(OFFSET($T$66,($F303-1)*$A$13+(Q291-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F303-1)*$A$13+(Q291-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F303-1)*$A$13+(Q291-1)*8,0)=\"per 1K\"),1000,1)))","v":""},null,null,null,null,{"$f":"IF(ISERROR(V296/V298*IF(OFFSET($T$66,($F303-1)*$A$13+(V291-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F303-1)*$A$13+(V291-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F303-1)*$A$13+(V291-1)*8,0)=\"per 1K\"),1000,1))),\"\",V296/V298*IF(OFFSET($T$66,($F303-1)*$A$13+(V291-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F303-1)*$A$13+(V291-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F303-1)*$A$13+(V291-1)*8,0)=\"per 1K\"),1000,1)))","v":""},null,null,null,null,{"$f":"IF(ISERROR(AA296/AA298*IF(OFFSET($T$66,($F303-1)*$A$13+(AA291-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F303-1)*$A$13+(AA291-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F303-1)*$A$13+(AA291-1)*8,0)=\"per 1K\"),1000,1))),\"\",AA296/AA298*IF(OFFSET($T$66,($F303-1)*$A$13+(AA291-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F303-1)*$A$13+(AA291-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F303-1)*$A$13+(AA291-1)*8,0)=\"per 1K\"),1000,1)))","v":""},null,null,null,null,{"$f":"IF(ISERROR(AF296/AF298*IF(OFFSET($T$66,($F303-1)*$A$13+(AF291-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F303-1)*$A$13+(AF291-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F303-1)*$A$13+(AF291-1)*8,0)=\"per 1K\"),1000,1))),\"\",AF296/AF298*IF(OFFSET($T$66,($F303-1)*$A$13+(AF291-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F303-1)*$A$13+(AF291-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F303-1)*$A$13+(AF291-1)*8,0)=\"per 1K\"),1000,1)))","v":""},null,null,null,null,{"$f":"IF(ISERROR(AK296/AK298*IF(OFFSET($T$66,($F303-1)*$A$13+(AK291-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F303-1)*$A$13+(AK291-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F303-1)*$A$13+(AK291-1)*8,0)=\"per 1K\"),1000,1))),\"\",AK296/AK298*IF(OFFSET($T$66,($F303-1)*$A$13+(AK291-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F303-1)*$A$13+(AK291-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F303-1)*$A$13+(AK291-1)*8,0)=\"per 1K\"),1000,1)))","v":""},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
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[null,null,null,1,287,2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,288,2,null,null,null,null,null,null,null,null,null,null,"Metric 1",null,null,null,null,"Metric 2",null,null,null,null,"Metric 3",null,null,null,null,"Metric 4",null,null,null,null,"Metric 5",null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,289,2,null,null,null,null,null,"Percentage of Goal Achieved",null,null,null,null,{"$f":"IF(OR(Q291=\"\",Q303=\"\"),\"\",IF(ISERROR(MIN(MAX(ROUNDDOWN((Q303-OFFSET($T$68,($F308-1)*$A$13+(Q291-1)*8,0))/(OFFSET($AH$66,($F308-1)*$A$13+(Q291-1)*8,0)-OFFSET($T$68,($F308-1)*$A$13+(Q291-1)*8,0))*4,0)/4,0),1)),\"\",MIN(MAX(ROUNDDOWN((Q303-OFFSET($T$68,($F308-1)*$A$13+(Q291-1)*8,0))/(OFFSET($AH$66,($F308-1)*$A$13+(Q291-1)*8,0)-OFFSET($T$68,($F308-1)*$A$13+(Q291-1)*8,0))*4,0)/4,0),1)))","v":""},null,null,null,null,{"$f":"IF(OR(V291=\"\",V303=\"\"),\"\",MIN(MAX(ROUNDDOWN((V303-OFFSET($T$68,($F308-1)*$A$13+(V291-1)*8,0))/(OFFSET($AH$66,($F308-1)*$A$13+(V291-1)*8,0)-OFFSET($T$68,($F308-1)*$A$13+(V291-1)*8,0))*4,0)/4,0),1))","v":""},null,null,null,null,{"$f":"IF(OR(AA291=\"\",AA303=\"\"),\"\",MIN(MAX(ROUNDDOWN((AA303-OFFSET($T$68,($F308-1)*$A$13+(AA291-1)*8,0))/(OFFSET($AH$66,($F308-1)*$A$13+(AA291-1)*8,0)-OFFSET($T$68,($F308-1)*$A$13+(AA291-1)*8,0))*4,0)/4,0),1))","v":""},null,null,null,null,{"$f":"IF(OR(AF291=\"\",AF303=\"\"),\"\",MIN(MAX(ROUNDDOWN((AF303-OFFSET($T$68,($F308-1)*$A$13+(AF291-1)*8,0))/(OFFSET($AH$66,($F308-1)*$A$13+(AF291-1)*8,0)-OFFSET($T$68,($F308-1)*$A$13+(AF291-1)*8,0))*4,0)/4,0),1))","v":""},null,null,null,null,{"$f":"IF(OR(AK291=\"\",AK303=\"\"),\"\",MIN(MAX(ROUNDDOWN((AK303-OFFSET($T$68,($F308-1)*$A$13+(AK291-1)*8,0))/(OFFSET($AH$66,($F308-1)*$A$13+(AK291-1)*8,0)-OFFSET($T$68,($F308-1)*$A$13+(AK291-1)*8,0))*4,0)/4,0),1))","v":""},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,290,2,null,null,null,null,null,"Status",null,null,null,null,{"$f":"IF(Q308=\"\",\"\",IF(Q308<1,\"Partially Achieved\",\"Achieved\"))","v":""},null,null,null,null,{"$f":"IF(V308=\"\",\"\",IF(V308<1,\"Partially Achieved\",\"Achieved\"))","v":""},null,null,null,null,{"$f":"IF(AA308=\"\",\"\",IF(AA308<1,\"Partially Achieved\",\"Achieved\"))","v":""},null,null,null,null,{"$f":"IF(AF308=\"\",\"\",IF(AF308<1,\"Partially Achieved\",\"Achieved\"))","v":""},null,null,null,null,{"$f":"IF(AK308=\"\",\"\",IF(AK308<1,\"Partially Achieved\",\"Achieved\"))","v":""},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,291,2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F311=\"\",1,IF(OR(OFFSET($T$31,($F311-1)*$A$13,0)=\"P4R\",OFFSET($T$107,($F311-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F311-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F311-1)*$A$13,0)=FALSE,1,0)))+IF(SUM(Q311:AO311)=0,0,1)","v":1},292,2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,293,2,null,null,null,null,null,"Please explain why your achievement is less than expected.",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,{"$f":"IF(ISERROR(IF(OR(Q291=\"\",$D312=1,Q309<>\"Partially Achieved\"),0,IF(Q312=\"Free Text\",1,0))),0,IF(OR(Q291=\"\",$D312=1,Q309<>\"Partially Achieved\"),0,IF(Q312=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(V291=\"\",$D312=1,V309<>\"Partially Achieved\"),0,IF(V312=\"Free Text\",1,0))),0,IF(OR(V291=\"\",$D312=1,V309<>\"Partially Achieved\"),0,IF(V312=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AA291=\"\",$D312=1,AA309<>\"Partially Achieved\"),0,IF(AA312=\"Free Text\",1,0))),0,IF(OR(AA291=\"\",$D312=1,AA309<>\"Partially Achieved\"),0,IF(AA312=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AF291=\"\",$D312=1,AF309<>\"Partially Achieved\"),0,IF(AF312=\"Free Text\",1,0))),0,IF(OR(AF291=\"\",$D312=1,AF309<>\"Partially Achieved\"),0,IF(AF312=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AK291=\"\",$D312=1,AK309<>\"Partially Achieved\"),0,IF(AK312=\"Free Text\",1,0))),0,IF(OR(AK291=\"\",$D312=1,AK309<>\"Partially Achieved\"),0,IF(AK312=\"Free Text\",1,0)))","v":0},0,0,0,0,0]
[null,null,null,1,294,2,null,null,null,null,null,"What is your plan to improve performance by the end of the following DY?",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,{"$f":"IF(ISERROR(IF(OR(Q291=\"\",$D313=1,Q309<>\"Partially Achieved\"),0,IF(Q313=\"Free Text\",1,0))),0,IF(OR(Q291=\"\",$D313=1,Q309<>\"Partially Achieved\"),0,IF(Q313=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(V291=\"\",$D313=1,V309<>\"Partially Achieved\"),0,IF(V313=\"Free Text\",1,0))),0,IF(OR(V291=\"\",$D313=1,V309<>\"Partially Achieved\"),0,IF(V313=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AA291=\"\",$D313=1,AA309<>\"Partially Achieved\"),0,IF(AA313=\"Free Text\",1,0))),0,IF(OR(AA291=\"\",$D313=1,AA309<>\"Partially Achieved\"),0,IF(AA313=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AF291=\"\",$D313=1,AF309<>\"Partially Achieved\"),0,IF(AF313=\"Free Text\",1,0))),0,IF(OR(AF291=\"\",$D313=1,AF309<>\"Partially Achieved\"),0,IF(AF313=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AK291=\"\",$D313=1,AK309<>\"Partially Achieved\"),0,IF(AK313=\"Free Text\",1,0))),0,IF(OR(AK291=\"\",$D313=1,AK309<>\"Partially Achieved\"),0,IF(AK313=\"Free Text\",1,0)))","v":0},0,0,0,0,0]
[null,null,null,1,295,2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,296,2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F316=\"\",1,IF(OR(OFFSET($T$107,($F316-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F316-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F316-1)*$A$13,0)=FALSE,1,0)))","v":1},297,2,null,null,null,null,null,"Performance Reporting - Qualitative",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F317=\"\",1,IF(OR(OFFSET($T$107,($F317-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F317-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F317-1)*$A$13,0)=FALSE,1,0)))","v":1},298,2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F318=\"\",1,IF(OR(OFFSET($T$107,($F318-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F318-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F318-1)*$A$13,0)=FALSE,1,0)))","v":1},299,2,null,null,null,null,null,"Please describe your interpretation of the rate above, including factors that may have caused a change in the rate (e.g. intervention, population shifts, system changes, etc.) as well as any trends identified within groups in your denominator (e.g. patient characteristics, seasonality, location of care, etc.)",null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T262<>\"Eligible to Report in April DY4\",$T267<>\"Yes\"),0,IF(T318=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F319=\"\",1,IF(OR(OFFSET($T$107,($F319-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F319-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F319-1)*$A$13,0)=FALSE,1,0)))","v":1},300,2,null,null,null,null,null,"Please estimate what percentage of your intervention population (QPI) is also represented by the denominator used to calculate your DY4 performance above",null,null,null,null,null,null,null,"Input",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T262<>\"Eligible to Report in April DY4\",$T267<>\"Yes\"),0,IF(T319=\"Input\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,{"$f":"CELL(\"Address\",T320)","v":"$T$320"},{"$f":"IF($F320=\"\",1,IF(OR(OFFSET($T$107,($F320-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F320-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F320-1)*$A$13,0)=FALSE,1,0)))","v":1},301,2,null,null,null,null,null,"Are you able to report performance in this outcome exclusively for the individuals receiving the intervention?",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T262<>\"Eligible to Report in April DY4\",$T267<>\"Yes\"),0,IF(T320=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F321=\"\",1,IF(OR(OFFSET($T$107,($F321-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F321-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F321-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$165,($F321-1)*$A$13,0)=\"Yes\",0,1))))","v":1},302,2,null,null,null,null,null,"Intervention Input",null,null,null,null,null,null,null,"Intervention Only Numerator:",null,"Input",null,null,null,"Intervention Only Denominator:",null,"Input",null,null,null,"Intervention Only Performance Rate:",null,null,null,null,null,{"$f":"IF(ISERROR(V321/AB321),\"\",V321/AB321)","v":""},null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T262<>\"Eligible to Report in April DY4\",$T267<>\"Yes\",$T320<>\"Yes\"),0,IF(V321=\"Input\",1,0))","v":0},0,0,0,0,0,{"$f":"IF(OR($T262<>\"Eligible to Report in April DY4\",$T267<>\"Yes\",$T320<>\"Yes\"),0,IF(AB321=\"Input\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F322=\"\",1,IF(OR(OFFSET($T$107,($F322-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F322-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F322-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$165,($F322-1)*$A$13,0)=\"Yes\",0,1))))","v":1},303,2,null,null,null,null,null,null,"Please describe your interpretation of the Intervention only performance rate including any factors contributing to this result",null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T262<>\"Eligible to Report in April DY4\",$T267<>\"Yes\",$T320<>\"Yes\"),0,IF(T322=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,{"$f":"CELL(\"Address\",T323)","v":"$T$323"},{"$f":"IF($F323=\"\",1,IF(OR(OFFSET($T$107,($F323-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F323-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F323-1)*$A$13,0)=FALSE,1,0)))","v":1},304,2,null,null,null,null,null,"Are you able to report performance in this outcome at a level broader than the denominator used to determine DY4 performance (i.e. system level performance)?",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T262<>\"Eligible to Report in April DY4\",$T267<>\"Yes\"),0,IF(T323=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F324=\"\",1,IF(OR(OFFSET($T$107,($F324-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F324-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F324-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$168,($F324-1)*$A$13,0)=\"Yes\",0,1))))","v":1},305,2,null,null,null,null,null,"System Level Input",null,null,null,null,null,null,null,"System Level Numerator:",null,"Input",null,null,null,"System Level Denominator:",null,"Input",null,null,null,"System Level Performance Rate:",null,null,null,null,null,{"$f":"IF(ISERROR(V324/AB324),\"\",V324/AB324)","v":""},null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T262<>\"Eligible to Report in April DY4\",$T267<>\"Yes\",$T323<>\"Yes\"),0,IF(V324=\"Input\",1,0))","v":0},0,0,0,0,0,{"$f":"IF(OR($T262<>\"Eligible to Report in April DY4\",$T267<>\"Yes\",$T323<>\"Yes\"),0,IF(AB324=\"Input\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F325=\"\",1,IF(OR(OFFSET($T$107,($F325-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F325-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F325-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$168,($F325-1)*$A$13,0)=\"Yes\",0,1))))","v":1},306,2,null,null,null,null,null,null,"Please describe your interpretation of the system level performance rate including any factors contributing to this result",null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T262<>\"Eligible to Report in April DY4\",$T267<>\"Yes\",$T323<>\"Yes\"),0,IF(T325=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F326=\"\",1,IF(OR(OFFSET($T$107,($F326-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F326-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F326-1)*$A$13,0)=FALSE,1,0)))","v":1},307,2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F327=\"\",1,IF(OR(OFFSET($T$107,($F327-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F327-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F327-1)*$A$13,0)=FALSE,1,0)))","v":1},308,2,null,null,null,null,null,"Are there any other process or improvement outcomes, beyond the Category 3 outcomes associated with this project, that are being used to monitor intervention effects or impact?",null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T262<>\"Eligible to Report in April DY4\",$T267<>\"Yes\"),0,IF(T327=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F328=\"\",1,IF(OR(OFFSET($T$107,($F328-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F328-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F328-1)*$A$13,0)=FALSE,1,0)))","v":1},309,2,null,null,null,null,null,"Please Include any Additional Comments here:",null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T262<>\"Eligible to Report in April DY4\",$T267<>\"Yes\"),0,IF(T328=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F329=\"\",1,IF(OR(OFFSET($T$107,($F329-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F329-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F329-1)*$A$13,0)=FALSE,1,0)))","v":1},310,2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
["#Metrics",null,null,{"$f":"IF($O$14=\"\",0,IF($F330=\"\",1,0))","v":0},{"$f":"E329+1","v":311},{"$f":"IF(F329=\"\",\"\",IF(G330=\"New\",IF(F329+1>$A$15,\"\",F329+1),F329))","v":3},"New",null,null,null,{"$f":"\"Outcome \"&$F330&\" Details\"","v":"Outcome 3 Details"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"X",{"$f":"K330","v":"Outcome 3 Details"}]
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["#Milestones",null,null,0,313,3,null,null,null,null,null,"Category 3 Outcome ID:",null,null,null,{"$f":"IF($F332=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$E$4:$E$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F332,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$E$4:$E$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F332,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$E$4:$E$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F332,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
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[null,null,null,{"$f":"IF($F410=\"\",1,IF(OFFSET($A$26,($F410-1)*$A$13,0)=FALSE,1,IF(H410=\"\",1,0)))","v":1},391,3,null,5,null,null,null,null,null,null,null,null,null,null,"Performance:",{"$f":"IF($H408=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$CH$4:$CH$5000,0,($H408-1)*4),MATCH(RHP&\"_\"&$O$14&\"_\"&$F409,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$CH$4:$CH$5000,0,($H408-1)*4),MATCH(RHP&\"_\"&$O$14&\"_\"&$F409,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":{"$error":"#N/A"}},null,null,null,null,null,null,null,null,null,null,null,null,"Measurement Period End:",{"$f":"IF($F410=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$FB$4:$FB$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F410,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$FB$4:$FB$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F410,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$FB$4:$FB$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F410,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F411=\"\",1,IF(OFFSET($A$26,($F411-1)*$A$13,0)=FALSE,1,IF(H411=\"\",1,0)))","v":1},392,3,null,5,null,null,null,null,null,null,null,null,null,null,"Measurement Period Start:",{"$f":"IF($F411=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$FE$4:$FE$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F411,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$FE$4:$FE$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F411,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$FE$4:$FE$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F411,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,"DY5",null,null,null,null,null,"Goal:",{"$f":"IF($H411=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$DE$4:$DE$5000,0,($H411-1)*4),MATCH(RHP&\"_\"&$O$14&\"_\"&$F411,'Master Data Mock'!$FM$4:$FM$5000,0))=\"Maintain\",T410,INDEX(OFFSET('Master Data Mock'!$DE$4:$DE$5000,0,($H411-1)*4),MATCH(RHP&\"_\"&$O$14&\"_\"&$F411,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":{"$error":"#N/A"}},null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F412=\"\",1,IF(OFFSET($A$26,($F412-1)*$A$13,0)=FALSE,1,IF(H412=\"\",1,0)))","v":1},393,3,null,5,null,null,null,null,null,null,null,null,null,null,"Measurement Period End:",{"$f":"IF($F412=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$FF$4:$FF$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F412,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$FF$4:$FF$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F412,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$FF$4:$FF$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F412,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,"Measurement Period Start:",{"$f":"IF($F412=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$FC$4:$FC$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F412,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$FC$4:$FC$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F412,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$FC$4:$FC$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F412,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F413=\"\",1,IF(OFFSET($A$26,($F413-1)*$A$13,0)=FALSE,1,IF(H413=\"\",1,0)))","v":1},394,3,null,5,null,null,null,null,null,null,null,{"$f":"IF($H413=\"\",\"\",IF(INDEX('Master Data Mock'!$H$4:$H$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F364,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX('Master Data Mock'!$H$4:$H$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F364,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":{"$error":"#N/A"}},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Measurement Period End:",{"$f":"IF($F413=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$FD$4:$FD$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F413,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$FD$4:$FD$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F413,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$FD$4:$FD$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F413,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F414=\"\",1,IF(OFFSET($A$26,($F414-1)*$A$13,0)=FALSE,1,IF(H414=\"\",1,0)))","v":1},395,3,null,5,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F415=\"\",1,IF(OFFSET($A$26,($F415-1)*$A$13,0)=FALSE,1,0))","v":1},396,3,null,null,null,null,null,"Performance Reporting - Readiness:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F416=\"\",1,IF(OFFSET($A$26,($F416-1)*$A$13,0)=FALSE,1,0))","v":1},397,3,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F417=\"\",1,IF(OFFSET($A$26,($F417-1)*$A$13,0)=FALSE,1,0))","v":1},398,3,null,null,null,null,null,"Eligible to report in April DY4?",null,null,null,null,null,null,null,{"$f":"IF(F417=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$I$4:$I$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F417,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$I$4:$I$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F417,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$I$4:$I$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F417,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F418=\"\",1,IF(OFFSET($A$26,($F418-1)*$A$13,0)=FALSE,1,0))","v":1},399,3,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F419=\"\",1,IF(OFFSET($A$26,($F419-1)*$A$13,0)=FALSE,1,0))","v":1},400,3,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F420=\"\",1,IF(OFFSET($A$26,($F420-1)*$A$13,0),IF(T417=\"Eligible to Report in October DY4\",0,1),1))","v":1},401,3,null,null,null,null,null,"Outcome is eligible to be reported in October of DY4",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F421=\"\",1,IF(OFFSET($A$26,($F421-1)*$A$13,0)=FALSE,1,0))","v":1},{"$f":"E420+1","v":402},{"$f":"IF(F420=\"\",\"\",IF(G421=\"New\",IF(F420+1>$A$15,\"\",F420+1),F420))","v":3},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,{"$f":"CELL(\"Address\",T422)","v":"$T$422"},null,{"$f":"IF($F422=\"\",1,IF(OFFSET($T$107,($F422-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F422-1)*$A$13,0)=FALSE,1,0)))","v":1},403,3,null,null,null,null,null,"Are you ready to report this outcome with 12 months of data aligning with your DY4 measurement period?",null,null,null,null,null,null,null,null,null,"If not, within the online reporting system please include a progress update regarding the status of your performance.  If no updates to performance are available, please describe any salient updates to the measure collection process.  This progress update fulfills your semi-annual reporting requirement for this milestone. Please indicate that you will do this by selecting 'Yes' to the right",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T417<>\"Eligible to Report in April DY4\",0,IF(T422=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T417<>\"Eligible to Report in April DY4\",$T422=\"Yes\"),0,IF(AE422=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,404,3,null,null,null,null,null,"Provider intention to Carry forward",null,null,null,null,null,null,null,"NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,405,3,null,null,null,null,null,"Provider intention to report in October DY4",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,406,3,null,null,null,null,null,"Additional text boxes to use in October",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,407,3,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,408,3,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,409,3,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,410,3,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,411,3,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[{"$f":"CELL(\"Address\",T431)","v":"$T$431"},null,null,{"$f":"IF($F431=\"\",1,IF(OFFSET($T$107,($F431-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F431-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F431-1)*$A$13,0)=\"Yes\",0,1))))","v":1},412,3,null,null,null,null,null,"Are you reporting to approved measure specifications?  This includes numerator description, denominator description and any approved subsets",null,null,null,null,null,null,null,null,null,"Please describe any differences between specifications used to determine DY4 performance and the approved measure specifications:",null,null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T422<>\"Yes\",0,IF(T431=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,{"$f":"IF($T422<>\"Yes\",0,IF(AND(T431=\"No\",AE431=\"Free Text\"),1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0]
[{"$f":"CELL(\"Address\",T432)","v":"$T$432"},null,null,{"$f":"IF($F432=\"\",1,IF(OFFSET($T$107,($F432-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F432-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F432-1)*$A$13,0)=\"Yes\",0,1))))","v":1},413,3,null,null,null,null,null,"Are there any changes/improvements/clarifications to your data abstraction process for the performance reported in DY4 relative to how the baseline was described in the field above?",null,null,null,null,null,null,null,null,null,"Please describe the changes/improvements to your abstraction process",null,null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T422<>\"Yes\",0,IF(T432=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,{"$f":"IF($T422<>\"Yes\",0,IF(AND(T432=\"Yes\",AE432=\"Free Text\"),1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0]
[{"$f":"CELL(\"Address\",T433)","v":"$T$433"},null,null,{"$f":"IF($F433=\"\",1,IF(OFFSET($T$107,($F433-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F433-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F433-1)*$A$13,0)=\"Yes\",0,1))))","v":1},414,3,null,null,null,null,null,"Are there any changes or improvements to your tool administration process as reported at baseline?",null,null,null,null,null,null,null,null,null,"Please describe changes in tool/survey administration process",null,null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T422<>\"Yes\",0,IF(T433=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,{"$f":"IF($T422<>\"Yes\",0,IF(AND(T433=\"Yes\",AE433=\"Free Text\"),1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F434=\"\",1,IF(OR(OFFSET($T$107,($F434-1)*$A$13,0)<>\"Eligible to Report in April DY4\",$T434=\"\"),1,IF(OFFSET($A$26,($F434-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F434-1)*$A$13,0)=\"Yes\",0,1))))","v":1},415,3,null,null,null,null,null,"Risk Adjustment Type",null,null,null,null,null,null,null,{"$f":"IF(F433=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$EZ$4:$EZ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F433,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$EZ$4:$EZ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F433,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$EZ$4:$EZ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F433,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[{"$f":"CELL(\"Address\",T435)","v":"$T$435"},null,null,{"$f":"IF($F435=\"\",1,IF(OR(OFFSET($T$107,($F435-1)*$A$13,0)<>\"Eligible to Report in April DY4\",$T434=\"\"),1,IF(OFFSET($A$26,($F435-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F435-1)*$A$13,0)=\"Yes\",0,1))))","v":1},416,3,null,null,null,null,null,null,"Are there any changes or improvements to risk adjustment process?",null,null,null,null,null,null,null,null,"Please describe changes in risk adjustment process",null,null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T422<>\"Yes\",0,IF($T434=\"\",0,IF(T435=\"\",1,0)))","v":0},0,0,0,0,0,0,0,0,0,{"$f":"IF($T422<>\"Yes\",0,IF(AND(T435=\"Yes\",AE435=\"Free Text\"),1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F436=\"\",1,IF(OFFSET($T$107,($F436-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F436-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F436-1)*$A$13,0)=\"Yes\",IF(IF(F436=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F436,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F436,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F436,'Master Data Mock'!$FM$4:$FM$5000,0))))<>\"\",0,1),1))))","v":1},417,3,null,null,null,null,null,{"$f":"\"Provider used a proxy population to determine baseline performance described as:  \"&IF(F436=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F436,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F436,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F436,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":"Provider used a proxy population to determine baseline performance described as:  "},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F437=\"\",1,IF(OFFSET($T$107,($F437-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F437-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F437-1)*$A$13,0)=\"Yes\",IF(IF(F437=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F437,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F437,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F437,'Master Data Mock'!$FM$4:$FM$5000,0))))<>\"\",0,1),1))))","v":1},418,3,null,null,null,null,null,null,"Please describe the alignment (similarities and differences) between the proxy population reported for baseline and the cohort used for the DY4 measurement period",null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($D436=1,$T422<>\"Yes\"),0,IF(T437=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F438=\"\",1,IF(OFFSET($A$26,($F438-1)*$A$13,0)=FALSE,1,0))","v":1},419,3,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F439=\"\",1,IF(OFFSET($T$107,($F439-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F439-1)*$A$13,0)=FALSE,1,IF(OR(OFFSET($T$112,($F439-1)*$A$13,0)=\"Yes\",OFFSET($T$31,($F439-1)*$A$13,0)<>\"P4R\"),1,0))))","v":1},420,3,null,null,null,null,null,"Alternate Achievement Activity Status Update",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,421,3,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,422,3,null,null,null,null,null,"Alternate Achievement Activity:",null,null,null,null,null,null,null,{"$f":"IF(OR(ISERROR(INDEX('Master Data Mock'!$P$4:$P$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F441,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$P$4:$P$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F441,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$P$4:$P$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F441,'Master Data Mock'!$FM$4:$FM$5000,0)))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,423,3,null,null,null,null,null,"Alternative Achievement Activity Baseline Reported:",null,null,null,null,null,null,null,{"$f":"IF(LEFT(T441,2)=\"SA\",IF(OR(ISERROR(INDEX('Master Data Mock'!$EP$4:$EP$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F442,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$EP$4:$EP$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F442,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$EP$4:$EP$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F442,'Master Data Mock'!$FM$4:$FM$5000,0))),IF(OR(ISERROR(INDEX('Master Data Mock'!$EQ$4:$EQ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F442,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$EQ$4:$EQ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F442,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$EQ$4:$EQ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F442,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,424,3,null,null,null,null,null,"Please include an update for any activities to date related to the selected Stretch Activity above or performance in the PFP measure above. If baseline for this PFP measure has not yet been reported, please indicate when this will be submitted and which 12 month measurement period it will reflect (DY3 or DY4).  If ready to report PFP baseline now please complete the PFP Baseline form found here: http://www.hhsc.state.tx.us/1115-Waiver-Guideline.shtml ",null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T341<>\"P4R\",0,IF(T443=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,425,3,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F445=\"\",1,IF(OR(OFFSET($T$107,($F445-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F445-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F445-1)*$A$13,0)=FALSE,1,0)))","v":1},426,3,null,null,null,null,null,"Performance Reporting - Quantitative",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,427,3,null,null,null,null,null,null,null,null,null,null,{"$f":"IF($F446=\"\",\"\",1)","v":1},null,null,null,null,{"$f":"IF($F446=\"\",\"\",IF(Q446=\"\",\"\",IF(Q446+1>OFFSET($A$21,($F446-1)*$A$13,0),\"\",Q446+1)))","v":2},null,null,null,null,{"$f":"IF($F446=\"\",\"\",IF(V446=\"\",\"\",IF(V446+1>OFFSET($A$21,($F446-1)*$A$13,0),\"\",V446+1)))","v":3},null,null,null,null,{"$f":"IF($F446=\"\",\"\",IF(AA446=\"\",\"\",IF(AA446+1>OFFSET($A$21,($F446-1)*$A$13,0),\"\",AA446+1)))","v":4},null,null,null,null,{"$f":"IF($F446=\"\",\"\",IF(AF446=\"\",\"\",IF(AF446+1>OFFSET($A$21,($F446-1)*$A$13,0),\"\",AF446+1)))","v":5},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,428,3,null,null,null,null,null,null,null,null,null,null,"Metric 1",null,null,null,null,"Metric 2",null,null,null,null,"Metric 3",null,null,null,null,"Metric 4",null,null,null,null,"Metric 5",null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,429,3,null,null,null,null,null,"Milestone ID:",null,null,null,null,{"$f":"IF($F448=\"\",\"\",IF(Q446=\"\",\"\",\"AM-1.\"&Q446))","v":"AM-1.1"},null,null,null,null,{"$f":"IF($F448=\"\",\"\",IF(V446=\"\",\"\",\"AM-1.\"&V446))","v":"AM-1.2"},null,null,null,null,{"$f":"IF($F448=\"\",\"\",IF(AA446=\"\",\"\",\"AM-1.\"&AA446))","v":"AM-1.3"},null,null,null,null,{"$f":"IF($F448=\"\",\"\",IF(AF446=\"\",\"\",\"AM-1.\"&AF446))","v":"AM-1.4"},null,null,null,null,{"$f":"IF($F448=\"\",\"\",IF(AK446=\"\",\"\",\"AM-1.\"&AK446))","v":"AM-1.5"},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,430,3,null,null,null,null,null,"Milestone Description:",null,null,null,null,{"$f":"IF(Q446=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(Q446-1)*5),MATCH(Q448,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(Q446-1)*5),0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(Q446-1)*5),MATCH(Q448,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(Q446-1)*5),0))))","v":"Achievement of DY4 performance goal"},null,null,null,null,{"$f":"IF(V446=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(V446-1)*5),MATCH(V448,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(V446-1)*5),0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(V446-1)*5),MATCH(V448,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(V446-1)*5),0))))","v":"Achievement of DY4 performance goal- 30 day follow-up"},null,null,null,null,{"$f":"IF(AA446=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AA446-1)*5),MATCH(AA448,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AA446-1)*5),0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AA446-1)*5),MATCH(AA448,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AA446-1)*5),0))))","v":"Achievement of DY4 performance goal- Counseling for physical activity"},null,null,null,null,{"$f":"IF(AF446=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AF446-1)*5),MATCH(AF448,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AF446-1)*5),0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AF446-1)*5),MATCH(AF448,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AF446-1)*5),0))))","v":"Achievement of DY4 performance goal- GSMC"},null,null,null,null,{"$f":"IF(AK446=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AK446-1)*5),MATCH(AK448,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AK446-1)*5),0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AK446-1)*5),MATCH(AK448,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AK446-1)*5),0))))","v":"Achievement of DY4 performance goal- Mortality O/E"},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
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[null,null,null,1,443,3,null,null,null,null,null,null,null,null,null,null,"Metric 1",null,null,null,null,"Metric 2",null,null,null,null,"Metric 3",null,null,null,null,"Metric 4",null,null,null,null,"Metric 5",null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,444,3,null,null,null,null,null,"Percentage of Goal Achieved",null,null,null,null,{"$f":"IF(OR(Q446=\"\",Q458=\"\"),\"\",IF(ISERROR(MIN(MAX(ROUNDDOWN((Q458-OFFSET($T$68,($F463-1)*$A$13+(Q446-1)*8,0))/(OFFSET($AH$66,($F463-1)*$A$13+(Q446-1)*8,0)-OFFSET($T$68,($F463-1)*$A$13+(Q446-1)*8,0))*4,0)/4,0),1)),\"\",MIN(MAX(ROUNDDOWN((Q458-OFFSET($T$68,($F463-1)*$A$13+(Q446-1)*8,0))/(OFFSET($AH$66,($F463-1)*$A$13+(Q446-1)*8,0)-OFFSET($T$68,($F463-1)*$A$13+(Q446-1)*8,0))*4,0)/4,0),1)))","v":""},null,null,null,null,{"$f":"IF(OR(V446=\"\",V458=\"\"),\"\",MIN(MAX(ROUNDDOWN((V458-OFFSET($T$68,($F463-1)*$A$13+(V446-1)*8,0))/(OFFSET($AH$66,($F463-1)*$A$13+(V446-1)*8,0)-OFFSET($T$68,($F463-1)*$A$13+(V446-1)*8,0))*4,0)/4,0),1))","v":""},null,null,null,null,{"$f":"IF(OR(AA446=\"\",AA458=\"\"),\"\",MIN(MAX(ROUNDDOWN((AA458-OFFSET($T$68,($F463-1)*$A$13+(AA446-1)*8,0))/(OFFSET($AH$66,($F463-1)*$A$13+(AA446-1)*8,0)-OFFSET($T$68,($F463-1)*$A$13+(AA446-1)*8,0))*4,0)/4,0),1))","v":""},null,null,null,null,{"$f":"IF(OR(AF446=\"\",AF458=\"\"),\"\",MIN(MAX(ROUNDDOWN((AF458-OFFSET($T$68,($F463-1)*$A$13+(AF446-1)*8,0))/(OFFSET($AH$66,($F463-1)*$A$13+(AF446-1)*8,0)-OFFSET($T$68,($F463-1)*$A$13+(AF446-1)*8,0))*4,0)/4,0),1))","v":""},null,null,null,null,{"$f":"IF(OR(AK446=\"\",AK458=\"\"),\"\",MIN(MAX(ROUNDDOWN((AK458-OFFSET($T$68,($F463-1)*$A$13+(AK446-1)*8,0))/(OFFSET($AH$66,($F463-1)*$A$13+(AK446-1)*8,0)-OFFSET($T$68,($F463-1)*$A$13+(AK446-1)*8,0))*4,0)/4,0),1))","v":""},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,445,3,null,null,null,null,null,"Status",null,null,null,null,{"$f":"IF(Q463=\"\",\"\",IF(Q463<1,\"Partially Achieved\",\"Achieved\"))","v":""},null,null,null,null,{"$f":"IF(V463=\"\",\"\",IF(V463<1,\"Partially Achieved\",\"Achieved\"))","v":""},null,null,null,null,{"$f":"IF(AA463=\"\",\"\",IF(AA463<1,\"Partially Achieved\",\"Achieved\"))","v":""},null,null,null,null,{"$f":"IF(AF463=\"\",\"\",IF(AF463<1,\"Partially Achieved\",\"Achieved\"))","v":""},null,null,null,null,{"$f":"IF(AK463=\"\",\"\",IF(AK463<1,\"Partially Achieved\",\"Achieved\"))","v":""},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,446,3,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F466=\"\",1,IF(OR(OFFSET($T$31,($F466-1)*$A$13,0)=\"P4R\",OFFSET($T$107,($F466-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F466-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F466-1)*$A$13,0)=FALSE,1,0)))+IF(SUM(Q466:AO466)=0,0,1)","v":1},447,3,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,448,3,null,null,null,null,null,"Please explain why your achievement is less than expected.",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,{"$f":"IF(ISERROR(IF(OR(Q446=\"\",$D467=1,Q464<>\"Partially Achieved\"),0,IF(Q467=\"Free Text\",1,0))),0,IF(OR(Q446=\"\",$D467=1,Q464<>\"Partially Achieved\"),0,IF(Q467=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(V446=\"\",$D467=1,V464<>\"Partially Achieved\"),0,IF(V467=\"Free Text\",1,0))),0,IF(OR(V446=\"\",$D467=1,V464<>\"Partially Achieved\"),0,IF(V467=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AA446=\"\",$D467=1,AA464<>\"Partially Achieved\"),0,IF(AA467=\"Free Text\",1,0))),0,IF(OR(AA446=\"\",$D467=1,AA464<>\"Partially Achieved\"),0,IF(AA467=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AF446=\"\",$D467=1,AF464<>\"Partially Achieved\"),0,IF(AF467=\"Free Text\",1,0))),0,IF(OR(AF446=\"\",$D467=1,AF464<>\"Partially Achieved\"),0,IF(AF467=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AK446=\"\",$D467=1,AK464<>\"Partially Achieved\"),0,IF(AK467=\"Free Text\",1,0))),0,IF(OR(AK446=\"\",$D467=1,AK464<>\"Partially Achieved\"),0,IF(AK467=\"Free Text\",1,0)))","v":0},0,0,0,0,0]
[null,null,null,1,449,3,null,null,null,null,null,"What is your plan to improve performance by the end of the following DY?",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,{"$f":"IF(ISERROR(IF(OR(Q446=\"\",$D468=1,Q464<>\"Partially Achieved\"),0,IF(Q468=\"Free Text\",1,0))),0,IF(OR(Q446=\"\",$D468=1,Q464<>\"Partially Achieved\"),0,IF(Q468=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(V446=\"\",$D468=1,V464<>\"Partially Achieved\"),0,IF(V468=\"Free Text\",1,0))),0,IF(OR(V446=\"\",$D468=1,V464<>\"Partially Achieved\"),0,IF(V468=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AA446=\"\",$D468=1,AA464<>\"Partially Achieved\"),0,IF(AA468=\"Free Text\",1,0))),0,IF(OR(AA446=\"\",$D468=1,AA464<>\"Partially Achieved\"),0,IF(AA468=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AF446=\"\",$D468=1,AF464<>\"Partially Achieved\"),0,IF(AF468=\"Free Text\",1,0))),0,IF(OR(AF446=\"\",$D468=1,AF464<>\"Partially Achieved\"),0,IF(AF468=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AK446=\"\",$D468=1,AK464<>\"Partially Achieved\"),0,IF(AK468=\"Free Text\",1,0))),0,IF(OR(AK446=\"\",$D468=1,AK464<>\"Partially Achieved\"),0,IF(AK468=\"Free Text\",1,0)))","v":0},0,0,0,0,0]
[null,null,null,1,450,3,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,451,3,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F471=\"\",1,IF(OR(OFFSET($T$107,($F471-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F471-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F471-1)*$A$13,0)=FALSE,1,0)))","v":1},452,3,null,null,null,null,null,"Performance Reporting - Qualitative",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F472=\"\",1,IF(OR(OFFSET($T$107,($F472-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F472-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F472-1)*$A$13,0)=FALSE,1,0)))","v":1},453,3,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F473=\"\",1,IF(OR(OFFSET($T$107,($F473-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F473-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F473-1)*$A$13,0)=FALSE,1,0)))","v":1},454,3,null,null,null,null,null,"Please describe your interpretation of the rate above, including factors that may have caused a change in the rate (e.g. intervention, population shifts, system changes, etc.) as well as any trends identified within groups in your denominator (e.g. patient characteristics, seasonality, location of care, etc.)",null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T417<>\"Eligible to Report in April DY4\",$T422<>\"Yes\"),0,IF(T473=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F474=\"\",1,IF(OR(OFFSET($T$107,($F474-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F474-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F474-1)*$A$13,0)=FALSE,1,0)))","v":1},455,3,null,null,null,null,null,"Please estimate what percentage of your intervention population (QPI) is also represented by the denominator used to calculate your DY4 performance above",null,null,null,null,null,null,null,"Input",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T417<>\"Eligible to Report in April DY4\",$T422<>\"Yes\"),0,IF(T474=\"Input\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,{"$f":"CELL(\"Address\",T475)","v":"$T$475"},{"$f":"IF($F475=\"\",1,IF(OR(OFFSET($T$107,($F475-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F475-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F475-1)*$A$13,0)=FALSE,1,0)))","v":1},456,3,null,null,null,null,null,"Are you able to report performance in this outcome exclusively for the individuals receiving the intervention?",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T417<>\"Eligible to Report in April DY4\",$T422<>\"Yes\"),0,IF(T475=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F476=\"\",1,IF(OR(OFFSET($T$107,($F476-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F476-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F476-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$165,($F476-1)*$A$13,0)=\"Yes\",0,1))))","v":1},457,3,null,null,null,null,null,"Intervention Input",null,null,null,null,null,null,null,"Intervention Only Numerator:",null,"Input",null,null,null,"Intervention Only Denominator:",null,"Input",null,null,null,"Intervention Only Performance Rate:",null,null,null,null,null,{"$f":"IF(ISERROR(V476/AB476),\"\",V476/AB476)","v":""},null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T417<>\"Eligible to Report in April DY4\",$T422<>\"Yes\",$T475<>\"Yes\"),0,IF(V476=\"Input\",1,0))","v":0},0,0,0,0,0,{"$f":"IF(OR($T417<>\"Eligible to Report in April DY4\",$T422<>\"Yes\",$T475<>\"Yes\"),0,IF(AB476=\"Input\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F477=\"\",1,IF(OR(OFFSET($T$107,($F477-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F477-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F477-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$165,($F477-1)*$A$13,0)=\"Yes\",0,1))))","v":1},458,3,null,null,null,null,null,null,"Please describe your interpretation of the Intervention only performance rate including any factors contributing to this result",null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T417<>\"Eligible to Report in April DY4\",$T422<>\"Yes\",$T475<>\"Yes\"),0,IF(T477=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,{"$f":"CELL(\"Address\",T478)","v":"$T$478"},{"$f":"IF($F478=\"\",1,IF(OR(OFFSET($T$107,($F478-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F478-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F478-1)*$A$13,0)=FALSE,1,0)))","v":1},459,3,null,null,null,null,null,"Are you able to report performance in this outcome at a level broader than the denominator used to determine DY4 performance (i.e. system level performance)?",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T417<>\"Eligible to Report in April DY4\",$T422<>\"Yes\"),0,IF(T478=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F479=\"\",1,IF(OR(OFFSET($T$107,($F479-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F479-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F479-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$168,($F479-1)*$A$13,0)=\"Yes\",0,1))))","v":1},460,3,null,null,null,null,null,"System Level Input",null,null,null,null,null,null,null,"System Level Numerator:",null,"Input",null,null,null,"System Level Denominator:",null,"Input",null,null,null,"System Level Performance Rate:",null,null,null,null,null,{"$f":"IF(ISERROR(V479/AB479),\"\",V479/AB479)","v":""},null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T417<>\"Eligible to Report in April DY4\",$T422<>\"Yes\",$T478<>\"Yes\"),0,IF(V479=\"Input\",1,0))","v":0},0,0,0,0,0,{"$f":"IF(OR($T417<>\"Eligible to Report in April DY4\",$T422<>\"Yes\",$T478<>\"Yes\"),0,IF(AB479=\"Input\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F480=\"\",1,IF(OR(OFFSET($T$107,($F480-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F480-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F480-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$168,($F480-1)*$A$13,0)=\"Yes\",0,1))))","v":1},461,3,null,null,null,null,null,null,"Please describe your interpretation of the system level performance rate including any factors contributing to this result",null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T417<>\"Eligible to Report in April DY4\",$T422<>\"Yes\",$T478<>\"Yes\"),0,IF(T480=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F481=\"\",1,IF(OR(OFFSET($T$107,($F481-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F481-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F481-1)*$A$13,0)=FALSE,1,0)))","v":1},462,3,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F482=\"\",1,IF(OR(OFFSET($T$107,($F482-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F482-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F482-1)*$A$13,0)=FALSE,1,0)))","v":1},463,3,null,null,null,null,null,"Are there any other process or improvement outcomes, beyond the Category 3 outcomes associated with this project, that are being used to monitor intervention effects or impact?",null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T417<>\"Eligible to Report in April DY4\",$T422<>\"Yes\"),0,IF(T482=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F483=\"\",1,IF(OR(OFFSET($T$107,($F483-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F483-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F483-1)*$A$13,0)=FALSE,1,0)))","v":1},464,3,null,null,null,null,null,"Please Include any Additional Comments here:",null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T417<>\"Eligible to Report in April DY4\",$T422<>\"Yes\"),0,IF(T483=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
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[null,null,null,{"$f":"IF($F571=\"\",1,IF(OFFSET($A$26,($F571-1)*$A$13,0)=FALSE,1,0))","v":1},552,4,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F572=\"\",1,IF(OFFSET($A$26,($F572-1)*$A$13,0)=FALSE,1,0))","v":1},553,4,null,null,null,null,null,"Eligible to report in April DY4?",null,null,null,null,null,null,null,{"$f":"IF(F572=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$I$4:$I$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F572,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$I$4:$I$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F572,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$I$4:$I$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F572,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F573=\"\",1,IF(OFFSET($A$26,($F573-1)*$A$13,0)=FALSE,1,0))","v":1},554,4,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F574=\"\",1,IF(OFFSET($A$26,($F574-1)*$A$13,0)=FALSE,1,0))","v":1},555,4,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F575=\"\",1,IF(OFFSET($A$26,($F575-1)*$A$13,0),IF(T572=\"Eligible to Report in October DY4\",0,1),1))","v":1},556,4,null,null,null,null,null,"Outcome is eligible to be reported in October of DY4",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F576=\"\",1,IF(OFFSET($A$26,($F576-1)*$A$13,0)=FALSE,1,0))","v":1},{"$f":"E575+1","v":557},{"$f":"IF(F575=\"\",\"\",IF(G576=\"New\",IF(F575+1>$A$15,\"\",F575+1),F575))","v":4},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,{"$f":"CELL(\"Address\",T577)","v":"$T$577"},null,{"$f":"IF($F577=\"\",1,IF(OFFSET($T$107,($F577-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F577-1)*$A$13,0)=FALSE,1,0)))","v":1},558,4,null,null,null,null,null,"Are you ready to report this outcome with 12 months of data aligning with your DY4 measurement period?",null,null,null,null,null,null,null,null,null,"If not, within the online reporting system please include a progress update regarding the status of your performance.  If no updates to performance are available, please describe any salient updates to the measure collection process.  This progress update fulfills your semi-annual reporting requirement for this milestone. Please indicate that you will do this by selecting 'Yes' to the right",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T572<>\"Eligible to Report in April DY4\",0,IF(T577=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T572<>\"Eligible to Report in April DY4\",$T577=\"Yes\"),0,IF(AE577=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,559,4,null,null,null,null,null,"Provider intention to Carry forward",null,null,null,null,null,null,null,"NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,560,4,null,null,null,null,null,"Provider intention to report in October DY4",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,561,4,null,null,null,null,null,"Additional text boxes to use in October",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,562,4,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,563,4,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,564,4,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,565,4,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,566,4,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[{"$f":"CELL(\"Address\",T586)","v":"$T$586"},null,null,{"$f":"IF($F586=\"\",1,IF(OFFSET($T$107,($F586-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F586-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F586-1)*$A$13,0)=\"Yes\",0,1))))","v":1},567,4,null,null,null,null,null,"Are you reporting to approved measure specifications?  This includes numerator description, denominator description and any approved subsets",null,null,null,null,null,null,null,null,null,"Please describe any differences between specifications used to determine DY4 performance and the approved measure specifications:",null,null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T577<>\"Yes\",0,IF(T586=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,{"$f":"IF($T577<>\"Yes\",0,IF(AND(T586=\"No\",AE586=\"Free Text\"),1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0]
[{"$f":"CELL(\"Address\",T587)","v":"$T$587"},null,null,{"$f":"IF($F587=\"\",1,IF(OFFSET($T$107,($F587-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F587-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F587-1)*$A$13,0)=\"Yes\",0,1))))","v":1},568,4,null,null,null,null,null,"Are there any changes/improvements/clarifications to your data abstraction process for the performance reported in DY4 relative to how the baseline was described in the field above?",null,null,null,null,null,null,null,null,null,"Please describe the changes/improvements to your abstraction process",null,null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T577<>\"Yes\",0,IF(T587=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,{"$f":"IF($T577<>\"Yes\",0,IF(AND(T587=\"Yes\",AE587=\"Free Text\"),1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0]
[{"$f":"CELL(\"Address\",T588)","v":"$T$588"},null,null,{"$f":"IF($F588=\"\",1,IF(OFFSET($T$107,($F588-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F588-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F588-1)*$A$13,0)=\"Yes\",0,1))))","v":1},569,4,null,null,null,null,null,"Are there any changes or improvements to your tool administration process as reported at baseline?",null,null,null,null,null,null,null,null,null,"Please describe changes in tool/survey administration process",null,null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T577<>\"Yes\",0,IF(T588=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,{"$f":"IF($T577<>\"Yes\",0,IF(AND(T588=\"Yes\",AE588=\"Free Text\"),1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F589=\"\",1,IF(OR(OFFSET($T$107,($F589-1)*$A$13,0)<>\"Eligible to Report in April DY4\",$T589=\"\"),1,IF(OFFSET($A$26,($F589-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F589-1)*$A$13,0)=\"Yes\",0,1))))","v":1},570,4,null,null,null,null,null,"Risk Adjustment Type",null,null,null,null,null,null,null,{"$f":"IF(F588=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$EZ$4:$EZ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F588,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$EZ$4:$EZ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F588,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$EZ$4:$EZ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F588,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[{"$f":"CELL(\"Address\",T590)","v":"$T$590"},null,null,{"$f":"IF($F590=\"\",1,IF(OR(OFFSET($T$107,($F590-1)*$A$13,0)<>\"Eligible to Report in April DY4\",$T589=\"\"),1,IF(OFFSET($A$26,($F590-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F590-1)*$A$13,0)=\"Yes\",0,1))))","v":1},571,4,null,null,null,null,null,null,"Are there any changes or improvements to risk adjustment process?",null,null,null,null,null,null,null,null,"Please describe changes in risk adjustment process",null,null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T577<>\"Yes\",0,IF($T589=\"\",0,IF(T590=\"\",1,0)))","v":0},0,0,0,0,0,0,0,0,0,{"$f":"IF($T577<>\"Yes\",0,IF(AND(T590=\"Yes\",AE590=\"Free Text\"),1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F591=\"\",1,IF(OFFSET($T$107,($F591-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F591-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F591-1)*$A$13,0)=\"Yes\",IF(IF(F591=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F591,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F591,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F591,'Master Data Mock'!$FM$4:$FM$5000,0))))<>\"\",0,1),1))))","v":1},572,4,null,null,null,null,null,{"$f":"\"Provider used a proxy population to determine baseline performance described as:  \"&IF(F591=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F591,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F591,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F591,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":"Provider used a proxy population to determine baseline performance described as:  "},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F592=\"\",1,IF(OFFSET($T$107,($F592-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F592-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F592-1)*$A$13,0)=\"Yes\",IF(IF(F592=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F592,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F592,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F592,'Master Data Mock'!$FM$4:$FM$5000,0))))<>\"\",0,1),1))))","v":1},573,4,null,null,null,null,null,null,"Please describe the alignment (similarities and differences) between the proxy population reported for baseline and the cohort used for the DY4 measurement period",null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($D591=1,$T577<>\"Yes\"),0,IF(T592=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F593=\"\",1,IF(OFFSET($A$26,($F593-1)*$A$13,0)=FALSE,1,0))","v":1},574,4,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F594=\"\",1,IF(OFFSET($T$107,($F594-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F594-1)*$A$13,0)=FALSE,1,IF(OR(OFFSET($T$112,($F594-1)*$A$13,0)=\"Yes\",OFFSET($T$31,($F594-1)*$A$13,0)<>\"P4R\"),1,0))))","v":1},575,4,null,null,null,null,null,"Alternate Achievement Activity Status Update",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,576,4,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,577,4,null,null,null,null,null,"Alternate Achievement Activity:",null,null,null,null,null,null,null,{"$f":"IF(OR(ISERROR(INDEX('Master Data Mock'!$P$4:$P$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F596,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$P$4:$P$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F596,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$P$4:$P$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F596,'Master Data Mock'!$FM$4:$FM$5000,0)))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,578,4,null,null,null,null,null,"Alternative Achievement Activity Baseline Reported:",null,null,null,null,null,null,null,{"$f":"IF(LEFT(T596,2)=\"SA\",IF(OR(ISERROR(INDEX('Master Data Mock'!$EP$4:$EP$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F597,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$EP$4:$EP$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F597,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$EP$4:$EP$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F597,'Master Data Mock'!$FM$4:$FM$5000,0))),IF(OR(ISERROR(INDEX('Master Data Mock'!$EQ$4:$EQ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F597,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$EQ$4:$EQ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F597,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$EQ$4:$EQ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F597,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,579,4,null,null,null,null,null,"Please include an update for any activities to date related to the selected Stretch Activity above or performance in the PFP measure above. If baseline for this PFP measure has not yet been reported, please indicate when this will be submitted and which 12 month measurement period it will reflect (DY3 or DY4).  If ready to report PFP baseline now please complete the PFP Baseline form found here: http://www.hhsc.state.tx.us/1115-Waiver-Guideline.shtml ",null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T496<>\"P4R\",0,IF(T598=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,580,4,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F600=\"\",1,IF(OR(OFFSET($T$107,($F600-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F600-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F600-1)*$A$13,0)=FALSE,1,0)))","v":1},581,4,null,null,null,null,null,"Performance Reporting - Quantitative",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,582,4,null,null,null,null,null,null,null,null,null,null,{"$f":"IF($F601=\"\",\"\",1)","v":1},null,null,null,null,{"$f":"IF($F601=\"\",\"\",IF(Q601=\"\",\"\",IF(Q601+1>OFFSET($A$21,($F601-1)*$A$13,0),\"\",Q601+1)))","v":2},null,null,null,null,{"$f":"IF($F601=\"\",\"\",IF(V601=\"\",\"\",IF(V601+1>OFFSET($A$21,($F601-1)*$A$13,0),\"\",V601+1)))","v":3},null,null,null,null,{"$f":"IF($F601=\"\",\"\",IF(AA601=\"\",\"\",IF(AA601+1>OFFSET($A$21,($F601-1)*$A$13,0),\"\",AA601+1)))","v":4},null,null,null,null,{"$f":"IF($F601=\"\",\"\",IF(AF601=\"\",\"\",IF(AF601+1>OFFSET($A$21,($F601-1)*$A$13,0),\"\",AF601+1)))","v":5},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,583,4,null,null,null,null,null,null,null,null,null,null,"Metric 1",null,null,null,null,"Metric 2",null,null,null,null,"Metric 3",null,null,null,null,"Metric 4",null,null,null,null,"Metric 5",null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,584,4,null,null,null,null,null,"Milestone ID:",null,null,null,null,{"$f":"IF($F603=\"\",\"\",IF(Q601=\"\",\"\",\"AM-1.\"&Q601))","v":"AM-1.1"},null,null,null,null,{"$f":"IF($F603=\"\",\"\",IF(V601=\"\",\"\",\"AM-1.\"&V601))","v":"AM-1.2"},null,null,null,null,{"$f":"IF($F603=\"\",\"\",IF(AA601=\"\",\"\",\"AM-1.\"&AA601))","v":"AM-1.3"},null,null,null,null,{"$f":"IF($F603=\"\",\"\",IF(AF601=\"\",\"\",\"AM-1.\"&AF601))","v":"AM-1.4"},null,null,null,null,{"$f":"IF($F603=\"\",\"\",IF(AK601=\"\",\"\",\"AM-1.\"&AK601))","v":"AM-1.5"},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,585,4,null,null,null,null,null,"Milestone Description:",null,null,null,null,{"$f":"IF(Q601=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(Q601-1)*5),MATCH(Q603,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(Q601-1)*5),0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(Q601-1)*5),MATCH(Q603,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(Q601-1)*5),0))))","v":"Achievement of DY4 performance goal"},null,null,null,null,{"$f":"IF(V601=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(V601-1)*5),MATCH(V603,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(V601-1)*5),0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(V601-1)*5),MATCH(V603,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(V601-1)*5),0))))","v":"Achievement of DY4 performance goal- 30 day follow-up"},null,null,null,null,{"$f":"IF(AA601=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AA601-1)*5),MATCH(AA603,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AA601-1)*5),0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AA601-1)*5),MATCH(AA603,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AA601-1)*5),0))))","v":"Achievement of DY4 performance goal- Counseling for physical activity"},null,null,null,null,{"$f":"IF(AF601=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AF601-1)*5),MATCH(AF603,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AF601-1)*5),0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AF601-1)*5),MATCH(AF603,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AF601-1)*5),0))))","v":"Achievement of DY4 performance goal- GSMC"},null,null,null,null,{"$f":"IF(AK601=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AK601-1)*5),MATCH(AK603,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AK601-1)*5),0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AK601-1)*5),MATCH(AK603,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AK601-1)*5),0))))","v":"Achievement of DY4 performance goal- Mortality O/E"},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,586,4,null,null,null,null,null,"Numerator Description:",null,null,null,null,{"$f":"IF(Q601=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(Q601-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F605,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(Q601-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F605,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":{"$error":"#N/A"}},null,null,null,null,{"$f":"IF(V601=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(V601-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F605,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(V601-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F605,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":{"$error":"#N/A"}},null,null,null,null,{"$f":"IF(AA601=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(AA601-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F605,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(AA601-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F605,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":{"$error":"#N/A"}},null,null,null,null,{"$f":"IF(AF601=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(AF601-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F605,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(AF601-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F605,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":{"$error":"#N/A"}},null,null,null,null,{"$f":"IF(AK601=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(AK601-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F605,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$ED$4:$ED$5000,0,(AK601-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F605,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":{"$error":"#N/A"}},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,587,4,null,null,null,null,null,"Numerator Value:",null,null,null,null,"Input",null,null,null,null,"Input",null,null,null,null,"Input",null,null,null,null,"Input",null,null,null,null,"Input",null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,{"$f":"IF(OR($T572<>\"Eligible to Report in April DY4\",$T577<>\"Yes\",Q601=\"\"),0,IF(Q606=\"Input\",1,0))","v":0},0,0,0,0,{"$f":"IF(OR($T572<>\"Eligible to Report in April DY4\",$T577<>\"Yes\",V601=\"\"),0,IF(V606=\"Input\",1,0))","v":0},0,0,0,0,{"$f":"IF(OR($T572<>\"Eligible to Report in April DY4\",$T577<>\"Yes\",AA601=\"\"),0,IF(AA606=\"Input\",1,0))","v":0},0,0,0,0,{"$f":"IF(OR($T572<>\"Eligible to Report in April DY4\",$T577<>\"Yes\",AF601=\"\"),0,IF(AF606=\"Input\",1,0))","v":0},0,0,0,0,{"$f":"IF(OR($T572<>\"Eligible to Report in April DY4\",$T577<>\"Yes\",AK601=\"\"),0,IF(AK606=\"Input\",1,0))","v":0},0,0,0,0,0]
[null,null,null,1,588,4,null,null,null,null,null,"Denominator Description:",null,null,null,null,{"$f":"IF(Q601=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(Q601-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F607,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(Q601-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F607,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":{"$error":"#N/A"}},null,null,null,null,{"$f":"IF(V601=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(V601-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F607,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(V601-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F607,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":{"$error":"#N/A"}},null,null,null,null,{"$f":"IF(AA601=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(AA601-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F607,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(AA601-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F607,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":{"$error":"#N/A"}},null,null,null,null,{"$f":"IF(AF601=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(AF601-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F607,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(AF601-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F607,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":{"$error":"#N/A"}},null,null,null,null,{"$f":"IF(AK601=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(AK601-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F607,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$EE$4:$EE$5000,0,(AK601-1)*2),MATCH(RHP&\"_\"&$O$14&\"_\"&$F607,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":{"$error":"#N/A"}},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,589,4,null,null,null,null,null,"Denominator:",null,null,null,null,"Input",null,null,null,null,"Input",null,null,null,null,"Input",null,null,null,null,"Input",null,null,null,null,"Input",null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,{"$f":"IF(OR($T572<>\"Eligible to Report in April DY4\",$T577<>\"Yes\",Q601=\"\"),0,IF(Q608=\"Input\",1,0))","v":0},0,0,0,0,{"$f":"IF(OR($T572<>\"Eligible to Report in April DY4\",$T577<>\"Yes\",V601=\"\"),0,IF(V608=\"Input\",1,0))","v":0},0,0,0,0,{"$f":"IF(OR($T572<>\"Eligible to Report in April DY4\",$T577<>\"Yes\",AA601=\"\"),0,IF(AA608=\"Input\",1,0))","v":0},0,0,0,0,{"$f":"IF(OR($T572<>\"Eligible to Report in April DY4\",$T577<>\"Yes\",AF601=\"\"),0,IF(AF608=\"Input\",1,0))","v":0},0,0,0,0,{"$f":"IF(OR($T572<>\"Eligible to Report in April DY4\",$T577<>\"Yes\",AK601=\"\"),0,IF(AK608=\"Input\",1,0))","v":0},0,0,0,0,0]
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[null,null,null,1,591,4,null,null,null,null,null,"Measurement Period Start:",null,null,null,null,"MM/DD/YYYY",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,{"$f":"IF(OR($T572<>\"Eligible to Report in April DY4\",$T577<>\"Yes\"),0,IF(Q610=\"MM/DD/YY\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,592,4,null,null,null,null,null,"Measurement Period End:",null,null,null,null,"MM/DD/YYYY",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,{"$f":"IF(OR($T572<>\"Eligible to Report in April DY4\",$T577<>\"Yes\"),0,IF(Q611=\"MM/DD/YY\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
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[null,null,null,1,594,4,null,null,null,null,null,"DY4 Performance Rate:",null,null,null,null,{"$f":"IF(ISERROR(Q606/Q608*IF(OFFSET($T$66,($F613-1)*$A$13+(Q601-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F613-1)*$A$13+(Q601-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F613-1)*$A$13+(Q601-1)*8,0)=\"per 1K\"),1000,1))),\"\",Q606/Q608*IF(OFFSET($T$66,($F613-1)*$A$13+(Q601-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F613-1)*$A$13+(Q601-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F613-1)*$A$13+(Q601-1)*8,0)=\"per 1K\"),1000,1)))","v":""},null,null,null,null,{"$f":"IF(ISERROR(V606/V608*IF(OFFSET($T$66,($F613-1)*$A$13+(V601-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F613-1)*$A$13+(V601-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F613-1)*$A$13+(V601-1)*8,0)=\"per 1K\"),1000,1))),\"\",V606/V608*IF(OFFSET($T$66,($F613-1)*$A$13+(V601-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F613-1)*$A$13+(V601-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F613-1)*$A$13+(V601-1)*8,0)=\"per 1K\"),1000,1)))","v":""},null,null,null,null,{"$f":"IF(ISERROR(AA606/AA608*IF(OFFSET($T$66,($F613-1)*$A$13+(AA601-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F613-1)*$A$13+(AA601-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F613-1)*$A$13+(AA601-1)*8,0)=\"per 1K\"),1000,1))),\"\",AA606/AA608*IF(OFFSET($T$66,($F613-1)*$A$13+(AA601-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F613-1)*$A$13+(AA601-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F613-1)*$A$13+(AA601-1)*8,0)=\"per 1K\"),1000,1)))","v":""},null,null,null,null,{"$f":"IF(ISERROR(AF606/AF608*IF(OFFSET($T$66,($F613-1)*$A$13+(AF601-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F613-1)*$A$13+(AF601-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F613-1)*$A$13+(AF601-1)*8,0)=\"per 1K\"),1000,1))),\"\",AF606/AF608*IF(OFFSET($T$66,($F613-1)*$A$13+(AF601-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F613-1)*$A$13+(AF601-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F613-1)*$A$13+(AF601-1)*8,0)=\"per 1K\"),1000,1)))","v":""},null,null,null,null,{"$f":"IF(ISERROR(AK606/AK608*IF(OFFSET($T$66,($F613-1)*$A$13+(AK601-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F613-1)*$A$13+(AK601-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F613-1)*$A$13+(AK601-1)*8,0)=\"per 1K\"),1000,1))),\"\",AK606/AK608*IF(OFFSET($T$66,($F613-1)*$A$13+(AK601-1)*8,0)=\"number per 100K\",100000,IF(OR(OFFSET($T$66,($F613-1)*$A$13+(AK601-1)*8,0)=\"number per 1K\",OFFSET($T$66,($F613-1)*$A$13+(AK601-1)*8,0)=\"per 1K\"),1000,1)))","v":""},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
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[null,null,null,1,598,4,null,null,null,null,null,null,null,null,null,null,"Metric 1",null,null,null,null,"Metric 2",null,null,null,null,"Metric 3",null,null,null,null,"Metric 4",null,null,null,null,"Metric 5",null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,599,4,null,null,null,null,null,"Percentage of Goal Achieved",null,null,null,null,{"$f":"IF(OR(Q601=\"\",Q613=\"\"),\"\",IF(ISERROR(MIN(MAX(ROUNDDOWN((Q613-OFFSET($T$68,($F618-1)*$A$13+(Q601-1)*8,0))/(OFFSET($AH$66,($F618-1)*$A$13+(Q601-1)*8,0)-OFFSET($T$68,($F618-1)*$A$13+(Q601-1)*8,0))*4,0)/4,0),1)),\"\",MIN(MAX(ROUNDDOWN((Q613-OFFSET($T$68,($F618-1)*$A$13+(Q601-1)*8,0))/(OFFSET($AH$66,($F618-1)*$A$13+(Q601-1)*8,0)-OFFSET($T$68,($F618-1)*$A$13+(Q601-1)*8,0))*4,0)/4,0),1)))","v":""},null,null,null,null,{"$f":"IF(OR(V601=\"\",V613=\"\"),\"\",MIN(MAX(ROUNDDOWN((V613-OFFSET($T$68,($F618-1)*$A$13+(V601-1)*8,0))/(OFFSET($AH$66,($F618-1)*$A$13+(V601-1)*8,0)-OFFSET($T$68,($F618-1)*$A$13+(V601-1)*8,0))*4,0)/4,0),1))","v":""},null,null,null,null,{"$f":"IF(OR(AA601=\"\",AA613=\"\"),\"\",MIN(MAX(ROUNDDOWN((AA613-OFFSET($T$68,($F618-1)*$A$13+(AA601-1)*8,0))/(OFFSET($AH$66,($F618-1)*$A$13+(AA601-1)*8,0)-OFFSET($T$68,($F618-1)*$A$13+(AA601-1)*8,0))*4,0)/4,0),1))","v":""},null,null,null,null,{"$f":"IF(OR(AF601=\"\",AF613=\"\"),\"\",MIN(MAX(ROUNDDOWN((AF613-OFFSET($T$68,($F618-1)*$A$13+(AF601-1)*8,0))/(OFFSET($AH$66,($F618-1)*$A$13+(AF601-1)*8,0)-OFFSET($T$68,($F618-1)*$A$13+(AF601-1)*8,0))*4,0)/4,0),1))","v":""},null,null,null,null,{"$f":"IF(OR(AK601=\"\",AK613=\"\"),\"\",MIN(MAX(ROUNDDOWN((AK613-OFFSET($T$68,($F618-1)*$A$13+(AK601-1)*8,0))/(OFFSET($AH$66,($F618-1)*$A$13+(AK601-1)*8,0)-OFFSET($T$68,($F618-1)*$A$13+(AK601-1)*8,0))*4,0)/4,0),1))","v":""},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,600,4,null,null,null,null,null,"Status",null,null,null,null,{"$f":"IF(Q618=\"\",\"\",IF(Q618<1,\"Partially Achieved\",\"Achieved\"))","v":""},null,null,null,null,{"$f":"IF(V618=\"\",\"\",IF(V618<1,\"Partially Achieved\",\"Achieved\"))","v":""},null,null,null,null,{"$f":"IF(AA618=\"\",\"\",IF(AA618<1,\"Partially Achieved\",\"Achieved\"))","v":""},null,null,null,null,{"$f":"IF(AF618=\"\",\"\",IF(AF618<1,\"Partially Achieved\",\"Achieved\"))","v":""},null,null,null,null,{"$f":"IF(AK618=\"\",\"\",IF(AK618<1,\"Partially Achieved\",\"Achieved\"))","v":""},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
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[null,null,null,{"$f":"IF($F621=\"\",1,IF(OR(OFFSET($T$31,($F621-1)*$A$13,0)=\"P4R\",OFFSET($T$107,($F621-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F621-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F621-1)*$A$13,0)=FALSE,1,0)))+IF(SUM(Q621:AO621)=0,0,1)","v":1},602,4,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,603,4,null,null,null,null,null,"Please explain why your achievement is less than expected.",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,{"$f":"IF(ISERROR(IF(OR(Q601=\"\",$D622=1,Q619<>\"Partially Achieved\"),0,IF(Q622=\"Free Text\",1,0))),0,IF(OR(Q601=\"\",$D622=1,Q619<>\"Partially Achieved\"),0,IF(Q622=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(V601=\"\",$D622=1,V619<>\"Partially Achieved\"),0,IF(V622=\"Free Text\",1,0))),0,IF(OR(V601=\"\",$D622=1,V619<>\"Partially Achieved\"),0,IF(V622=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AA601=\"\",$D622=1,AA619<>\"Partially Achieved\"),0,IF(AA622=\"Free Text\",1,0))),0,IF(OR(AA601=\"\",$D622=1,AA619<>\"Partially Achieved\"),0,IF(AA622=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AF601=\"\",$D622=1,AF619<>\"Partially Achieved\"),0,IF(AF622=\"Free Text\",1,0))),0,IF(OR(AF601=\"\",$D622=1,AF619<>\"Partially Achieved\"),0,IF(AF622=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AK601=\"\",$D622=1,AK619<>\"Partially Achieved\"),0,IF(AK622=\"Free Text\",1,0))),0,IF(OR(AK601=\"\",$D622=1,AK619<>\"Partially Achieved\"),0,IF(AK622=\"Free Text\",1,0)))","v":0},0,0,0,0,0]
[null,null,null,1,604,4,null,null,null,null,null,"What is your plan to improve performance by the end of the following DY?",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,{"$f":"IF(ISERROR(IF(OR(Q601=\"\",$D623=1,Q619<>\"Partially Achieved\"),0,IF(Q623=\"Free Text\",1,0))),0,IF(OR(Q601=\"\",$D623=1,Q619<>\"Partially Achieved\"),0,IF(Q623=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(V601=\"\",$D623=1,V619<>\"Partially Achieved\"),0,IF(V623=\"Free Text\",1,0))),0,IF(OR(V601=\"\",$D623=1,V619<>\"Partially Achieved\"),0,IF(V623=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AA601=\"\",$D623=1,AA619<>\"Partially Achieved\"),0,IF(AA623=\"Free Text\",1,0))),0,IF(OR(AA601=\"\",$D623=1,AA619<>\"Partially Achieved\"),0,IF(AA623=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AF601=\"\",$D623=1,AF619<>\"Partially Achieved\"),0,IF(AF623=\"Free Text\",1,0))),0,IF(OR(AF601=\"\",$D623=1,AF619<>\"Partially Achieved\"),0,IF(AF623=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AK601=\"\",$D623=1,AK619<>\"Partially Achieved\"),0,IF(AK623=\"Free Text\",1,0))),0,IF(OR(AK601=\"\",$D623=1,AK619<>\"Partially Achieved\"),0,IF(AK623=\"Free Text\",1,0)))","v":0},0,0,0,0,0]
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[null,null,null,1,606,4,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F626=\"\",1,IF(OR(OFFSET($T$107,($F626-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F626-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F626-1)*$A$13,0)=FALSE,1,0)))","v":1},607,4,null,null,null,null,null,"Performance Reporting - Qualitative",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F627=\"\",1,IF(OR(OFFSET($T$107,($F627-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F627-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F627-1)*$A$13,0)=FALSE,1,0)))","v":1},608,4,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F628=\"\",1,IF(OR(OFFSET($T$107,($F628-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F628-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F628-1)*$A$13,0)=FALSE,1,0)))","v":1},609,4,null,null,null,null,null,"Please describe your interpretation of the rate above, including factors that may have caused a change in the rate (e.g. intervention, population shifts, system changes, etc.) as well as any trends identified within groups in your denominator (e.g. patient characteristics, seasonality, location of care, etc.)",null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T572<>\"Eligible to Report in April DY4\",$T577<>\"Yes\"),0,IF(T628=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F629=\"\",1,IF(OR(OFFSET($T$107,($F629-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F629-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F629-1)*$A$13,0)=FALSE,1,0)))","v":1},610,4,null,null,null,null,null,"Please estimate what percentage of your intervention population (QPI) is also represented by the denominator used to calculate your DY4 performance above",null,null,null,null,null,null,null,"Input",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T572<>\"Eligible to Report in April DY4\",$T577<>\"Yes\"),0,IF(T629=\"Input\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,{"$f":"CELL(\"Address\",T630)","v":"$T$630"},{"$f":"IF($F630=\"\",1,IF(OR(OFFSET($T$107,($F630-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F630-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F630-1)*$A$13,0)=FALSE,1,0)))","v":1},611,4,null,null,null,null,null,"Are you able to report performance in this outcome exclusively for the individuals receiving the intervention?",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T572<>\"Eligible to Report in April DY4\",$T577<>\"Yes\"),0,IF(T630=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F631=\"\",1,IF(OR(OFFSET($T$107,($F631-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F631-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F631-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$165,($F631-1)*$A$13,0)=\"Yes\",0,1))))","v":1},612,4,null,null,null,null,null,"Intervention Input",null,null,null,null,null,null,null,"Intervention Only Numerator:",null,"Input",null,null,null,"Intervention Only Denominator:",null,"Input",null,null,null,"Intervention Only Performance Rate:",null,null,null,null,null,{"$f":"IF(ISERROR(V631/AB631),\"\",V631/AB631)","v":""},null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T572<>\"Eligible to Report in April DY4\",$T577<>\"Yes\",$T630<>\"Yes\"),0,IF(V631=\"Input\",1,0))","v":0},0,0,0,0,0,{"$f":"IF(OR($T572<>\"Eligible to Report in April DY4\",$T577<>\"Yes\",$T630<>\"Yes\"),0,IF(AB631=\"Input\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F632=\"\",1,IF(OR(OFFSET($T$107,($F632-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F632-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F632-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$165,($F632-1)*$A$13,0)=\"Yes\",0,1))))","v":1},613,4,null,null,null,null,null,null,"Please describe your interpretation of the Intervention only performance rate including any factors contributing to this result",null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T572<>\"Eligible to Report in April DY4\",$T577<>\"Yes\",$T630<>\"Yes\"),0,IF(T632=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,{"$f":"CELL(\"Address\",T633)","v":"$T$633"},{"$f":"IF($F633=\"\",1,IF(OR(OFFSET($T$107,($F633-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F633-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F633-1)*$A$13,0)=FALSE,1,0)))","v":1},614,4,null,null,null,null,null,"Are you able to report performance in this outcome at a level broader than the denominator used to determine DY4 performance (i.e. system level performance)?",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T572<>\"Eligible to Report in April DY4\",$T577<>\"Yes\"),0,IF(T633=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F634=\"\",1,IF(OR(OFFSET($T$107,($F634-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F634-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F634-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$168,($F634-1)*$A$13,0)=\"Yes\",0,1))))","v":1},615,4,null,null,null,null,null,"System Level Input",null,null,null,null,null,null,null,"System Level Numerator:",null,"Input",null,null,null,"System Level Denominator:",null,"Input",null,null,null,"System Level Performance Rate:",null,null,null,null,null,{"$f":"IF(ISERROR(V634/AB634),\"\",V634/AB634)","v":""},null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T572<>\"Eligible to Report in April DY4\",$T577<>\"Yes\",$T633<>\"Yes\"),0,IF(V634=\"Input\",1,0))","v":0},0,0,0,0,0,{"$f":"IF(OR($T572<>\"Eligible to Report in April DY4\",$T577<>\"Yes\",$T633<>\"Yes\"),0,IF(AB634=\"Input\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F635=\"\",1,IF(OR(OFFSET($T$107,($F635-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F635-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F635-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$168,($F635-1)*$A$13,0)=\"Yes\",0,1))))","v":1},616,4,null,null,null,null,null,null,"Please describe your interpretation of the system level performance rate including any factors contributing to this result",null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T572<>\"Eligible to Report in April DY4\",$T577<>\"Yes\",$T633<>\"Yes\"),0,IF(T635=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F636=\"\",1,IF(OR(OFFSET($T$107,($F636-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F636-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F636-1)*$A$13,0)=FALSE,1,0)))","v":1},617,4,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F637=\"\",1,IF(OR(OFFSET($T$107,($F637-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F637-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F637-1)*$A$13,0)=FALSE,1,0)))","v":1},618,4,null,null,null,null,null,"Are there any other process or improvement outcomes, beyond the Category 3 outcomes associated with this project, that are being used to monitor intervention effects or impact?",null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T572<>\"Eligible to Report in April DY4\",$T577<>\"Yes\"),0,IF(T637=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F638=\"\",1,IF(OR(OFFSET($T$107,($F638-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F638-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F638-1)*$A$13,0)=FALSE,1,0)))","v":1},619,4,null,null,null,null,null,"Please Include any Additional Comments here:",null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T572<>\"Eligible to Report in April DY4\",$T577<>\"Yes\"),0,IF(T638=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F639=\"\",1,IF(OR(OFFSET($T$107,($F639-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F639-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F639-1)*$A$13,0)=FALSE,1,0)))","v":1},620,4,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
["#Metrics",null,null,{"$f":"IF($O$14=\"\",0,IF($F640=\"\",1,0))","v":0},{"$f":"E639+1","v":621},{"$f":"IF(F639=\"\",\"\",IF(G640=\"New\",IF(F639+1>$A$15,\"\",F639+1),F639))","v":5},"New",null,null,null,{"$f":"\"Outcome \"&$F640&\" Details\"","v":"Outcome 5 Details"},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"X",{"$f":"K640","v":"Outcome 5 Details"}]
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["#Milestones",null,null,0,623,5,null,null,null,null,null,"Category 3 Outcome ID:",null,null,null,{"$f":"IF($F642=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$E$4:$E$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F642,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$E$4:$E$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F642,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$E$4:$E$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F642,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
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[null,null,null,{"$f":"IF($F717=\"\",1,IF(OFFSET($A$26,($F717-1)*$A$13,0)=FALSE,1,IF(H717=\"\",1,0)))","v":1},698,5,null,5,"New",null,null,"Metric 5: AM-1.5",null,null,null,{"$f":"IF($F717=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$CG$4:$CG$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F717,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$CG$4:$CG$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F717,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$CG$4:$CG$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F717,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F718=\"\",1,IF(OFFSET($A$26,($F718-1)*$A$13,0)=FALSE,1,IF(H718=\"\",1,0)))","v":1},699,5,null,5,null,null,null,null,"Baseline",null,null,null,null,null,"Goal Type:",{"$f":"IF($F718=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$CG$4:$CG$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F718,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$CG$4:$CG$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F718,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$CG$4:$CG$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F718,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,"DY4",null,null,null,null,null,"Goal:",{"$f":"IF($H717=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$DC$4:$DC$5000,0,($H717-1)*4),MATCH(RHP&\"_\"&$O$14&\"_\"&$F718,'Master Data Mock'!$FM$4:$FM$5000,0))=\"Maintain\",$T720,INDEX(OFFSET('Master Data Mock'!$DC$4:$DC$5000,0,($H717-1)*4),MATCH(RHP&\"_\"&$O$14&\"_\"&$F718,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":{"$error":"#N/A"}},null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F719=\"\",1,IF(OFFSET($A$26,($F719-1)*$A$13,0)=FALSE,1,IF(H719=\"\",1,0)))","v":1},700,5,null,5,null,null,null,null,null,null,null,null,null,null,"Numerator/Denominator:",{"$f":"IF($H719=\"\",\"\",IF(ROUND(INDEX(OFFSET('Master Data Mock'!$CI$4:$CI$5000,0,($H719-1)*4),MATCH(RHP&\"_\"&$O$14&\"_\"&$F719,'Master Data Mock'!$FM$4:$FM$5000,0)),4)&\"/\"&ROUND(INDEX(OFFSET('Master Data Mock'!$CJ$4:$CJ$5000,0,($H719-1)*4),MATCH(RHP&\"_\"&$O$14&\"_\"&$F719,'Master Data Mock'!$FM$4:$FM$5000,0)),4)=\"0/0\",\"TBD\",ROUND(INDEX(OFFSET('Master Data Mock'!$CI$4:$CI$5000,0,($H719-1)*4),MATCH(RHP&\"_\"&$O$14&\"_\"&$F719,'Master Data Mock'!$FM$4:$FM$5000,0)),4)&\"/\"&ROUND(INDEX(OFFSET('Master Data Mock'!$CJ$4:$CJ$5000,0,($H719-1)*4),MATCH(RHP&\"_\"&$O$14&\"_\"&$F719,'Master Data Mock'!$FM$4:$FM$5000,0)),4)))","v":{"$error":"#N/A"}},null,null,null,null,null,null,null,null,null,null,null,null,"Measurement Period Start:",{"$f":"IF($F719=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$FA$4:$FA$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F719,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$FA$4:$FA$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F719,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$FA$4:$FA$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F719,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F720=\"\",1,IF(OFFSET($A$26,($F720-1)*$A$13,0)=FALSE,1,IF(H720=\"\",1,0)))","v":1},701,5,null,5,null,null,null,null,null,null,null,null,null,null,"Performance:",{"$f":"IF($H718=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$CH$4:$CH$5000,0,($H718-1)*4),MATCH(RHP&\"_\"&$O$14&\"_\"&$F719,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$CH$4:$CH$5000,0,($H718-1)*4),MATCH(RHP&\"_\"&$O$14&\"_\"&$F719,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":{"$error":"#N/A"}},null,null,null,null,null,null,null,null,null,null,null,null,"Measurement Period End:",{"$f":"IF($F720=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$FB$4:$FB$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F720,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$FB$4:$FB$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F720,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$FB$4:$FB$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F720,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F721=\"\",1,IF(OFFSET($A$26,($F721-1)*$A$13,0)=FALSE,1,IF(H721=\"\",1,0)))","v":1},702,5,null,5,null,null,null,null,null,null,null,null,null,null,"Measurement Period Start:",{"$f":"IF($F721=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$FE$4:$FE$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F721,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$FE$4:$FE$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F721,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$FE$4:$FE$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F721,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,"DY5",null,null,null,null,null,"Goal:",{"$f":"IF($H721=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$DE$4:$DE$5000,0,($H721-1)*4),MATCH(RHP&\"_\"&$O$14&\"_\"&$F721,'Master Data Mock'!$FM$4:$FM$5000,0))=\"Maintain\",T720,INDEX(OFFSET('Master Data Mock'!$DE$4:$DE$5000,0,($H721-1)*4),MATCH(RHP&\"_\"&$O$14&\"_\"&$F721,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":{"$error":"#N/A"}},null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F722=\"\",1,IF(OFFSET($A$26,($F722-1)*$A$13,0)=FALSE,1,IF(H722=\"\",1,0)))","v":1},703,5,null,5,null,null,null,null,null,null,null,null,null,null,"Measurement Period End:",{"$f":"IF($F722=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$FF$4:$FF$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F722,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$FF$4:$FF$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F722,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$FF$4:$FF$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F722,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,"Measurement Period Start:",{"$f":"IF($F722=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$FC$4:$FC$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F722,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$FC$4:$FC$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F722,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$FC$4:$FC$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F722,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F723=\"\",1,IF(OFFSET($A$26,($F723-1)*$A$13,0)=FALSE,1,IF(H723=\"\",1,0)))","v":1},704,5,null,5,null,null,null,null,null,null,null,{"$f":"IF($H723=\"\",\"\",IF(INDEX('Master Data Mock'!$H$4:$H$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F674,'Master Data Mock'!$FM$4:$FM$5000,0))=\"\",\"\",INDEX('Master Data Mock'!$H$4:$H$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F674,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":{"$error":"#N/A"}},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Measurement Period End:",{"$f":"IF($F723=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$FD$4:$FD$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F723,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$FD$4:$FD$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F723,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$FD$4:$FD$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F723,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F724=\"\",1,IF(OFFSET($A$26,($F724-1)*$A$13,0)=FALSE,1,IF(H724=\"\",1,0)))","v":1},705,5,null,5,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F725=\"\",1,IF(OFFSET($A$26,($F725-1)*$A$13,0)=FALSE,1,0))","v":1},706,5,null,null,null,null,null,"Performance Reporting - Readiness:",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F726=\"\",1,IF(OFFSET($A$26,($F726-1)*$A$13,0)=FALSE,1,0))","v":1},707,5,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F727=\"\",1,IF(OFFSET($A$26,($F727-1)*$A$13,0)=FALSE,1,0))","v":1},708,5,null,null,null,null,null,"Eligible to report in April DY4?",null,null,null,null,null,null,null,{"$f":"IF(F727=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$I$4:$I$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F727,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$I$4:$I$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F727,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$I$4:$I$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F727,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F728=\"\",1,IF(OFFSET($A$26,($F728-1)*$A$13,0)=FALSE,1,0))","v":1},709,5,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F729=\"\",1,IF(OFFSET($A$26,($F729-1)*$A$13,0)=FALSE,1,0))","v":1},710,5,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F730=\"\",1,IF(OFFSET($A$26,($F730-1)*$A$13,0),IF(T727=\"Eligible to Report in October DY4\",0,1),1))","v":1},711,5,null,null,null,null,null,"Outcome is eligible to be reported in October of DY4",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F731=\"\",1,IF(OFFSET($A$26,($F731-1)*$A$13,0)=FALSE,1,0))","v":1},{"$f":"E730+1","v":712},{"$f":"IF(F730=\"\",\"\",IF(G731=\"New\",IF(F730+1>$A$15,\"\",F730+1),F730))","v":5},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,{"$f":"CELL(\"Address\",T732)","v":"$T$732"},null,{"$f":"IF($F732=\"\",1,IF(OFFSET($T$107,($F732-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F732-1)*$A$13,0)=FALSE,1,0)))","v":1},713,5,null,null,null,null,null,"Are you ready to report this outcome with 12 months of data aligning with your DY4 measurement period?",null,null,null,null,null,null,null,null,null,"If not, within the online reporting system please include a progress update regarding the status of your performance.  If no updates to performance are available, please describe any salient updates to the measure collection process.  This progress update fulfills your semi-annual reporting requirement for this milestone. Please indicate that you will do this by selecting 'Yes' to the right",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T727<>\"Eligible to Report in April DY4\",0,IF(T732=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T727<>\"Eligible to Report in April DY4\",$T732=\"Yes\"),0,IF(AE732=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,714,5,null,null,null,null,null,"Provider intention to Carry forward",null,null,null,null,null,null,null,"NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,715,5,null,null,null,null,null,"Provider intention to report in October DY4",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,716,5,null,null,null,null,null,"Additional text boxes to use in October",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,717,5,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,718,5,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,719,5,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,720,5,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,721,5,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[{"$f":"CELL(\"Address\",T741)","v":"$T$741"},null,null,{"$f":"IF($F741=\"\",1,IF(OFFSET($T$107,($F741-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F741-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F741-1)*$A$13,0)=\"Yes\",0,1))))","v":1},722,5,null,null,null,null,null,"Are you reporting to approved measure specifications?  This includes numerator description, denominator description and any approved subsets",null,null,null,null,null,null,null,null,null,"Please describe any differences between specifications used to determine DY4 performance and the approved measure specifications:",null,null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T732<>\"Yes\",0,IF(T741=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,{"$f":"IF($T732<>\"Yes\",0,IF(AND(T741=\"No\",AE741=\"Free Text\"),1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0]
[{"$f":"CELL(\"Address\",T742)","v":"$T$742"},null,null,{"$f":"IF($F742=\"\",1,IF(OFFSET($T$107,($F742-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F742-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F742-1)*$A$13,0)=\"Yes\",0,1))))","v":1},723,5,null,null,null,null,null,"Are there any changes/improvements/clarifications to your data abstraction process for the performance reported in DY4 relative to how the baseline was described in the field above?",null,null,null,null,null,null,null,null,null,"Please describe the changes/improvements to your abstraction process",null,null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T732<>\"Yes\",0,IF(T742=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,{"$f":"IF($T732<>\"Yes\",0,IF(AND(T742=\"Yes\",AE742=\"Free Text\"),1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0]
[{"$f":"CELL(\"Address\",T743)","v":"$T$743"},null,null,{"$f":"IF($F743=\"\",1,IF(OFFSET($T$107,($F743-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F743-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F743-1)*$A$13,0)=\"Yes\",0,1))))","v":1},724,5,null,null,null,null,null,"Are there any changes or improvements to your tool administration process as reported at baseline?",null,null,null,null,null,null,null,null,null,"Please describe changes in tool/survey administration process",null,null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T732<>\"Yes\",0,IF(T743=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,{"$f":"IF($T732<>\"Yes\",0,IF(AND(T743=\"Yes\",AE743=\"Free Text\"),1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F744=\"\",1,IF(OR(OFFSET($T$107,($F744-1)*$A$13,0)<>\"Eligible to Report in April DY4\",$T744=\"\"),1,IF(OFFSET($A$26,($F744-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F744-1)*$A$13,0)=\"Yes\",0,1))))","v":1},725,5,null,null,null,null,null,"Risk Adjustment Type",null,null,null,null,null,null,null,{"$f":"IF(F743=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$EZ$4:$EZ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F743,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$EZ$4:$EZ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F743,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$EZ$4:$EZ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F743,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[{"$f":"CELL(\"Address\",T745)","v":"$T$745"},null,null,{"$f":"IF($F745=\"\",1,IF(OR(OFFSET($T$107,($F745-1)*$A$13,0)<>\"Eligible to Report in April DY4\",$T744=\"\"),1,IF(OFFSET($A$26,($F745-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F745-1)*$A$13,0)=\"Yes\",0,1))))","v":1},726,5,null,null,null,null,null,null,"Are there any changes or improvements to risk adjustment process?",null,null,null,null,null,null,null,null,"Please describe changes in risk adjustment process",null,null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T732<>\"Yes\",0,IF($T744=\"\",0,IF(T745=\"\",1,0)))","v":0},0,0,0,0,0,0,0,0,0,{"$f":"IF($T732<>\"Yes\",0,IF(AND(T745=\"Yes\",AE745=\"Free Text\"),1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F746=\"\",1,IF(OFFSET($T$107,($F746-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F746-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F746-1)*$A$13,0)=\"Yes\",IF(IF(F746=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F746,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F746,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F746,'Master Data Mock'!$FM$4:$FM$5000,0))))<>\"\",0,1),1))))","v":1},727,5,null,null,null,null,null,{"$f":"\"Provider used a proxy population to determine baseline performance described as:  \"&IF(F746=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F746,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F746,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F746,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":"Provider used a proxy population to determine baseline performance described as:  "},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F747=\"\",1,IF(OFFSET($T$107,($F747-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F747-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$112,($F747-1)*$A$13,0)=\"Yes\",IF(IF(F747=\"\",\"\",IF(OR(ISERROR(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F747,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F747,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$DX$4:$DX$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F747,'Master Data Mock'!$FM$4:$FM$5000,0))))<>\"\",0,1),1))))","v":1},728,5,null,null,null,null,null,null,"Please describe the alignment (similarities and differences) between the proxy population reported for baseline and the cohort used for the DY4 measurement period",null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($D746=1,$T732<>\"Yes\"),0,IF(T747=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F748=\"\",1,IF(OFFSET($A$26,($F748-1)*$A$13,0)=FALSE,1,0))","v":1},729,5,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F749=\"\",1,IF(OFFSET($T$107,($F749-1)*$A$13,0)<>\"Eligible to Report in April DY4\",1,IF(OFFSET($A$26,($F749-1)*$A$13,0)=FALSE,1,IF(OR(OFFSET($T$112,($F749-1)*$A$13,0)=\"Yes\",OFFSET($T$31,($F749-1)*$A$13,0)<>\"P4R\"),1,0))))","v":1},730,5,null,null,null,null,null,"Alternate Achievement Activity Status Update",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,731,5,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,732,5,null,null,null,null,null,"Alternate Achievement Activity:",null,null,null,null,null,null,null,{"$f":"IF(OR(ISERROR(INDEX('Master Data Mock'!$P$4:$P$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F751,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$P$4:$P$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F751,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$P$4:$P$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F751,'Master Data Mock'!$FM$4:$FM$5000,0)))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,733,5,null,null,null,null,null,"Alternative Achievement Activity Baseline Reported:",null,null,null,null,null,null,null,{"$f":"IF(LEFT(T751,2)=\"SA\",IF(OR(ISERROR(INDEX('Master Data Mock'!$EP$4:$EP$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F752,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$EP$4:$EP$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F752,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$EP$4:$EP$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F752,'Master Data Mock'!$FM$4:$FM$5000,0))),IF(OR(ISERROR(INDEX('Master Data Mock'!$EQ$4:$EQ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F752,'Master Data Mock'!$FM$4:$FM$5000,0))),ISBLANK(INDEX('Master Data Mock'!$EQ$4:$EQ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F752,'Master Data Mock'!$FM$4:$FM$5000,0)))),\"\",INDEX('Master Data Mock'!$EQ$4:$EQ$5000,MATCH(RHP&\"_\"&$O$14&\"_\"&$F752,'Master Data Mock'!$FM$4:$FM$5000,0))))","v":""},null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,734,5,null,null,null,null,null,"Please include an update for any activities to date related to the selected Stretch Activity above or performance in the PFP measure above. If baseline for this PFP measure has not yet been reported, please indicate when this will be submitted and which 12 month measurement period it will reflect (DY3 or DY4).  If ready to report PFP baseline now please complete the PFP Baseline form found here: http://www.hhsc.state.tx.us/1115-Waiver-Guideline.shtml ",null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF($T651<>\"P4R\",0,IF(T753=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,735,5,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F755=\"\",1,IF(OR(OFFSET($T$107,($F755-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F755-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F755-1)*$A$13,0)=FALSE,1,0)))","v":1},736,5,null,null,null,null,null,"Performance Reporting - Quantitative",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,737,5,null,null,null,null,null,null,null,null,null,null,{"$f":"IF($F756=\"\",\"\",1)","v":1},null,null,null,null,{"$f":"IF($F756=\"\",\"\",IF(Q756=\"\",\"\",IF(Q756+1>OFFSET($A$21,($F756-1)*$A$13,0),\"\",Q756+1)))","v":2},null,null,null,null,{"$f":"IF($F756=\"\",\"\",IF(V756=\"\",\"\",IF(V756+1>OFFSET($A$21,($F756-1)*$A$13,0),\"\",V756+1)))","v":3},null,null,null,null,{"$f":"IF($F756=\"\",\"\",IF(AA756=\"\",\"\",IF(AA756+1>OFFSET($A$21,($F756-1)*$A$13,0),\"\",AA756+1)))","v":4},null,null,null,null,{"$f":"IF($F756=\"\",\"\",IF(AF756=\"\",\"\",IF(AF756+1>OFFSET($A$21,($F756-1)*$A$13,0),\"\",AF756+1)))","v":5},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,738,5,null,null,null,null,null,null,null,null,null,null,"Metric 1",null,null,null,null,"Metric 2",null,null,null,null,"Metric 3",null,null,null,null,"Metric 4",null,null,null,null,"Metric 5",null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,739,5,null,null,null,null,null,"Milestone ID:",null,null,null,null,{"$f":"IF($F758=\"\",\"\",IF(Q756=\"\",\"\",\"AM-1.\"&Q756))","v":"AM-1.1"},null,null,null,null,{"$f":"IF($F758=\"\",\"\",IF(V756=\"\",\"\",\"AM-1.\"&V756))","v":"AM-1.2"},null,null,null,null,{"$f":"IF($F758=\"\",\"\",IF(AA756=\"\",\"\",\"AM-1.\"&AA756))","v":"AM-1.3"},null,null,null,null,{"$f":"IF($F758=\"\",\"\",IF(AF756=\"\",\"\",\"AM-1.\"&AF756))","v":"AM-1.4"},null,null,null,null,{"$f":"IF($F758=\"\",\"\",IF(AK756=\"\",\"\",\"AM-1.\"&AK756))","v":"AM-1.5"},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,740,5,null,null,null,null,null,"Milestone Description:",null,null,null,null,{"$f":"IF(Q756=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(Q756-1)*5),MATCH(Q758,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(Q756-1)*5),0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(Q756-1)*5),MATCH(Q758,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(Q756-1)*5),0))))","v":"Achievement of DY4 performance goal"},null,null,null,null,{"$f":"IF(V756=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(V756-1)*5),MATCH(V758,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(V756-1)*5),0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(V756-1)*5),MATCH(V758,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(V756-1)*5),0))))","v":"Achievement of DY4 performance goal- 30 day follow-up"},null,null,null,null,{"$f":"IF(AA756=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AA756-1)*5),MATCH(AA758,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AA756-1)*5),0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AA756-1)*5),MATCH(AA758,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AA756-1)*5),0))))","v":"Achievement of DY4 performance goal- Counseling for physical activity"},null,null,null,null,{"$f":"IF(AF756=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AF756-1)*5),MATCH(AF758,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AF756-1)*5),0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AF756-1)*5),MATCH(AF758,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AF756-1)*5),0))))","v":"Achievement of DY4 performance goal- GSMC"},null,null,null,null,{"$f":"IF(AK756=\"\",\"\",IF(INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AK756-1)*5),MATCH(AK758,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AK756-1)*5),0))=\"\",\"\",INDEX(OFFSET('Master Data Mock'!$AI$4:$AI$5000,0,(AK756-1)*5),MATCH(AK758,OFFSET('Master Data Mock'!$AH$4:$AH$5000,0,(AK756-1)*5),0))))","v":"Achievement of DY4 performance goal- Mortality O/E"},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
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[null,null,null,1,753,5,null,null,null,null,null,null,null,null,null,null,"Metric 1",null,null,null,null,"Metric 2",null,null,null,null,"Metric 3",null,null,null,null,"Metric 4",null,null,null,null,"Metric 5",null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,754,5,null,null,null,null,null,"Percentage of Goal Achieved",null,null,null,null,{"$f":"IF(OR(Q756=\"\",Q768=\"\"),\"\",IF(ISERROR(MIN(MAX(ROUNDDOWN((Q768-OFFSET($T$68,($F773-1)*$A$13+(Q756-1)*8,0))/(OFFSET($AH$66,($F773-1)*$A$13+(Q756-1)*8,0)-OFFSET($T$68,($F773-1)*$A$13+(Q756-1)*8,0))*4,0)/4,0),1)),\"\",MIN(MAX(ROUNDDOWN((Q768-OFFSET($T$68,($F773-1)*$A$13+(Q756-1)*8,0))/(OFFSET($AH$66,($F773-1)*$A$13+(Q756-1)*8,0)-OFFSET($T$68,($F773-1)*$A$13+(Q756-1)*8,0))*4,0)/4,0),1)))","v":""},null,null,null,null,{"$f":"IF(OR(V756=\"\",V768=\"\"),\"\",MIN(MAX(ROUNDDOWN((V768-OFFSET($T$68,($F773-1)*$A$13+(V756-1)*8,0))/(OFFSET($AH$66,($F773-1)*$A$13+(V756-1)*8,0)-OFFSET($T$68,($F773-1)*$A$13+(V756-1)*8,0))*4,0)/4,0),1))","v":""},null,null,null,null,{"$f":"IF(OR(AA756=\"\",AA768=\"\"),\"\",MIN(MAX(ROUNDDOWN((AA768-OFFSET($T$68,($F773-1)*$A$13+(AA756-1)*8,0))/(OFFSET($AH$66,($F773-1)*$A$13+(AA756-1)*8,0)-OFFSET($T$68,($F773-1)*$A$13+(AA756-1)*8,0))*4,0)/4,0),1))","v":""},null,null,null,null,{"$f":"IF(OR(AF756=\"\",AF768=\"\"),\"\",MIN(MAX(ROUNDDOWN((AF768-OFFSET($T$68,($F773-1)*$A$13+(AF756-1)*8,0))/(OFFSET($AH$66,($F773-1)*$A$13+(AF756-1)*8,0)-OFFSET($T$68,($F773-1)*$A$13+(AF756-1)*8,0))*4,0)/4,0),1))","v":""},null,null,null,null,{"$f":"IF(OR(AK756=\"\",AK768=\"\"),\"\",MIN(MAX(ROUNDDOWN((AK768-OFFSET($T$68,($F773-1)*$A$13+(AK756-1)*8,0))/(OFFSET($AH$66,($F773-1)*$A$13+(AK756-1)*8,0)-OFFSET($T$68,($F773-1)*$A$13+(AK756-1)*8,0))*4,0)/4,0),1))","v":""},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,755,5,null,null,null,null,null,"Status",null,null,null,null,{"$f":"IF(Q773=\"\",\"\",IF(Q773<1,\"Partially Achieved\",\"Achieved\"))","v":""},null,null,null,null,{"$f":"IF(V773=\"\",\"\",IF(V773<1,\"Partially Achieved\",\"Achieved\"))","v":""},null,null,null,null,{"$f":"IF(AA773=\"\",\"\",IF(AA773<1,\"Partially Achieved\",\"Achieved\"))","v":""},null,null,null,null,{"$f":"IF(AF773=\"\",\"\",IF(AF773<1,\"Partially Achieved\",\"Achieved\"))","v":""},null,null,null,null,{"$f":"IF(AK773=\"\",\"\",IF(AK773<1,\"Partially Achieved\",\"Achieved\"))","v":""},null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,756,5,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F776=\"\",1,IF(OR(OFFSET($T$31,($F776-1)*$A$13,0)=\"P4R\",OFFSET($T$107,($F776-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F776-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F776-1)*$A$13,0)=FALSE,1,0)))+IF(SUM(Q776:AO776)=0,0,1)","v":1},757,5,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,758,5,null,null,null,null,null,"Please explain why your achievement is less than expected.",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,{"$f":"IF(ISERROR(IF(OR(Q756=\"\",$D777=1,Q774<>\"Partially Achieved\"),0,IF(Q777=\"Free Text\",1,0))),0,IF(OR(Q756=\"\",$D777=1,Q774<>\"Partially Achieved\"),0,IF(Q777=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(V756=\"\",$D777=1,V774<>\"Partially Achieved\"),0,IF(V777=\"Free Text\",1,0))),0,IF(OR(V756=\"\",$D777=1,V774<>\"Partially Achieved\"),0,IF(V777=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AA756=\"\",$D777=1,AA774<>\"Partially Achieved\"),0,IF(AA777=\"Free Text\",1,0))),0,IF(OR(AA756=\"\",$D777=1,AA774<>\"Partially Achieved\"),0,IF(AA777=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AF756=\"\",$D777=1,AF774<>\"Partially Achieved\"),0,IF(AF777=\"Free Text\",1,0))),0,IF(OR(AF756=\"\",$D777=1,AF774<>\"Partially Achieved\"),0,IF(AF777=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AK756=\"\",$D777=1,AK774<>\"Partially Achieved\"),0,IF(AK777=\"Free Text\",1,0))),0,IF(OR(AK756=\"\",$D777=1,AK774<>\"Partially Achieved\"),0,IF(AK777=\"Free Text\",1,0)))","v":0},0,0,0,0,0]
[null,null,null,1,759,5,null,null,null,null,null,"What is your plan to improve performance by the end of the following DY?",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,{"$f":"IF(ISERROR(IF(OR(Q756=\"\",$D778=1,Q774<>\"Partially Achieved\"),0,IF(Q778=\"Free Text\",1,0))),0,IF(OR(Q756=\"\",$D778=1,Q774<>\"Partially Achieved\"),0,IF(Q778=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(V756=\"\",$D778=1,V774<>\"Partially Achieved\"),0,IF(V778=\"Free Text\",1,0))),0,IF(OR(V756=\"\",$D778=1,V774<>\"Partially Achieved\"),0,IF(V778=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AA756=\"\",$D778=1,AA774<>\"Partially Achieved\"),0,IF(AA778=\"Free Text\",1,0))),0,IF(OR(AA756=\"\",$D778=1,AA774<>\"Partially Achieved\"),0,IF(AA778=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AF756=\"\",$D778=1,AF774<>\"Partially Achieved\"),0,IF(AF778=\"Free Text\",1,0))),0,IF(OR(AF756=\"\",$D778=1,AF774<>\"Partially Achieved\"),0,IF(AF778=\"Free Text\",1,0)))","v":0},0,0,0,0,{"$f":"IF(ISERROR(IF(OR(AK756=\"\",$D778=1,AK774<>\"Partially Achieved\"),0,IF(AK778=\"Free Text\",1,0))),0,IF(OR(AK756=\"\",$D778=1,AK774<>\"Partially Achieved\"),0,IF(AK778=\"Free Text\",1,0)))","v":0},0,0,0,0,0]
[null,null,null,1,760,5,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,1,761,5,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F781=\"\",1,IF(OR(OFFSET($T$107,($F781-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F781-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F781-1)*$A$13,0)=FALSE,1,0)))","v":1},762,5,null,null,null,null,null,"Performance Reporting - Qualitative",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F782=\"\",1,IF(OR(OFFSET($T$107,($F782-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F782-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F782-1)*$A$13,0)=FALSE,1,0)))","v":1},763,5,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F783=\"\",1,IF(OR(OFFSET($T$107,($F783-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F783-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F783-1)*$A$13,0)=FALSE,1,0)))","v":1},764,5,null,null,null,null,null,"Please describe your interpretation of the rate above, including factors that may have caused a change in the rate (e.g. intervention, population shifts, system changes, etc.) as well as any trends identified within groups in your denominator (e.g. patient characteristics, seasonality, location of care, etc.)",null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T727<>\"Eligible to Report in April DY4\",$T732<>\"Yes\"),0,IF(T783=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F784=\"\",1,IF(OR(OFFSET($T$107,($F784-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F784-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F784-1)*$A$13,0)=FALSE,1,0)))","v":1},765,5,null,null,null,null,null,"Please estimate what percentage of your intervention population (QPI) is also represented by the denominator used to calculate your DY4 performance above",null,null,null,null,null,null,null,"Input",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T727<>\"Eligible to Report in April DY4\",$T732<>\"Yes\"),0,IF(T784=\"Input\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,{"$f":"CELL(\"Address\",T785)","v":"$T$785"},{"$f":"IF($F785=\"\",1,IF(OR(OFFSET($T$107,($F785-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F785-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F785-1)*$A$13,0)=FALSE,1,0)))","v":1},766,5,null,null,null,null,null,"Are you able to report performance in this outcome exclusively for the individuals receiving the intervention?",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T727<>\"Eligible to Report in April DY4\",$T732<>\"Yes\"),0,IF(T785=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F786=\"\",1,IF(OR(OFFSET($T$107,($F786-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F786-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F786-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$165,($F786-1)*$A$13,0)=\"Yes\",0,1))))","v":1},767,5,null,null,null,null,null,"Intervention Input",null,null,null,null,null,null,null,"Intervention Only Numerator:",null,"Input",null,null,null,"Intervention Only Denominator:",null,"Input",null,null,null,"Intervention Only Performance Rate:",null,null,null,null,null,{"$f":"IF(ISERROR(V786/AB786),\"\",V786/AB786)","v":""},null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T727<>\"Eligible to Report in April DY4\",$T732<>\"Yes\",$T785<>\"Yes\"),0,IF(V786=\"Input\",1,0))","v":0},0,0,0,0,0,{"$f":"IF(OR($T727<>\"Eligible to Report in April DY4\",$T732<>\"Yes\",$T785<>\"Yes\"),0,IF(AB786=\"Input\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F787=\"\",1,IF(OR(OFFSET($T$107,($F787-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F787-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F787-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$165,($F787-1)*$A$13,0)=\"Yes\",0,1))))","v":1},768,5,null,null,null,null,null,null,"Please describe your interpretation of the Intervention only performance rate including any factors contributing to this result",null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T727<>\"Eligible to Report in April DY4\",$T732<>\"Yes\",$T785<>\"Yes\"),0,IF(T787=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,{"$f":"CELL(\"Address\",T788)","v":"$T$788"},{"$f":"IF($F788=\"\",1,IF(OR(OFFSET($T$107,($F788-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F788-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F788-1)*$A$13,0)=FALSE,1,0)))","v":1},769,5,null,null,null,null,null,"Are you able to report performance in this outcome at a level broader than the denominator used to determine DY4 performance (i.e. system level performance)?",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T727<>\"Eligible to Report in April DY4\",$T732<>\"Yes\"),0,IF(T788=\"\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F789=\"\",1,IF(OR(OFFSET($T$107,($F789-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F789-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F789-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$168,($F789-1)*$A$13,0)=\"Yes\",0,1))))","v":1},770,5,null,null,null,null,null,"System Level Input",null,null,null,null,null,null,null,"System Level Numerator:",null,"Input",null,null,null,"System Level Denominator:",null,"Input",null,null,null,"System Level Performance Rate:",null,null,null,null,null,{"$f":"IF(ISERROR(V789/AB789),\"\",V789/AB789)","v":""},null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T727<>\"Eligible to Report in April DY4\",$T732<>\"Yes\",$T788<>\"Yes\"),0,IF(V789=\"Input\",1,0))","v":0},0,0,0,0,0,{"$f":"IF(OR($T727<>\"Eligible to Report in April DY4\",$T732<>\"Yes\",$T788<>\"Yes\"),0,IF(AB789=\"Input\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F790=\"\",1,IF(OR(OFFSET($T$107,($F790-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F790-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F790-1)*$A$13,0)=FALSE,1,IF(OFFSET($T$168,($F790-1)*$A$13,0)=\"Yes\",0,1))))","v":1},771,5,null,null,null,null,null,null,"Please describe your interpretation of the system level performance rate including any factors contributing to this result",null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T727<>\"Eligible to Report in April DY4\",$T732<>\"Yes\",$T788<>\"Yes\"),0,IF(T790=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F791=\"\",1,IF(OR(OFFSET($T$107,($F791-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F791-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F791-1)*$A$13,0)=FALSE,1,0)))","v":1},772,5,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F792=\"\",1,IF(OR(OFFSET($T$107,($F792-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F792-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F792-1)*$A$13,0)=FALSE,1,0)))","v":1},773,5,null,null,null,null,null,"Are there any other process or improvement outcomes, beyond the Category 3 outcomes associated with this project, that are being used to monitor intervention effects or impact?",null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T727<>\"Eligible to Report in April DY4\",$T732<>\"Yes\"),0,IF(T792=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
[null,null,null,{"$f":"IF($F793=\"\",1,IF(OR(OFFSET($T$107,($F793-1)*$A$13,0)<>\"Eligible to Report in April DY4\",OFFSET($T$112,($F793-1)*$A$13,0)<>\"Yes\"),1,IF(OFFSET($A$26,($F793-1)*$A$13,0)=FALSE,1,0)))","v":1},774,5,null,null,null,null,null,"Please Include any Additional Comments here:",null,null,null,null,null,null,null,"Free Text",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,0,0,0,0,0,0,0,{"$f":"IF(OR($T727<>\"Eligible to Report in April DY4\",$T732<>\"Yes\"),0,IF(T793=\"Free Text\",1,0))","v":0},0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0,0]
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["RHP/Cat 3","Round 1 or 2","JS/AQ touch","RHP","TPI","Provider Name","Category 3 project ID","Tied to Category 1,2 project ID","Cat 1,2 project ID from reviewer file","Match","IT-reference number","IT ref from reviewer file","Match","Measure Title","Measure title","Match","Number of components","format","Performance Type (P4P/P4R)","QISMC/IOS","Alt Activity Type (SA or PFP)","which ","Baseline reporting status","baseline DY4 measurement period","Maintainance goals for DY4/DY5"," DY2 total  "," DY3 total  "," DY4 total  "," DY5 total  ","Cat 3 Affiliation ID (1)","Cat 3 Affiliation ID (2)","Cat 3 Affiliation ID (3)","Cat 3 Affiliation ID (4)","Cat 3 Affiliation ID (5)","Target Setting Methodology","HHSC Interpretation (Project Summary)","DY2 Milestone ID (1)","DY2 Milestone Description (1) "," DY2 Milestone Value $ (1) ","DY2 Milestone ID (2)","DY2 Milestone Description (2) "," DY2 Milestone Value (2) ","DY2 Milestone ID (3)","DY2 Milestone Description (3) "," DY2 Milestone Value (3) ","DY2 Milestone ID (4)","DY2 Milestone Description (4) ","DY2 Milestone Value (4)","DY2 Milestone ID (5)","DY2 Milestone Description (5) ","DY2 Milestone Value $ (5)","DY2 Milestone ID (6)","DY2 Milestone Description (6) ","DY2 Milestone Value $ (6)","DY2 Milestone ID (7)","DY2 Milestone Description (7) ","DY2 Milestone Value $ (7)","DY3 Milestone ID (1)","DY3 Milestone Description (1)"," Milestone 1 Value ","Goal Type (1)",null,"Reporting Status","DY3 Milestone ID (2)","DY3 Milestone Description (2)"," Milestone 2 Value ","Goal Type (2)",null,"Reporting Status","DY4 Milestone ID (1)","DY4 Milestone Description (1)","DY4 Milestone Value (1)","Goal Type (1)","Numeric Goal (1)","DY4 Milestone ID (2)","DY4 Milestone Description (2)","DY4 Milestone Value (2)","Goal Type (2)","Numeric Goal (2)","DY4 Milestone ID (3)","DY4 Milestone Description (3)","DY4 Milestone Value (3)","Goal Type (3)","Numeric Goal (3)","DY4 Milestone ID (4)","DY4 Milestone Description (4)","DY4 Milestone Value (4)","Goal Type (4)","Numeric Goal (4)","DY4 Milestone ID (5)","DY4 Milestone Description (5)","DY4 Milestone Value (5)","Goal Type (5)","Numeric Goal (5)","DY4 Milestone ID (6)","DY4 Milestone Description (6)","DY4 Milestone Value (6)","Goal Type (6)","Numeric Goal (6)","DY4 Milestone ID (7)","DY4 Milestone Description (7)","DY4 Milestone Value (7)","Goal Type (7)","Numeric Goal (7)","DY5 Milestone ID (1)","DY5 Milestone Description (1)","DY5 Milestone Value (1)",null,"Goal Type (1)",null,"Numeric Goal (1)","DY5 Milestone ID (2)","DY5 Milestone Description (2)","DY5 Milestone Value (2)","Goal Type (2)","Numeric Goal (2)",null,null,null,null,null,null,null,null,null,null,null,"DY5 Milestone Description (3)","DY5 Milestone Value (3)","Goal Type (3)","Numeric Goal (3)","DY5 Milestone ID (4)","DY5 Milestone Description (4)","DY5 Milestone Value (4)","Goal Type (4)","Numeric Goal (4)","DY5 Milestone ID (5)","DY5 Milestone Description (5)","DY5 Milestone Value (5)","Goal Type (5)","Numeric Goal (5)","DY5 Milestone ID (6)","DY5 Milestone Description (6)","DY5 Milestone Value (6)","Goal Type (6)","Numeric Goal (6)","DY5 Milestone ID (7)",null,"DY5 Milestone Value (7)","Goal Type (7)","Numeric Goal (7)","Final IT code","Subsets approved (Y/N)","subset 1","subset 2","subset 3","subset 4","subset 5","subset 6","Alternate Improvement Activity ID",null,null,"Alternate Improvement Activity Description",null,"DY5 Milestone Description (7)","DY5 Milestone ID (3)"]
["RHP","TPI ","Provider name","Cat 1 or 2 project ID","Cat 3 project ID","IT Reference #","Measure Title- Brief","Baseline performance approved","Eligible to report in April DY4","Brief Description of Project","Measure Title-Full","Outcome Interpretation","Approved Subsets","Provider description of Subsets","Metric Achievement Type","Stretch activity or PFP measure","DY3 Milestone ID (1)","DY3 Milestone Description (1)"," Milestone 1 Value ","Goal Type (1)","RHP/CAT3/Mlstone","Milestone 1 Status","DY3 Milestone ID (2)","DY3 Milestone Description (2)"," Milestone 2 Value ","Goal Type (2)","RHP/CAT3/Mlstone","Milestone 2 Status"," DY4 Milestone ID (1) "," DY4 Milestone Description (1) "," DY4 Milestone Value (1) "," Goal Type (1) "," Numeric Goal (1) "," DY4 Milestone ID (2) "," DY4 Milestone Description (2) "," DY4 Milestone Value (2) "," Goal Type (2) "," Numeric Goal (2) "," DY4 Milestone ID (3) "," DY4 Milestone Description (3) "," DY4 Milestone Value (3) "," Goal Type (3) "," Numeric Goal (3) "," DY4 Milestone ID (4) "," DY4 Milestone Description (4) "," DY4 Milestone Value (4) "," Goal Type (4) "," Numeric Goal (4) "," DY4 Milestone ID (5) "," DY4 Milestone Description (5) "," DY4 Milestone Value (5) "," Goal Type (5) "," Numeric Goal (5) "," DY4 Milestone ID (6) "," DY4 Milestone Description (6) "," DY4 Milestone Value (6) "," Goal Type (6) "," Numeric Goal (6) "," DY5 Milestone ID (1) "," DY5 Milestone Description (1) "," DY5 Milestone Value (1) "," Goal Type (1) "," Numeric Goal (1) "," DY5 Milestone ID (2) "," DY5 Milestone Description (2) "," DY5 Milestone Value (2) "," Goal Type (2) "," Numeric Goal (2) "," DY5 Milestone ID (3) "," DY5 Milestone Description (3) "," DY5 Milestone Value (3) "," Goal Type (3) "," Numeric Goal (3) "," DY5 Milestone ID (4) "," DY5 Milestone Description (4) "," DY5 Milestone Value (4) "," Goal Type (4) "," Numeric Goal (4) "," DY5 Milestone ID (5) "," DY5 Milestone Description (5) "," DY5 Milestone Value (5) "," Goal Type (5) "," Numeric Goal (5) ","Number of outcome components","Format type","Metric #1 Resulting baseline rate","Metric #1 Numerator cases","Metric #1 Denom cases ","Metric #1 Baseline measurement period","Metric #2 Resulting baseline rate","Metric #2 Numerator cases","Metric #2 Denom cases with subset","Metric #2 Baseline measurement period","Metric #3 Resulting baseline rate","Metric #3 Numerator cases","Metric #3 Denom cases with subset","Metric #3 Baseline measurement period","Metric #4 Resulting baseline rate","Metric #4 Numerator cases","Metric #4 Denom cases with subset","Metric #4 Baseline measurement period","Metric #5 Resulting baseline rate","Metric #5 Numerator cases","Metric #5 Denom cases with subset","Metric #5 Baseline measurement period","Approved for baseline exemption (proxy, short, DY4)","Metric 1  DY4 Achievement Level","Metric 1 DY4 measurement period","Metric 1  DY5 Achievement Level","Metric 1 DY5 measurement period","Metric 2  DY4 Achievement Level","Metric 2 DY4 measurement period","Metric 2  DY5 Achievement Level","Metric 2 DY5 measurement period","Metric 3  DY4 Achievement Level","Metric 3 DY4 measurement period","Metric 3  DY5 Achievement Level","Metric 3 DY5 measurement period","Metric 4  DY4 Achievement Level","Metric 4 DY4 measurement period","Metric 4  DY5 Achievement Level","Metric 4 DY5 measurement period","Metric 5  DY4 Achievement Level","Metric 5 DY4 measurement period","Metric 5  DY5 Achievement Level","Metric 5 DY5 measurement period",null,"proxy population ","num and denom determination","interpretation of baseline rate","Title of measure","Setting, as identified by measure specs (in patient, outpatient, both)","Description","Part 1 Numerator","Part 1 Denominator","Part 2 Numerator","Part 2 Denominator","Part 3 Numerator","Part 3 Denominator","Part 4 Numerator","Part 4 Denominator","Part 5 Numerator","Part 5 Denominator","Part 6 Numerator","Part 6 Denominator","Stretch activity baseline text","PFP baseline rate",null,"Project Area","Reporting Scenario","Metric 1 Functional Title","Metric 2 Functional Title","Metric 3 Functional Title","Metric 4 Functional Title","Metric 5 Functional Title","Risk Adjustment Type:","DY4 beginning of Measurement period","DY4 end of measurement period","DY5 beginning of Measurement period","DY5 end of measurement period","DY3 beginning of Measurement period","DY3 end of measurement period",null,null,"RHP/Cat 1,2 ID","RHP/Cat 3 ID",{"$f":"A3&\"_\"&D3&\"_\"&E3","v":"RHP_Cat 1 or 2 project ID_Cat 3 project ID"},"Outcome Count per Project",{"$f":"FI3&\"_\"&FL3","v":"RHP/Cat 1,2 ID_Outcome Count per Project"},null,"#Milestone","#Metrics","Check",{"$f":"A3&\"_\"&RIGHT(\"000000000\"&B3,9)","v":"RHP_00000TPI "},"Outcome Count per TPI",{"$f":"FR3&\"_\"&FS3","v":"RHP_00000TPI _Outcome Count per TPI"}]
["RHP 1","017624002","East Texas Medical Center Quitman","017624002.1.1","017624002.3.200","IT-2.21","Ambulatory Care Sensitive Conditions Admissions Rate","Baseline Approved","Eligible to Report in October DY4","This project increases access to healthcare through recruiting two primary care providers and adding needed support staff. \n","Ambulatory Care Sensitive Conditions Admissions Rate","In DY4 and DY5 provider will reduce the percentage of admissions for conditions defined as ambulatory care sensitive  for individuals 18 to  75 years of age out of the total number of  admissions to ETMC Quitman.","Facility","ETMC-Quitman","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",34351.095000000001,"Yes/No","RHP 1_017624002.3.200_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",34351.095000000001,"Yes/No","RHP 1_017624002.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",55121.52,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",55121.52,"Numeric",36181.640625,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",263624.67,"Numeric",34277.34375,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",38085.9375,390,1024,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,36181.640625,null,34277.34375,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Potentially Preventable Hospitalization Conditions for the hospital for the specific time period (10/1/13-9/30/14)","Total Discharges for the hospital for the specific time period (10/1/13-9/30/14)","Ambulatory Care Sensitive Conditions Admissions Rate","inpatient",null,"Total number of acute care hospitalizations for ambulatory care sensitive conditions younger than age 75 years ","Total mid-measurement period population younger than age 75",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","Ambulatory Care Sensitive Conditions Admissions Rate",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,{"$f":"A4&\"_\"&D4","v":"RHP 1_017624002.1.1"},{"$f":"A4&\"_\"&E4","v":"RHP 1_017624002.3.200"},"RHP 1_017624002.1.1_017624002.3.200",{"$f":"COUNTIFS($FI$4:$FI4,FI4)","v":1},"RHP 1_017624002.1.1_1",null,{"$f":"MAX(IF(AC4=\"\",0,1)+IF(AH4=\"\",0,1)+IF(AM4=\"\",0,1)+IF(AR4=\"\",0,1)+IF(AW4=\"\",0,1)+IF(BB4=\"\",0,1),IF(BG4=\"\",0,1)+IF(BL4=\"\",0,1)+IF(BQ4=\"\",0,1)+IF(BV4=\"\",0,1)+IF(CA4=\"\",0,1))","v":2},{"$f":"IF(DC4=\"\",0,1)+IF(DG4=\"\",0,1)+IF(DK4=\"\",0,1)+IF(DO4=\"\",0,1)+IF(DS4=\"\",0,1)","v":1},{"$f":"FO4-FP4","v":1},"RHP 1_017624002",{"$f":"COUNTIFS($FR$4:$FR4,FR4)","v":1},{"$f":"FR4&\"_\"&FS4","v":"RHP 1_017624002_1"}]
["RHP 1","020812601","East Texas Medical Center","020812601.1.1","020812601.3.1","IT-1.10","Diabetes care: HbA1c poor control (>9.0%) ","Pending Approval","Eligible to Report in October DY4","This project increases access to specialty healthcare through recruiting a full-time endocrinologist to establish a specialty clinic location and improve access to diabetes management.","Diabetes care: HbA1c poor control (>9.0%) ","In DY4 and DY5 provider will reduce the proportion of individuals whose most recent A1c was >9 or not tested during the measurement year out of all individuals served by the provider aged 18-75 with diabetes. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",63510.175000000003,"Yes/No","RHP 1_020812601.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",63510.175000000003,"Yes/No","RHP 1_020812601.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",101911.69,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",101911.69,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",487403.75,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ETMC understands that this project measures Risk adjusted rate of hospital admissions (stays) for Congestive Heart Failure (CHF) with a subsequent readmission for any reason within 30 days of discharge for patients 18-75 years of age. ","It is ETMC's understanding that 11.08% of patients within our target population of patients with Type 1 and Type 2 Diabetes within the age range of 18-75 have >9%HbA1c poor control results.","Diabetes care: HbA1c poor control (>9.0%) ","ambulatory",null,"Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2 ","","Diabetes care: HbA1c poor control (>9.0%) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_020812601.1.1","RHP 1_020812601.3.1","RHP 1_020812601.1.1_020812601.3.1",{"$f":"COUNTIFS($FI$4:$FI5,FI5)","v":1},"RHP 1_020812601.1.1_1",null,{"$f":"MAX(IF(AC5=\"\",0,1)+IF(AH5=\"\",0,1)+IF(AM5=\"\",0,1)+IF(AR5=\"\",0,1)+IF(AW5=\"\",0,1)+IF(BB5=\"\",0,1),IF(BG5=\"\",0,1)+IF(BL5=\"\",0,1)+IF(BQ5=\"\",0,1)+IF(BV5=\"\",0,1)+IF(CA5=\"\",0,1))","v":2},1,{"$f":"FO5-FP5","v":1},"RHP 1_020812601",{"$f":"COUNTIFS($FR$4:$FR5,FR5)","v":1},"RHP 1_020812601_1"]
["RHP 1","020812601","East Texas Medical Center","020812601.1.2","020812601.3.200","IT-3.3","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","Pending Approval","Eligible to Report in October DY4","This project increases access to specialty healthcare through establishing cardiology clinics in 5 new, underserved areas.","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","In DY4 and DY5 provider will improve the ratio of actual readmissions to expected readmissions for individuals discharged for a CHF related inpatient stay. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",103690.08,"Yes/No","RHP 1_020812601.3.200_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",103690.08,"Yes/No","RHP 1_020812601.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",166386.43,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",166386.43,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",795761.23,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"\"ETMC understands that this project measures Risk adjusted rate of hospital admissions (stays) for Congestive Heart Failure (CHF) with a subsequent readmission for any reason within 30 days of discharge for patients 18 years of age and older. \n\nA readmission is a subsequent hospital admission in the same hospital within 30 days following an original admission. The discharge date for the index admission must occur within the time period defined as one month prior to the beginning of the measurement period and ending one month prior to the end of the measurement year to allow for the 30-day follow-up period for readmissions within the measurement year\n\"ETMC understands that this project measures Risk adjusted rate of hospital admissions (stays) for Congestive Heart Failure (CHF) with a subsequent readmission for any reason within 30 days of discharge for patients 18 years of age and older. \n\nA readmission is a subsequent hospital admission in the same hospital within 30 days following an original admission. The discharge date for the index admission must occur within the time period defined as one month prior to the beginning of the measurement period and ending one month prior to the end of the measurement year to allow for the 30-day follow-up period for readmissions within the measurement year","using this methodology, ETMC believes that 5.05% of eligible CHF patients are re-admitted within 30 days.","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission for CHF during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk CHF admissions during the measurement period.\n","Expected (risk-adjusted) rate of readmissions for CHF during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc. \n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2 ","","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate",null,null,null,null,"\"ETMC understands that this project measures Risk adjusted rate of hospital admissions (stays) for Congestive Heart Failure (CHF) with a subsequent readmission for any reason within 30 days of discharge for patients 18 years of age and older. \n\nA readmission is a subsequent hospital admission in the same hospital within 30 days following an original admission. The discharge date for the index admission must occur within the time period defined as one month prior to the beginning of the measurement period and ending one month prior to the end of the measurement year to allow for the 30-day follow-up period for readmissions within the measurement year\n\"ETMC understands that this project measures Risk adjusted rate of hospital admissions (stays) for Congestive Heart Failure (CHF) with a subsequent readmission for any reason within 30 days of discharge for patients 18 years of age and older. \n\nA readmission is a subsequent hospital admission in the same hospital within 30 days following an original admission. The discharge date for the index admission must occur within the time period defined as one month prior to the beginning of the measurement period and ending one month prior to the end of the measurement year to allow for the 30-day follow-up period for readmissions within the measurement year","2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 1_020812601.1.2","RHP 1_020812601.3.200","RHP 1_020812601.1.2_020812601.3.200",{"$f":"COUNTIFS($FI$4:$FI6,FI6)","v":1},"RHP 1_020812601.1.2_1",null,2,1,1,"RHP 1_020812601",{"$f":"COUNTIFS($FR$4:$FR6,FR6)","v":2},"RHP 1_020812601_2"]
["RHP 1","020812601","East Texas Medical Center","020812601.2.3","020812601.3.203","IT-6.1.a.ix","HCAHPS Overall Hospital Rating","Baseline Approved","Eligible to Report in October DY4","This project is to develop and implement a patient experience improvement plan in order to improve how the patient experiences care and the patient’s satisfaction with the care provided.","HCAHPS Overall Hospital Rating","In DY4 and DY5 provider will improve patient satisfaction as demonstrated through the increasing percentage of 'top box' scores on HCAHPS - Overall Rating.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",106714.375,"Yes/No","RHP 1_020812601.3.203_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",106714.375,"Yes/No","RHP 1_020812601.3.203_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",171239.37,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",171239.37,"Numeric",0.71057827100000004,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",818970.93,"Numeric",0.72051401800000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.70064300000000002,2399,3424,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.71057827100000004,null,0.72051401800000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Survey data provided by 3rd party.","70% of people surveyed rated hospital as 9 or 10 out of 10 on survery","HCAHPS Overall Hospital Rating","Inpatient",null,"Patient-mix and survey mode adjusted percent \"top box\" score for a given subdomain as provided by your survey administrator, multiplied by the number of completed surveys represented in the \"top box\" score.","The number of HCAHPS surveys completed during the measurement period as reported by your survey administrator. The denominator should be the same as the multiplier used in the numerator. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.4.1 ","","HCAHPS Overall Hospital Rating",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_020812601.2.3","RHP 1_020812601.3.203","RHP 1_020812601.2.3_020812601.3.203",{"$f":"COUNTIFS($FI$4:$FI7,FI7)","v":1},"RHP 1_020812601.2.3_1",null,2,1,1,"RHP 1_020812601",{"$f":"COUNTIFS($FR$4:$FR7,FR7)","v":3},"RHP 1_020812601_3"]
["RHP 1","084434201","Texoma Community Center","084434201.1.1","084434201.3.1","IT-10.1.a.iv","Assessment of Quality of Life (AQoL-8D) ","Baseline Approved","Eligible to Report in October DY4","This project enhances access through telemedicine services and electronic health records (EHR) for TCC patients residing in RHP 1 by expanding psychiatric appointments, psychosocial rehabilitation, skills training, case management, mental health assessments, counseling and crisis intervention for adults and children.","Assessment of Quality of Life (AQoL-8D) ","In DY4 and DY5 provider will improve reported scores on the AQoL instruments completed during the measurement period for individuals receiving new telemedicine services.","Facility ","Individuals using any of the telemedicine facilities","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",2160.6,"Yes/No","RHP 1_084434201.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",2160.6,"Yes/No","RHP 1_084434201.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",2314.65,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",2314.65,"Numeric",58.828140189999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",10069.200000000001,"Numeric",59.19216823,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",58.464109999999998,6255.66,107,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,58.828140189999999,null,59.19216823,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"As approved by HHSC, Texoma Community Center serves individuals from three adjacent counties, each of which falls into a different RHP. As a result, TCC has three projects providing the same type of services in each county. For the purpose of establishing a baseline, we strongly believe that it makes more sense from a statistical perspective, as well as for practicality, to use the data from all of the individuals served. Our baseline subset is defined as those individuals receiving services at the Substance Abuse center, which is in one location but serves and supports individuals from all three regions. The following rationale was applied:\n• It’s the same staff providing the same services at the same location for all individuals regardless of their county of residence. Establishing different baselines arbitrarily based on the individual’s county of residence, solely for the purpose of reporting, does not seem to provide any meaningful distinction.\n• Including all of the individuals served by these projects provides the largest number of surveys from which to establish a statistically meaningful baseline, and would allow us to use the more appropriate and accurate scenario 1 for reporting, as opposed to having to use scenario 2.\nWe believe that scenario 1 is the better measure and would much prefer to use it, but we do not have sufficient follow-up surveys. We have a sufficient number of initial surveys for scenario 2, but far fewer follow-up surveys. By combining the surveys from all the counties, this provides more than enough to use scenario 1.\n• Having a consistent goal across all three projects will help us keep the different projects “in-line” with each other, prevent confusion, and allow us to better concentrate on improving the services rather than having to focus on multiple measurements.\nGoing forward for DY4 and DY5, the population will be narrowed to those individuals residing in the specific region only. ","The denominator value was selected by taking all of the AQoL surveys in the system and filtering out only those that had an initial survey (survey type \"I\"), had a follow-up survey administered during the baseline period (survey type \"F\" dated between 4/1/214 and 9/30/2014), and received an intervention through one of the projects using the telemedicine services (project ID \"201\", \"202\", \"203\", \"205\", \"206\", or \"207\").  The numerator was determined by adding up the scores for the last follow-up survey for each person from the group selected by the denominator.","The baseline rate is the average of the AQoL scores for the last follow-up survey to fall within the second half of DY3 (April 1st, 2014 thru September 30th, 2014)  for individuals who received an intervention through one of the waiver projects using the telemedicine services.","Assessment of Quality of Life (AQoL-8D) ","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.11.2","Scenario 1: Pre/Posttest Baseline","Assessment of Quality of Life (AQoL-8D) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 1_084434201.1.1","RHP 1_084434201.3.1","RHP 1_084434201.1.1_084434201.3.1",{"$f":"COUNTIFS($FI$4:$FI8,FI8)","v":1},"RHP 1_084434201.1.1_1",null,2,1,1,"RHP 1_084434201",{"$f":"COUNTIFS($FR$4:$FR8,FR8)","v":1},"RHP 1_084434201_1"]
["RHP 1","084434201","Texoma Community Center","084434201.1.2","084434201.3.2","IT-10.1.a.iv","Assessment of Quality of Life (AQoL-8D) ","Baseline Approved","Eligible to Report in October DY4","This project will enhance behavioral health service availability in Fannin County by establishing a stand-alone out-patient (SA) treatment center and a SAMHSA-based LCDC internship program that will increase the provider pool.","Assessment of Quality of Life (AQoL-8D) ","In DY4 and DY5 provider will improve reported scores on the AQoL instruments completed during the measurement period for individuals receiving new substance abuse services. ","Facility ","Individuals receiving treatment at the identified substance abuse facility","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",3601,"Yes/No","RHP 1_084434201.3.2_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",3601,"Yes/No","RHP 1_084434201.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",3857.75,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",3857.75,"Numeric",63.585000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",16782,"Numeric",63.943680000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",63.226300000000002,1201.3,19,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,63.585000000000001,null,63.943680000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"As approved by HHSC, Texoma Community Center serves individuals from three adjacent counties, each of which falls into a different RHP. As a result, TCC has three projects providing the same type of services in each county. For the purpose of establishing a baseline, we strongly believe that it makes more sense from a statistical perspective, as well as for practicality, to use the data from all of the individuals served. Our baseline subset is defined as those individuals receiving services at the Substance Abuse center, which is in one location but serves and supports individuals from all three regions. The following rationale was applied:\n• It’s the same staff providing the same services at the same location for all individuals regardless of their county of residence. Establishing different baselines arbitrarily based on the individual’s county of residence, solely for the purpose of reporting, does not seem to provide any meaningful distinction.\n• Including all of the individuals served by these projects provides the largest number of surveys from which to establish a statistically meaningful baseline, and would allow us to use the more appropriate and accurate scenario 1 for reporting, as opposed to having to use scenario 2.\nWe believe that scenario 1 is the better measure and would much prefer to use it, but we do not have sufficient follow-up surveys. We have a sufficient number of initial surveys for scenario 2, but far fewer follow-up surveys. By combining the surveys from all the counties, this provides more than enough to use scenario 1.\n• Having a consistent goal across all three projects will help us keep the different projects “in-line” with each other, prevent confusion, and allow us to better concentrate on improving the services rather than having to focus on multiple measurements.\nGoing forward for DY4 and DY5, the population will be narrowed to those individuals residing in the specific region only. ","The denominator value was selected by taking all of the AQoL surveys and filtering out only those that had an initial survey (survey type \"I\"), had a follow-up survey administered during the baseline period (survey type \"F\" and date between 4/1/214 and 9/30/2014), and received an intervention through the project (project ID \"202\").  The numerator was determined by adding up the scores for the last follow-up survey for each person from the group selected by the denominator.","The baseline rate is the average of the AQoL scores for the last follow-up survey to fall within the second half of DY3 (April 1st, 2014 thru September 30th, 2014)  for individuals who received an intervention through the waiver Substance Abuse project.","Assessment of Quality of Life (AQoL-8D) ","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.12.2","Scenario 1: Pre/Posttest Baseline","Assessment of Quality of Life (AQoL-8D) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 1_084434201.1.2","RHP 1_084434201.3.2","RHP 1_084434201.1.2_084434201.3.2",{"$f":"COUNTIFS($FI$4:$FI9,FI9)","v":1},"RHP 1_084434201.1.2_1",null,2,1,1,"RHP 1_084434201",{"$f":"COUNTIFS($FR$4:$FR9,FR9)","v":2},"RHP 1_084434201_2"]
["RHP 1","084434201","Texoma Community Center","084434201.1.3","084434201.3.3","IT-10.1.a.iv","Assessment of Quality of Life (AQoL-8D) ","Baseline Approved","Eligible to Report in October DY4","This project will enhance behavioral health service availability, specifically evidence-based counseling treatment. TCC intends to provide prompt, evidenced-based, clinically appropriate counseling to a broader patient base of individuals needing treatment for Post-Traumatic Stress Disorder, depression, personality disorders and other emotional disturbances.","Assessment of Quality of Life (AQoL-8D) ","In DY4 and DY5 provider will improve reported scores on the AQoL instruments completed during the measurement period for  individuals receiving new counseling services. ","Facility ","Individuals receiving treatment at the identified counselling center","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",2160.6,"Yes/No","RHP 1_084434201.3.3_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",2160.6,"Yes/No","RHP 1_084434201.3.3_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",2314.65,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",2314.65,"Numeric",58.671300000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",10069.200000000001,"Numeric",59.059800000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",58.282800000000002,2914.14,50,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,58.671300000000002,null,59.059800000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"As approved by HHSC, Texoma Community Center serves individuals from three adjacent counties, each of which falls into a different RHP. As a result, TCC has three projects providing the same type of services in each county. For the purpose of establishing a baseline, we strongly believe that it makes more sense from a statistical perspective, as well as for practicality, to use the data from all of the individuals served. Our baseline subset is defined as those individuals receiving services at the Expanded Counselling center, which is in one location but serves and supports individuals from all three regions. The following rationale was applied:\n• It’s the same staff providing the same services at the same location for all individuals regardless of their county of residence. Establishing different baselines arbitrarily based on the individual’s county of residence, solely for the purpose of reporting, does not seem to provide any meaningful distinction.\n• Including all of the individuals served by these projects provides the largest number of surveys from which to establish a statistically meaningful baseline, and would allow us to use the more appropriate and accurate scenario 1 for reporting, as opposed to having to use scenario 2.\nWe believe that scenario 1 is the better measure and would much prefer to use it, but we do not have sufficient follow-up surveys. We have a sufficient number of initial surveys for scenario 2, but far fewer follow-up surveys. By combining the surveys from all the counties, this provides more than enough to use scenario 1.\n• Having a consistent goal across all three projects will help us keep the different projects “in-line” with each other, prevent confusion, and allow us to better concentrate on improving the services rather than having to focus on multiple measurements.\nGoing forward for DY4 and DY5, the population will be narrowed to those individuals residing in the specific region only. ","The denominator value was selected by taking all of the AQoL surveys and filtering out only those that had an initial survey (survey type \"I\"), had a follow-up survey administered during the baseline period (survey type \"F\" and date between 4/1/214 and 9/30/2014), and received an intervention through the project (project ID \"203\").  The numerator was determined by adding up the scores for the last follow-up survey for each person from the group selected by the denominator.","The baseline rate is the average of the AQoL scores for the last follow-up survey to fall within the second half of DY3 (April 1st, 2014 thru September 30th, 2014)  for individuals who received an intervention through the waiver Expanded Counselling project.","Assessment of Quality of Life (AQoL-8D) ","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.12.2","Scenario 1: Pre/Posttest Baseline","Assessment of Quality of Life (AQoL-8D) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 1_084434201.1.3","RHP 1_084434201.3.3","RHP 1_084434201.1.3_084434201.3.3",{"$f":"COUNTIFS($FI$4:$FI10,FI10)","v":1},"RHP 1_084434201.1.3_1",null,2,1,1,"RHP 1_084434201",{"$f":"COUNTIFS($FR$4:$FR10,FR10)","v":3},"RHP 1_084434201_3"]
["RHP 1","084434201","Texoma Community Center","084434201.1.4","084434201.3.4","IT-1.18","Follow-Up After Hospitalization for Mental Illness ","Baseline Approved","Eligible to Report in October DY4","This project expands quality improvement capacity through people, processes and technology in order to conduct, report, drive and measure quality improvement. The interventions will utilize rapid cycle improvement methodology, increase data reports to expand the patient population and services, improve efficiencies and solve key challenges.","Follow-Up After Hospitalization for Mental Illness ","In DY4 and DY5 provider will improve the percent of Medicaid/uninsured individuals who receive a follow-up appointment within 30 days of discharge out of all patients who have been discharged from an inpatient setting within the first 11 months of the measurement year. ","Payer ","Individuals who are indigent/uninsured or have Medicaid.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",2160.6,"Yes/No","RHP 1_084434201.3.4_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",2160.6,"Yes/No","RHP 1_084434201.3.4_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",2314.65,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- 7 day follow-up",1157.325,"Numeric",0.46440870899999998,"AM-1.2","Achievement of DY4 performance goal- 30 day follow-up",1157.325,"Numeric",0.57289999999999996,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- 7 day follow-up",5034.6000000000004,"Numeric",0.49010774200000001,"AM-2.2","Achievement of DY5 performance goal- 30 day follow-up",5034.6000000000004,"Numeric",0.59989000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"%",0.43870999999999999,68,155,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",0.458065,71,155,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0.46440870899999998,null,0.49010774200000001,null,0.57289999999999996,null,0.59989000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"State Hospital Report HC029135 – “Admissions to State Mental Health Facility my MHA” which records hospital admission dates and discharge dates by county (via county codes assigned to this MHA for each county served) for Texoma Community Center (MHA).\n Secondly, data on this report was cross-referenced with the State Facility Action Form initiated by the LMHA which records the date, type of admit and discharge, and the encounter date for both admit screening and discharge follow-up.\n Both of these were  cross-referenced with encounter data from TCC’s data base.\n For local hospitalizations, data was gathered from encounter data using specific codes for hospital discharge encounters as well as the referring hospitals referred Discharge Papers which are faxed to TCC when an individual is referred from a local hospital.  These discharge papers are placed in the patient’s chart when an encounter occurs, or are kept is a separate secured file when no follow up occurs.\n The encounter data run from the data base was cross-referenced with the faxed paperwork to discern individuals who had been referred but not seen for a follow up within 7 or 30 days.\n The records were tallied together to determine both the state and local hospital referrals upon discharge, and then divided into those seen within 7 days after discharge, those seen within 30 days after discharge and those not seen at all after hospital discharge.  These percentages were used to establish the baseline for this outcome measure.","The baseline rate is the number of individuals we saw either 7 or 30 days after discharge from either the state facilities or local hospitals that were referred to us, divided by the total number of referrals.","Follow-Up After Hospitalization for Mental Illness ","ambulatory",null,"Rate #1: 7-Day Follow-Up: An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 7 days after discharge. ","Patients 6 years and older as of the date of discharge who were discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal diagnosis of mental illness during the first 11 months of the measurement year. ","Rate #2: 30-Day Follow-Up: An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 30 days after discharge. ","Patients 6 years and older as of the date of discharge who were discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal diagnosis of mental illness during the first 11 months of the measurement year. ",null,null,null,null,null,null,null,null,null,null,null,"1.10.3","","7 day follow-up","30 day follow-up",null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 1_084434201.1.4","RHP 1_084434201.3.4","RHP 1_084434201.1.4_084434201.3.4",{"$f":"COUNTIFS($FI$4:$FI11,FI11)","v":1},"RHP 1_084434201.1.4_1",null,3,2,1,"RHP 1_084434201",{"$f":"COUNTIFS($FR$4:$FR11,FR11)","v":4},"RHP 1_084434201_4"]
["RHP 1","084434201","Texoma Community Center","084434201.2.1","084434201.3.5","IT-10.1.a.iv","Assessment of Quality of Life (AQoL-8D) ","Baseline Approved","Eligible to Report in October DY4","This project will implement a new initiative for TCC by incorporating a primary health care provider into the TCC behavioral health system, creating a “medical home” for the most “at risk” patients with mental illness and co-occurring chronic physical diseases.","Assessment of Quality of Life (AQoL-8D) ","In DY4 and DY5 provider will improve reported scores on the AQoL instruments completed during the measurement period for  individuals receiving integrated health services. ","Facility ","Individuals receiving treatment using the identified integrated health care services","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",2160.6,"Yes/No","RHP 1_084434201.3.5_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",2160.6,"Yes/No","RHP 1_084434201.3.5_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",2314.65,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",2314.65,"Numeric",56.656184209999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",10069.200000000001,"Numeric",56.990789479999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",56.321579999999997,2140.2199999999998,38,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,56.656184209999999,null,56.990789479999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"As approved by HHSC, Texoma Community Center serves individuals from three adjacent counties, each of which falls into a different RHP. As a result, TCC has three projects providing the same type of services in each county. For the purpose of establishing a baseline, we strongly believe that it makes more sense from a statistical perspective, as well as for practicality, to use the data from all of the individuals served. Our baseline subset is defined as those individuals receiving services at the Integrated Care center, which is in one location but serves and supports individuals from all three regions. The following rationale was applied:\n• It’s the same staff providing the same services at the same location for all individuals regardless of their county of residence. Establishing different baselines arbitrarily based on the individual’s county of residence, solely for the purpose of reporting, does not seem to provide any meaningful distinction.\n• Including all of the individuals served by these projects provides the largest number of surveys from which to establish a statistically meaningful baseline, and would allow us to use the more appropriate and accurate scenario 1 for reporting, as opposed to having to use scenario 2.\nWe believe that scenario 1 is the better measure and would much prefer to use it, but we do not have sufficient follow-up surveys. We have a sufficient number of initial surveys for scenario 2, but far fewer follow-up surveys. By combining the surveys from all the counties, this provides more than enough to use scenario 1.\n• Having a consistent goal across all three projects will help us keep the different projects “in-line” with each other, prevent confusion, and allow us to better concentrate on improving the services rather than having to focus on multiple measurements.\nGoing forward for DY4 and DY5, the population will be narrowed to those individuals residing in the specific region only. ","The denominator value was selected by taking all of the AQoL surveys and filtering out only those that had an initial survey (survey type \"I\"), had a follow-up survey administered during the baseline period (survey type \"F\" and date between 4/1/214 and 9/30/2014), and received an intervention through the project (project ID \"205\").  The numerator was determined by adding up the scores for the last follow-up survey for each person from the group selected by the denominator.","The baseline rate is the average of the AQoL scores for the last follow-up survey to fall within the second half of DY3 (April 1st, 2014 thru September 30th, 2014)  for individuals who received an intervention through the waiver Integrated Care project.","Assessment of Quality of Life (AQoL-8D) ","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.19.1","Scenario 1: Pre/Posttest Baseline","Assessment of Quality of Life (AQoL-8D) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 1_084434201.2.1","RHP 1_084434201.3.5","RHP 1_084434201.2.1_084434201.3.5",{"$f":"COUNTIFS($FI$4:$FI12,FI12)","v":1},"RHP 1_084434201.2.1_1",null,2,1,1,"RHP 1_084434201",{"$f":"COUNTIFS($FR$4:$FR12,FR12)","v":5},"RHP 1_084434201_5"]
["RHP 1","084434201","Texoma Community Center","084434201.2.2","084434201.3.6","IT-1.18","Follow-Up After Hospitalization for Mental Illness ","Baseline Approved","Eligible to Report in October DY4","This project will: “Design, implement, and evaluate research-supported and evidence-based interventions tailored towards individuals in the target population.” It represents both new initiatives and expanded current services for Texoma Community Center. The goals are to develop and provide a comprehensive treatment modality that includes twelve different community-based intervention options to substantially stabilize the mentally ill, functionally impaired and homeless individuals in Fannin County in order to reduce unnecessary use of emergency departments, physical and psychiatric hospitals and the criminal justice system. TCC has an excellent track record in accomplishing similar goals already and is poised to expand these outcome successes with this extensive project.","Follow-Up After Hospitalization for Mental Illness ","In DY4 and DY5 provider will improve the percent of Medicaid/uninsured individuals who receive a follow-up appointment within 30 days of discharge out of all patients who have been discharged from an inpatient setting within the first 11 months of the measurement year.","Payer ","Individuals who are indigent/uninsured or have Medicaid.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",2160.6,"Yes/No","RHP 1_084434201.3.6_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",2160.6,"Yes/No","RHP 1_084434201.3.6_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",2314.65,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- 7 day follow-up",1157.325,"Numeric",0.46440870899999998,"AM-1.2","Achievement of DY4 performance goal- 30 day follow-up",1157.325,"Numeric",0.57289999999999996,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- 7 day follow-up",5034.6000000000004,"Numeric",0.49010774200000001,"AM-2.2","Achievement of DY5 performance goal- 30 day follow-up",5034.6000000000004,"Numeric",0.59989000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"%",0.43870999999999999,68,155,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",0.458065,71,155,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0.46440870899999998,null,0.49010774200000001,null,0.57289999999999996,null,0.59989000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"State Hospital Report HC029135 – “Admissions to State Mental Health Facility my MHA” which records hospital admission dates and discharge dates by county (via county codes assigned to this MHA for each county served) for Texoma Community Center (MHA).\n Secondly, data on this report was cross-referenced with the State Facility Action Form initiated by the LMHA which records the date, type of admit and discharge, and the encounter date for both admit screening and discharge follow-up.\n Both of these were  cross-referenced with encounter data from TCC’s data base.\n For local hospitalizations, data was gathered from encounter data using specific codes for hospital discharge encounters as well as the referring hospitals referred Discharge Papers which are faxed to TCC when an individual is referred from a local hospital.  These discharge papers are placed in the patient’s chart when an encounter occurs, or are kept is a separate secured file when no follow up occurs.\n The encounter data run from the data base was cross-referenced with the faxed paperwork to discern individuals who had been referred but not seen for a follow up within 7 or 30 days.\n The records were tallied together to determine both the state and local hospital referrals upon discharge, and then divided into those seen within 7 days after discharge, those seen within 30 days after discharge and those not seen at all after hospital discharge.  These percentages were used to establish the baseline for this outcome measure.","The baseline rate is the number of individuals we saw either 7 or 30 days after discharge from either the state facilities or local hospitals that were referred to us, divided by the total number of referrals.","Follow-Up After Hospitalization for Mental Illness ","ambulatory",null,"Rate #1: 7-Day Follow-Up: An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 7 days after discharge. ","Patients 6 years and older as of the date of discharge who were discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal diagnosis of mental illness during the first 11 months of the measurement year. ","Rate #2: 30-Day Follow-Up: An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 30 days after discharge. ","Patients 6 years and older as of the date of discharge who were discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal diagnosis of mental illness during the first 11 months of the measurement year. ",null,null,null,null,null,null,null,null,null,null,null,"2.13.1","","7 day follow-up","30 day follow-up",null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 1_084434201.2.2","RHP 1_084434201.3.6","RHP 1_084434201.2.2_084434201.3.6",{"$f":"COUNTIFS($FI$4:$FI13,FI13)","v":1},"RHP 1_084434201.2.2_1",null,3,2,1,"RHP 1_084434201",{"$f":"COUNTIFS($FR$4:$FR13,FR13)","v":6},"RHP 1_084434201_6"]
["RHP 1","094095902","Good Shepherd Medical Center","094095902.2.1","094095902.3.1","IT-9.4.e","Reduce Emergency Department visits for Behavioral Health/Substance Abuse","Baseline Approved","Eligible to Report in October DY4"," GSMC will identify frequent ED users and use navigators as part of a preventable ED reduction program collaborating with Community Healthcore  and through the network will liaison with other community resources to address non-medical needs.\n\nThe Patient Care Navigation Program will recruit, train, and monitor skilled Patient Care Navigators (PCN) serving persons with severe mental illness and chronic medical conditions to assist in preventable ED admissions.  Training will include relationship building, problem solver, resource locator, and system navigation.  Certified PCNs will make contact with clients and review both behavioral and physical health needs.  PCNs will work with each individual in helping coordinate upcoming appointments and to identify emerging needs.  The PCN will assist the client in accessing physical health services and help them understand treatment options if needed and increase access to care management and/or chronic care management, including education in chronic disease self‐management.\n","Reduce Emergency Department visits for Behavioral Health/Substance Abuse","In DY4 and DY5 provider will reduce the number ED Visits from qualifying adults at Good Shepherd Medical Center Longview ED with a primary or secondary diagnosis of behavioral health and/or substance abuse out of all ED visits from qualifying adults during the measurement period. \n","Facility ","The Facility will be Good Shepherd Medical Center Longview Emergency Department. Provider will be using the Total number of GSMC ED visits for individuals 18 years or older during the measurement period","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",55781.5,"Yes/No","RHP 1_094095902.3.1_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",55781.5,"Yes/No","RHP 1_094095902.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",74375,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",74375,"Numeric",9.2802853000000005E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",282625,"Numeric",8.7918493E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",9.7686999999999996E-2,6285,64338,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,9.2802853000000005E-2,null,8.7918493E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"GSMC abstracted data from our EMR systems (Meditech 6.07 pp4 and Medhost EDIS 4.4) per Compendium document IT-9.4.e specifications to generate a manual data report with the required inclusion and exclusion criteria. ","During DY3 (October 1, 2013 to September 30, 2014), 9.77% of ED visits at Good Shepherd Medical Center – Longview patients aged 18 and older had a primary or secondary diagnosis of behavioral health and/or substance abuse.","Reduce Emergency Department visits for Behavioral Health/Substance Abuse","ED",null,"Total number of ED Visits with a primary or secondary diagnosis of behavioral health and/or substance abuse for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1 ","","Reduce Emergency Department visits for Behavioral Health/Substance Abuse",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_094095902.2.1","RHP 1_094095902.3.1","RHP 1_094095902.2.1_094095902.3.1",{"$f":"COUNTIFS($FI$4:$FI14,FI14)","v":1},"RHP 1_094095902.2.1_1",null,2,1,1,"RHP 1_094095902",{"$f":"COUNTIFS($FR$4:$FR14,FR14)","v":1},"RHP 1_094095902_1"]
["RHP 1","094108002","Mother Frances Hospital","094108002.1.1","094108002.3.1","IT-12.1","Breast Cancer Screening","Baseline Approved","Eligible to Report in October DY4","Goal is to expand and enhance primary care with a minimum of 7 full time providers, physicians and mid-levels, to open access and lower wait time. A mid-level will work with nursing homes to improve care, better coordinate the appointments and accommodate the needs of the patients.  Clinic hours and additional locations will be enhanced based on the demand for services, access to providers, wait time for appointments, and gap analysis providing additional new access capacity.","Breast Cancer Screening","In DY4 and DY5 provider will improve the percentage of women who had mammogram during the measurement year or the 18 months prior to the measurement year over all women 50-74 years old as of the measurement year who had at least one (1) outpatient encounter in the prior 12-month period",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",61002.555,"Yes/No","RHP 1_094108002.3.1_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",61002.555,"Yes/No","RHP 1_094108002.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",100298.625,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",100298.63,"Numeric",0.54328943699999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",460520.13,"Numeric",0.55265699999999995,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.53392200000000001,18455,34565,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.54328943699999999,null,0.55265699999999995,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator: Female patients, aged 50-74 years old with at least one outpatient encounter in the prior year, excluding the indicated CPT codes and ICD-9 codes and excluding women with previous bilateral mastectomy.\nNumerator: Using the EMR (Epic), denominator patients were filtered to identify women who had a mammogram during the measurement year or the 18 months prior to the measurement year.","During the baseline period of October 1, 2013 through September 30, 2014, of those female patients ages 50-74 with at least one outpatient encounter, 53.39% received breast cancer screening.","Breast Cancer Screening","ambulatory",null,"Women who had mammogram during the measurement year or the 18 months prior to the measurement year.","Women 50-74 years old as of the measurement year who had at least one (1) outpatient encounter in the prior 12-month period. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","Breast Cancer Screening",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_094108002.1.1","RHP 1_094108002.3.1","RHP 1_094108002.1.1_094108002.3.1",{"$f":"COUNTIFS($FI$4:$FI15,FI15)","v":1},"RHP 1_094108002.1.1_1",null,2,1,1,"RHP 1_094108002",{"$f":"COUNTIFS($FR$4:$FR15,FR15)","v":1},"RHP 1_094108002_1"]
["RHP 1","094108002","Mother Frances Hospital","094108002.1.1","094108002.3.7","IT-12.3","Colorectal Cancer Screening ","Baseline Approved","Eligible to Report in October DY4","Goal is to expand and enhance primary care with a minimum of 7 full time providers, physicians and mid-levels, to open access and lower wait time. A mid-level will work with nursing homes to improve care, better coordinate the appointments and accommodate the needs of the patients.  Clinic hours and additional locations will be enhanced based on the demand for services, access to providers, wait time for appointments, and gap analysis providing additional new access capacity.","Colorectal Cancer Screening ","In DY4 and DY5 provider will improve the percentage of patients who had one or more screenings for colorectal cancer (FOBT, sigmoidoscopy, or colonoscopy) over all patients 51–75 years of age as of December 31 of the measurement year",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",61002.555,"Yes/No","RHP 1_094108002.3.7_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",61002.555,"Yes/No","RHP 1_094108002.3.7_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",100298.625,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",100298.63,"Numeric",0.51,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",460520.13,"Numeric",0.53300000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.37631300000000001,23900,63511,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.51,null,0.53300000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator: Using the EMR (Epic), filters were applied using the Measure Specification: Patients 51-75 years as of September 30, 2014 with at least one outpatient encounter in the prior year, excluding patients with the specified diagnoses as indicated in the medical record.\nNumerator: Using the EMR (Epic), denominator patients were filtered according to the Measure Specification to identify patients who received one or more of the designated screenings in the indicated time frames.","During the baseline period of October 1, 2013 through September 30, 2014, of the patients 51-75 years of age having at least one outpatient encounter, 37.63% received one or more screenings for colorectal cancer.","Colorectal Cancer Screening ","ambulatory",null,"One or more screenings for colorectal cancer. Any of the following meet the criteria: \n\n• Fecal occult blood test (FOBT) during the measurement year. For administrative data, assume the required number of samples were returned regardless of FOBT type.\n• Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year.\n• Colonoscopy during the measurement year or the nine years prior to the measurement year.\n","Patients 51–75 years of age as of the end of the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","Colorectal Cancer Screening ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_094108002.1.1","RHP 1_094108002.3.7","RHP 1_094108002.1.1_094108002.3.7",{"$f":"COUNTIFS($FI$4:$FI16,FI16)","v":2},"RHP 1_094108002.1.1_2",null,2,1,1,"RHP 1_094108002",{"$f":"COUNTIFS($FR$4:$FR16,FR16)","v":2},"RHP 1_094108002_2"]
["RHP 1","094108002","Mother Frances Hospital","094108002.1.1","094108002.3.8","IT-12.4","Pneumonia vaccination status for older adults ","Baseline Approved","Eligible to Report in October DY4","Goal is to expand and enhance primary care with a minimum of 7 full time providers, physicians and mid-levels, to open access and lower wait time. A mid-level will work with nursing homes to improve care, better coordinate the appointments and accommodate the needs of the patients.  Clinic hours and additional locations will be enhanced based on the demand for services, access to providers, wait time for appointments, and gap analysis providing additional new access capacity.","Pneumonia vaccination status for older adults ","In DY4 and DY5 provider will improve the percentage of patients who have ever received a pneumococcal vaccination over all patients 65 years and older",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",61002.555,"Yes/No","RHP 1_094108002.3.8_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",61002.555,"Yes/No","RHP 1_094108002.3.8_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",100298.625,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",100298.63,"Numeric",0.66,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",460520.13,"Numeric",0.67600000000000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.45767099999999999,20538,44875,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.66,null,0.67600000000000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator: Using the EMR (Epic), filters were applied using the Measure Specification: Patients 65 years of age or older as of January 1 of the measurement year with at least one encounter in the prior year, excluding patients with documented medical reasons for not receiving the vaccine .\nNumerator: Using the EMR (Epic), denominator patients were filtered according to the Measure Specification to identify patients who answered 'yes' to the question \"Have you ever had a pneumonia shot?  \"","During the baseline period of October 1, 2013 through September 30, 2014, of the patients aged 65 and older, 45.77% responded \"yes\" to the questions \"Have you ever had a pneumonia shot?\"","Pneumonia vaccination status for older adults ","Ambulatory/Inpatient",null,"The number of patients in the denominator who responded “Yes” to the question “Have you ever had a pneumonia shot? This shot is usually given only once or twice in the person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.”","The number of patients who responded “Yes” or “No” to the question “Have you ever had a pneumonia shot? This shot is usually given only once or twice in a person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.” ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","Pneumonia vaccination status for older adults ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_094108002.1.1","RHP 1_094108002.3.8","RHP 1_094108002.1.1_094108002.3.8",{"$f":"COUNTIFS($FI$4:$FI17,FI17)","v":3},"RHP 1_094108002.1.1_3",null,2,1,1,"RHP 1_094108002",{"$f":"COUNTIFS($FR$4:$FR17,FR17)","v":3},"RHP 1_094108002_3"]
["RHP 1","094108002","Mother Frances Hospital","094108002.1.2","094108002.3.2","IT-3.1","Hospital-Wide All-Cause Unplanned Readmission Rate","Pending Approval","Eligible to Report in October DY4","Increase the capacity for specialty care services by adding 15 new providers (physicians and mid-levels)and the availability of targeted specialty providers to better accommodate the high demand for specialty care services for Medicaid and uninsured so that patients have increased access to specialty services as well as all payers","Hospital-Wide All-Cause Unplanned Readmission Rate","In DY4 and DY5 provider will improve the percentage of unplanned all-cause 30-day readmissions, with readmission defined as an inpatient admission to any acute care facility which occurs within 30 days of the discharge date of an eligible index admission over all admissions to acute care facilities for patients aged 18 years or older",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",266192.96000000002,"Yes/No","RHP 1_094108002.3.2_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",266192.96000000002,"Yes/No","RHP 1_094108002.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",437666.72,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",437666.72,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",2009542.4,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Queried MIDAS+ indicator \"CDBR:137 Acute Care - Percent Readmit within 30 Days\" described as \"Percentage of encounters for which the patient was readmitted to the same facility within 30 days among acute care inpatient encounters.  \nDenominator is described as \"Count of discharged acute care inpatient encounters (index population)\"  as described in indicator CDBR 137 description.\nNumerator is described as \"Count of the index encounters in the denominator population for which the patient was readmitted to the same facility within 30 days as a nonelective acute care inpatient\"","During the baseline period of calendar year 2013, of the index population, 8.47% were readmitted to the same facility within 30 days of the discharge date of the index encounter.","Hospital-Wide All-Cause Unplanned Readmission Rate","inpatient",null,"Any unplanned readmission to an acute care hospital or critical access hospital which occurs within 30 days of the discharge date of an eligible index admission. ","Index admissions to acute care hospitals and critical access hospitals for patients aged 18 years or older. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2 ","","Hospital-Wide All-Cause Unplanned Readmission Rate",null,null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 1_094108002.1.2","RHP 1_094108002.3.2","RHP 1_094108002.1.2_094108002.3.2",{"$f":"COUNTIFS($FI$4:$FI18,FI18)","v":1},"RHP 1_094108002.1.2_1",null,2,1,1,"RHP 1_094108002",{"$f":"COUNTIFS($FR$4:$FR18,FR18)","v":4},"RHP 1_094108002_4"]
["RHP 1","094108002","Mother Frances Hospital","094108002.1.3","094108002.3.4","IT-8.3","Early Elective Delivery","Baseline Approved","Eligible to Report in April DY4","Expand and enhance the capacity of providers in the region to manage complex pediatric patients locally through timely access to pediatric subspecialists and specialists via telemedicine","Early Elective Delivery","In DY4 and DY5 provider will improve the percentage of patients with elective deliveries over all patients delivering newborns with >= 37 and < 39 weeks of gestation completed",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",58229.71,"Yes/No","RHP 1_094108002.3.4_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",58229.71,"Yes/No","RHP 1_094108002.3.4_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",95739.595000000001,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",95739.6,"Numeric",8.1720429999999997E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",439587.4,"Numeric",7.7419000000000002E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",8.6022000000000001E-2,24,279,"CY 2013: Jan 1st, 2013 - Dec 31st, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,8.1720429999999997E-2,null,7.7419000000000002E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator and Denominator cases are chart-abstracted PC-01 cases identified by certified vendor MIDAS+ using specifications as defined by The Joint Commission.\nDenominator: Patients delivering newborns with >=37 and <39 weeks of gestation completed, excluding the conditions defined by The Joint Commission for measure PC-01.\nNumerator: Patients with elective deliveries as defined by The Joint Commission for measure PC-01.","During the baseline period of calendar year 2013, patients who delivered with >= 37 and < 39 weeks of gestation completed, 8.6% were considered elective.","Early Elective Delivery","inpatient",null,"Patients with elective deliveries with ICD-9-CM Principal Procedure Code or ICD-9-CM Other Procedure Codes for one or more of the following: \n• Medical induction of labor as defined in Appendix A, Table 11.05 available at: http://manual.jointcommission.org \n• Cesarean section as defined in Appendix A, Table 11.06 while not in Labor or experiencing Spontaneous Rupture of Membranes available at: http://manual.jointcommission.org\n","Patients delivering newborns with >= 37 and < 39 weeks of gestation completed",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.7.1 ","","Early Elective Delivery",null,null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 1_094108002.1.3","RHP 1_094108002.3.4","RHP 1_094108002.1.3_094108002.3.4",{"$f":"COUNTIFS($FI$4:$FI19,FI19)","v":1},"RHP 1_094108002.1.3_1",null,2,1,1,"RHP 1_094108002",{"$f":"COUNTIFS($FR$4:$FR19,FR19)","v":5},"RHP 1_094108002_5"]
["RHP 1","094108002","Mother Frances Hospital","094108002.2.1","094108002.3.9","IT-1.7","Controlling high blood pressure ","Baseline Approved","Eligible to Report in October DY4","Collaborate with an affiliated Patient-Centered Medical Home (PCMH) to integrate care management and coordination for shared, high-risk patients and to recertify the 20 current Medical Homes and add the new clinic site","Controlling high blood pressure ","In DY4 and DY5 provider will improve the percentage of patients in the denominator whose most recent BP is adequately controlled during the measurement year (for a patient’s BP to be controlled, both the systolic and diastolic BP must be <140/90 (adequate control)) over all patients 18 to 85 years of age by the end of the measurement year who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",149733.54,"Yes/No","RHP 1_094108002.3.9_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",149733.54,"Yes/No","RHP 1_094108002.3.9_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",246187.53,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",246187.53,"Numeric",0.75898119999999991,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1130367.6000000001,"Numeric",0.77166639999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.74629599999999996,37173,49810,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.75898119999999991,null,0.77166639999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator: Using filters, patients 18 to 85 years of age by end of the measurement year who had at least one outpatietnt encounter with a diagnosis of hypertension during the first six months of the measurement year were selected    Numerator: The number of patients in the denominator whose most recent BP is adequately controlled during the measurement year","During the baseline reporting period of October 1, 2013 through September 30, 2014, of those patients 18 to 85 years of age by the end of the measurement years who had a diagnosis of hypertension, 74.63% of patients most recent BP was controlled. ","Controlling high blood pressure ","ambulatory",null,"The number of patients in the denominator whose most recent BP is adequately controlled during the measurement year. For a patient’s BP to be controlled, both the systolic and diastolic BP must be <140/90 (adequate control). To determine if a patient’s BP is adequately controlled, the representative BP must be identified.\n","Patients 18 to 85 years of age by the end of the measurement year who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.1.2","","Controlling high blood pressure ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_094108002.2.1","RHP 1_094108002.3.9","RHP 1_094108002.2.1_094108002.3.9",{"$f":"COUNTIFS($FI$4:$FI20,FI20)","v":1},"RHP 1_094108002.2.1_1",null,2,1,1,"RHP 1_094108002",{"$f":"COUNTIFS($FR$4:$FR20,FR20)","v":6},"RHP 1_094108002_6"]
["RHP 1","094108002","Mother Frances Hospital","094108002.2.100","094108002.3.100","IT-13.4","Hospice and Palliative Care – ICU admissions in the last 30 days of life ","Baseline Approved","Eligible to Report in April DY4","Provide a formal business plan for expansion of the palliative care program that would formalize the collaborative team approach for patient consult, education on the palliative care program to hospitalists and primary care providers, including pediatricians, and internal medicine providers.  Additionally, training would be provided for the nurses, mid-levels and other key staff in both the hospital and outpatient clinic setting.  The project would also provide expansion of services to include the outpatient setting to focus on reaching the patients at an earlier time in the diagnosis. ","Hospice and Palliative Care – Proportion admitted to the ICU in the last 30 days of life ","In DY4 and DY5 provider will improve the percentage of patients who died from cancer and were admitted to the ICU in the last 30 days of life over all patients who died from cancer.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",58229.71,"Yes/No","RHP 1_094108002.3.100_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",58229.71,"Yes/No","RHP 1_094108002.3.100_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",95739.595000000001,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",95739.6,"Numeric",0.170920502,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",439587.4,"Numeric",0.16192500000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.17991599999999999,129,717,"CY 2013: Jan 1st, 2013 - Dec 31st, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.170920502,null,0.16192500000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator: Patient who died from cancer   Numerator: Patients who died from cancer and were admitted to the ICU in the last 30 days of life","During the baseline reporting perion January 1, 2013 through December 31, 2013, of the patients that died from cancer, 17.99% of patients were admitted to the ICU in the last 30 days of life.","Hospice and Palliative Care – ICU admissions in the last 30 days of life ","inpatient",null,"Patients who died from cancer and were admitted to the ICU in the last 30 days of life","Patients who died from cancer",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.10.1","","Hospice and Palliative Care – ICU admissions in the last 30 days of life ",null,null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 1_094108002.2.100","RHP 1_094108002.3.100","RHP 1_094108002.2.100_094108002.3.100",{"$f":"COUNTIFS($FI$4:$FI21,FI21)","v":1},"RHP 1_094108002.2.100_1",null,2,1,1,"RHP 1_094108002",{"$f":"COUNTIFS($FR$4:$FR21,FR21)","v":7},"RHP 1_094108002_7"]
["RHP 1","094108002","Mother Frances Hospital","094108002.2.2","094108002.3.5","IT-6.2.a","Client Satisfaction Questionnaire 8 (CSQ-8)","Baseline not yet reported","Eligible to Report in October DY4","Implement a patient navigator dedicated to guiding patients with breast cancer through their care needs. The interventions will include but not be limited to referral to primary care medical home, specialty care referral for disenfranchised or medically complex patients, and education on appropriate level of care needed and medical instructions, and follow‐up with patients","Client Satisfaction Questionnaire 8 (CSQ-8)","In DY4 and DY5 provider will improve the overall score on the Client Satisfaction Question (CSQ) 8 over all completed CSQ-8 surveys. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",58229.71,"Yes/No","RHP 1_094108002.3.5_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",58229.71,"Yes/No","RHP 1_094108002.3.5_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",95739.595000000001,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",95739.595000000001,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",439587.4,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Client Satisfaction Questionnaire 8 (CSQ-8)","Ambulatory",null,"The sum of the \"overall score\" for all CSQ-8 surveys completed during the measurement period.  ","The total number of CSQ-8 surveys completed during the measurement period. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1 ","","Client Satisfaction Questionnaire 8 (CSQ-8)",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 1_094108002.2.2","RHP 1_094108002.3.5","RHP 1_094108002.2.2_094108002.3.5",{"$f":"COUNTIFS($FI$4:$FI22,FI22)","v":1},"RHP 1_094108002.2.2_1",null,2,1,1,"RHP 1_094108002",{"$f":"COUNTIFS($FR$4:$FR22,FR22)","v":8},"RHP 1_094108002_8"]
["RHP 1","094108002","Mother Frances Hospital","094108002.2.3","094108002.3.6","IT-3.3","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","Baseline Approved","Eligible to Report in October DY4","Implement improvements in care transitions and coordination of care from impatient to outpatient, post-acute care, and home care settings in order to prevent increased health care costs and hospital readmissions","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","In DY4 and DY5 provider will improve the ratio of actual readmissions to expected readmissions for individuals discharged for a CHF related inpatient stay. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",58229.71,"Yes/No","RHP 1_094108002.3.6_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",58229.71,"Yes/No","RHP 1_094108002.3.6_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",95739.595000000001,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",95739.6,"Numeric",0.74098601900000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",439587.4,"Numeric",0.70198700000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",0.77998500000000004,10.6,13.59,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.74098601900000005,null,0.70198700000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator: Expected potentially preventable readmission rate as calculated using 3M PPR methodology.    Numerator: Observed potentially preventable readmission rate as calculated using 3M PPR methodology.","During the baseline period of October 1, 2013 through September 30, 2014, of those patients 18 years of age and older with hospital stays with Congestive Heart Failure, the observed readmissin rate was 10.60%  compared to an expected rate of 13.59%, with observed to expected ratio of 0.78 or potential preventable readmissions.","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission for CHF during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk CHF admissions during the measurement period.\n","Expected (risk-adjusted) rate of readmissions for CHF during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc. \n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.12.1","","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate",null,null,null,null,"MidasPlus, Inc","2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_094108002.2.3","RHP 1_094108002.3.6","RHP 1_094108002.2.3_094108002.3.6",{"$f":"COUNTIFS($FI$4:$FI23,FI23)","v":1},"RHP 1_094108002.2.3_1",null,2,1,1,"RHP 1_094108002",{"$f":"COUNTIFS($FR$4:$FR23,FR23)","v":9},"RHP 1_094108002_9"]
["RHP 1","094127002","East Texas Medical Center Carthage","094127002.1.1","094127002.3.200","IT-2.21","Ambulatory Care Sensitive Conditions Admissions Rate","Baseline Approved","Eligible to Report in October DY4","This project increases access to healthcare through extended clinic hours on nights and weekends, recruiting a family practice physician and a physician assistant, and adding needed support staff. \n","Ambulatory Care Sensitive Conditions Admissions Rate","In DY4 and DY5 provider will reduce the percentage of admissions for conditions defined as ambulatory care sensitive  for individuals 18 to  75 years of age out of the total number of  admissions to ETMC Carthage.","Facility","ETMC-Carthage","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",22722.224999999999,"Yes/No","RHP 1_094127002.3.200_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",22722.224999999999,"Yes/No","RHP 1_094127002.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",36461,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",36461,"Numeric",23490.909090909092,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",174379.4,"Numeric",22254.545454545456,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",24727.272727272728,204,825,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,23490.909090909092,null,22254.545454545456,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Potentially Preventable Hospitalization Conditions for the hospital for the specific time period (10/1/13-9/30/14)","Total Discharges for the hospital for the specific time period (10/1/13-9/30/14)","Ambulatory Care Sensitive Conditions Admissions Rate","inpatient",null,"Total number of acute care hospitalizations for ambulatory care sensitive conditions younger than age 75 years ","Total mid-measurement period population younger than age 75",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","Ambulatory Care Sensitive Conditions Admissions Rate",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_094127002.1.1","RHP 1_094127002.3.200","RHP 1_094127002.1.1_094127002.3.200",{"$f":"COUNTIFS($FI$4:$FI24,FI24)","v":1},"RHP 1_094127002.1.1_1",null,2,1,1,"RHP 1_094127002",{"$f":"COUNTIFS($FR$4:$FR24,FR24)","v":1},"RHP 1_094127002_1"]
["RHP 1","094127002","East Texas Medical Center Carthage","094127002.2.1","094127002.3.201","IT-2.21","Ambulatory Care Sensitive Conditions Admissions Rate","Baseline Approved","Eligible to Report in October DY4","This project is to implement a patient navigation service that shifts non-urgent patients to a more appropriate level of care.  The patient navigators will provide non-urgent patients with a referral to a primary care provider.","Ambulatory Care Sensitive Conditions Admissions Rate","In DY4 and DY5 provider will reduce the percentage of admissions for conditions defined as ambulatory care sensitive  for individuals 18 to  75 years of age out of the total number of  admissions to ETMC Carthage.","Facility","ETMC-Carthage","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",22722.224999999999,"Yes/No","RHP 1_094127002.3.201_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",22722.224999999999,"Yes/No","RHP 1_094127002.3.201_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",36461,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",36461,"Numeric",23490.909090909092,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",174379.4,"Numeric",22254.545454545456,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",24727.272727272728,204,825,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,23490.909090909092,null,22254.545454545456,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Potentially Preventable Hospitalization Conditions for the hospital for the specific time period (10/1/13-9/30/14)","Total Discharges for the hospital for the specific time period (10/1/13-9/30/14)","Ambulatory Care Sensitive Conditions Admissions Rate","inpatient",null,"Total number of acute care hospitalizations for ambulatory care sensitive conditions younger than age 75 years ","Total mid-measurement period population younger than age 75",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1 ","","Ambulatory Care Sensitive Conditions Admissions Rate",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_094127002.2.1","RHP 1_094127002.3.201","RHP 1_094127002.2.1_094127002.3.201",{"$f":"COUNTIFS($FI$4:$FI25,FI25)","v":1},"RHP 1_094127002.2.1_1",null,2,1,1,"RHP 1_094127002",{"$f":"COUNTIFS($FR$4:$FR25,FR25)","v":2},"RHP 1_094127002_2"]
["RHP 1","094190802","East Texas Medical Center Fairfield","094190802.1.1","094190802.3.200","IT-2.21","Ambulatory Care Sensitive Conditions Admissions Rate","Baseline Approved","Eligible to Report in October DY4","This project increases access to healthcare through extended clinic hours on nights and weekends and adding needed physician and support hours. \n","Ambulatory Care Sensitive Conditions Admissions Rate","In DY4 and DY5 provider will reduce the percentage of admissions for conditions defined as ambulatory care sensitive  for individuals 18 to  75 years of age out of the total number of  admissions to ETMC Fairfield","Facility","ETMC-Fairfield","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",7413.45,"Yes/No","RHP 1_094190802.3.200_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",7413.45,"Yes/No","RHP 1_094190802.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",11895.89,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",11895.89,"Numeric",26458.885941644563,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",56893.53,"Numeric",25066.312997347479,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",27851.458885941644,105,377,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,26458.885941644563,null,25066.312997347479,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Potentially Preventable Hospitalization Conditions for the hospital for the specific time period (10/1/13-9/30/14)\n","Total Discharges for the hospital for the specific time period (10/1/13-9/30/14)","Ambulatory Care Sensitive Conditions Admissions Rate","inpatient",null,"Total number of acute care hospitalizations for ambulatory care sensitive conditions younger than age 75 years ","Total mid-measurement period population younger than age 75",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","Ambulatory Care Sensitive Conditions Admissions Rate",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_094190802.1.1","RHP 1_094190802.3.200","RHP 1_094190802.1.1_094190802.3.200",{"$f":"COUNTIFS($FI$4:$FI26,FI26)","v":1},"RHP 1_094190802.1.1_1",null,2,1,1,"RHP 1_094190802",{"$f":"COUNTIFS($FR$4:$FR26,FR26)","v":1},"RHP 1_094190802_1"]
["RHP 1","094190802","East Texas Medical Center Fairfield","094190802.2.1","094190802.3.201","IT-2.21","Ambulatory Care Sensitive Conditions Admissions Rate","Baseline Approved","Eligible to Report in October DY4","This project is to implement a patient navigation service that shifts non-urgent patients to a more appropriate level of care.  The patient navigators will provide non-urgent patients with a referral to a primary care provider. \n","Ambulatory Care Sensitive Conditions Admissions Rate","In DY4 and DY5 provider will reduce the percentage of admissions for conditions defined as ambulatory care sensitive  for individuals 18 to  75 years of age out of the total number of  admissions to ETMC Fairfield","Facility","ETMC-Fairfield","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",12622.9,"Yes/No","RHP 1_094190802.3.201_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",12622.9,"Yes/No","RHP 1_094190802.3.201_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",20255.16,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",20255.16,"Numeric",26458.885941644563,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",96872.77,"Numeric",25066.312997347479,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",27851.458885941644,105,377,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,26458.885941644563,null,25066.312997347479,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Potentially Preventable Hospitalization Conditions for the hospital for the specific time period (10/1/13-9/30/14)\n","Total Discharges for the hospital for the specific time period (10/1/13-9/30/14)","Ambulatory Care Sensitive Conditions Admissions Rate","inpatient",null,"Total number of acute care hospitalizations for ambulatory care sensitive conditions younger than age 75 years ","Total mid-measurement period population younger than age 75",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1 ","","Ambulatory Care Sensitive Conditions Admissions Rate",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_094190802.2.1","RHP 1_094190802.3.201","RHP 1_094190802.2.1_094190802.3.201",{"$f":"COUNTIFS($FI$4:$FI27,FI27)","v":1},"RHP 1_094190802.2.1_1",null,2,1,1,"RHP 1_094190802",{"$f":"COUNTIFS($FR$4:$FR27,FR27)","v":2},"RHP 1_094190802_2"]
["RHP 1","111411803","Anderson Cherokee Community MHMR Center (ACCESS)","111411803.1.100","111411803.3.100","IT-1.18","Follow-Up After Hospitalization for Mental Illness ","Baseline not yet reported","Eligible to Report in October DY4","This project will support specialty care access to behavioral health providers in the underserved area by recruiting a full-time psychiatrist or other mental health provider for adult, outpatient services. \n","Follow-Up After Hospitalization for Mental Illness ","In DY4 and DY5 provider will increase the percentage of individuals who received follow-up from a mental health care provider after an acute inpatient discharge for a primary cause related to mental illness within 7 and 30 days. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",13536.6,"Yes/No","RHP 1_111411803.3.100_PM-8","Metric Carried Forward in October DY3","PM-9","Validation and submission of baseline performance",13536.6,"Yes/No","RHP 1_111411803.3.100_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",14279.1,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- 7 day follow-up",7139.55,"Numeric","TBD","AM-1.2","Achievement of DY4 performance goal- 30 day follow-up",7139.55,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- 7 day follow-up",30536.400000000001,"Numeric","TBD","AM-2.2","Achievement of DY5 performance goal- 30 day follow-up",30536.400000000001,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Follow-Up After Hospitalization for Mental Illness ","ambulatory",null,"Rate #1: 7-Day Follow-Up: An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 7 days after discharge. ","Patients 6 years and older as of the date of discharge who were discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal diagnosis of mental illness during the first 11 months of the measurement year. ","Rate #2: 30-Day Follow-Up: An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 30 days after discharge. ","Patients 6 years and older as of the date of discharge who were discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal diagnosis of mental illness during the first 11 months of the measurement year. ",null,null,null,null,null,null,null,null,null,null,null,"1.9.1","","7 day follow-up","30 day follow-up",null,null,null,null,null,null,null,null,"","",null,null,"RHP 1_111411803.1.100","RHP 1_111411803.3.100","RHP 1_111411803.1.100_111411803.3.100",{"$f":"COUNTIFS($FI$4:$FI28,FI28)","v":1},"RHP 1_111411803.1.100_1",null,3,2,1,"RHP 1_111411803",{"$f":"COUNTIFS($FR$4:$FR28,FR28)","v":1},"RHP 1_111411803_1"]
["RHP 1","111411803","Anderson Cherokee Community MHMR Center (ACCESS)","111411803.1.101","111411803.3.200","IT-9.4.e","Reduce Emergency Department visits for Behavioral Health/Substance Abuse","Baseline not yet reported","Eligible to Report in October DY4","ACCESS will establish outpatient substance abuse treatment sites in Anderson and Cherokee Counties to meet the needs of a growing population, especially the poor and uninsured. The sites will be in our current facilities and will be licensed for supportive outpatient services. \n","Reduce Emergency Department visits for Behavioral Health/Substance Abuse","In DY4 and DY5 provider will reduce the percentage of ED visits for BH/SA conditions out of the total number of ED visits at ETMC-Jacksonville and TMF-Jacksonville.","Facility ","East Texas Medical Center - Jacksonville and Trinity Mother Frances Jacksonville","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",5189.03,"Yes/No","RHP 1_111411803.3.200_PM-8","Metric Carried Forward in October DY3","PM-9","Validation and submission of baseline performance",5189.03,"Yes/No","RHP 1_111411803.3.200_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",5473.6549999999997,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",5473.6549999999997,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",23411.24,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Reduce Emergency Department visits for Behavioral Health/Substance Abuse","ED",null,"Total number of ED Visits with a primary or secondary diagnosis of behavioral health and/or substance abuse for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.12.2","","Reduce Emergency Department visits for Behavioral Health/Substance Abuse",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 1_111411803.1.101","RHP 1_111411803.3.200","RHP 1_111411803.1.101_111411803.3.200",{"$f":"COUNTIFS($FI$4:$FI29,FI29)","v":1},"RHP 1_111411803.1.101_1",null,2,1,1,"RHP 1_111411803",{"$f":"COUNTIFS($FR$4:$FR29,FR29)","v":2},"RHP 1_111411803_2"]
["RHP 1","111411803","Anderson Cherokee Community MHMR Center (ACCESS)","111411803.2.100","111411803.3.102","IT-1.18","Follow-Up After Hospitalization for Mental Illness ","Baseline not yet reported","Eligible to Report in October DY4"," ACCESS will train and employ Peer Specialists to provide peer support to other mental health consumers in Anderson County.  Specialist will also engage their peers to prevent or manage chronic health conditions.  The site will be in our current Anderson County facility. \n","Follow-Up After Hospitalization for Mental Illness ","In DY4 and DY5 provider will increase the percentage of individuals who received follow-up from a mental health care provider after an acute inpatient discharge for a primary cause related to mental illness within 7 and 30 days. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",3835.37,"Yes/No","RHP 1_111411803.3.102_PM-8","Metric Carried Forward in October DY3","PM-9","Validation and submission of baseline performance",3835.37,"Yes/No","RHP 1_111411803.3.102_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",4045.7449999999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- 7 day follow-up",2022.8724999999999,"Numeric","TBD","AM-1.2","Achievement of DY4 performance goal- 30 day follow-up",2022.8724999999999,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- 7 day follow-up",8651.98,"Numeric","TBD","AM-2.2","Achievement of DY5 performance goal- 30 day follow-up",8651.98,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Follow-Up After Hospitalization for Mental Illness ","ambulatory",null,"Rate #1: 7-Day Follow-Up: An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 7 days after discharge. ","Patients 6 years and older as of the date of discharge who were discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal diagnosis of mental illness during the first 11 months of the measurement year. ","Rate #2: 30-Day Follow-Up: An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 30 days after discharge. ","Patients 6 years and older as of the date of discharge who were discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal diagnosis of mental illness during the first 11 months of the measurement year. ",null,null,null,null,null,null,null,null,null,null,null,"2.18.1","","7 day follow-up","30 day follow-up",null,null,null,null,null,null,null,null,"","",null,null,"RHP 1_111411803.2.100","RHP 1_111411803.3.102","RHP 1_111411803.2.100_111411803.3.102",{"$f":"COUNTIFS($FI$4:$FI30,FI30)","v":1},"RHP 1_111411803.2.100_1",null,3,2,1,"RHP 1_111411803",{"$f":"COUNTIFS($FR$4:$FR30,FR30)","v":3},"RHP 1_111411803_3"]
["RHP 1","121817401","East Texas Medical Center Trinity","121817401.1.1","121817401.3.200","IT-2.21","Ambulatory Care Sensitive Conditions Admissions Rate","Baseline Approved","Eligible to Report in October DY4","This project increases access to healthcare through extended clinic hours on nights and weekends, recruiting a family practice physician, and adding needed support staff.","Ambulatory Care Sensitive Conditions Admissions Rate","In DY4 and DY5 provider will reduce the percentage of admissions for conditions defined as ambulatory care sensitive  for individuals 18 to  75 years of age out of the total number of  admissions to ETMC Trinity.","Facility","ETMC-Trinity","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",23302.375,"Yes/No","RHP 1_121817401.3.200_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",23302.375,"Yes/No","RHP 1_121817401.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",37392.199999999997,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",37392.199999999997,"Numeric",42614.879649890587,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",178832.5,"Numeric",40371.99124726477,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",44857.768052516411,205,457,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,42614.879649890587,null,40371.99124726477,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Potentially Preventable Hospitalization Conditions for the hospital for the specific time period (10/1/13-9/30/14)\n","Total Discharges for the hospital for the specific time period (10/1/13-9/30/14)","Ambulatory Care Sensitive Conditions Admissions Rate","inpatient",null,"Total number of acute care hospitalizations for ambulatory care sensitive conditions younger than age 75 years ","Total mid-measurement period population younger than age 75",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","Ambulatory Care Sensitive Conditions Admissions Rate",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_121817401.1.1","RHP 1_121817401.3.200","RHP 1_121817401.1.1_121817401.3.200",{"$f":"COUNTIFS($FI$4:$FI31,FI31)","v":1},"RHP 1_121817401.1.1_1",null,2,1,1,"RHP 1_121817401",{"$f":"COUNTIFS($FR$4:$FR31,FR31)","v":1},"RHP 1_121817401_1"]
["RHP 1","121817401","East Texas Medical Center Trinity","121817401.2.1","121817401.3.201","IT-2.21","Ambulatory Care Sensitive Conditions Admissions Rate","Baseline Approved","Eligible to Report in October DY4","This project is to implement a patient navigation service that shifts non-urgent patients to a more appropriate level of care.  The patient navigators will provide non-urgent patients with a referral to a primary care provider.","Ambulatory Care Sensitive Conditions Admissions Rate","In DY4 and DY5 provider will reduce the percentage of admissions for conditions defined as ambulatory care sensitive  for individuals 18 to  75 years of age out of the total number of  admissions to ETMC Trinity.","Facility","ETMC-Trinity","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",23302.375,"Yes/No","RHP 1_121817401.3.201_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",23302.375,"Yes/No","RHP 1_121817401.3.201_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",37392.199999999997,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",37392.199999999997,"Numeric",42614.879649890587,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",178832.5,"Numeric",40371.99124726477,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",44857.768052516411,205,457,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,42614.879649890587,null,40371.99124726477,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Potentially Preventable Hospitalization Conditions for the hospital for the specific time period (10/1/13-9/30/14)\n","Total Discharges for the hospital for the specific time period (10/1/13-9/30/14)","Ambulatory Care Sensitive Conditions Admissions Rate","inpatient",null,"Total number of acute care hospitalizations for ambulatory care sensitive conditions younger than age 75 years ","Total mid-measurement period population younger than age 75",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1 ","","Ambulatory Care Sensitive Conditions Admissions Rate",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_121817401.2.1","RHP 1_121817401.3.201","RHP 1_121817401.2.1_121817401.3.201",{"$f":"COUNTIFS($FI$4:$FI32,FI32)","v":1},"RHP 1_121817401.2.1_1",null,2,1,1,"RHP 1_121817401",{"$f":"COUNTIFS($FR$4:$FR32,FR32)","v":2},"RHP 1_121817401_2"]
["RHP 1","121988304","Lakes Regional MHMR Center","121988304.1.1","121988304.3.1","IT-10.1.b.iii","RAND Short Form 36[1] (SF-36) Health Survey","Baseline Approved","Eligible to Report in October DY4","This project will create three clinics new in RHP 1 for provision of evidence‐based services for individuals who suffer from depression or trauma related disorders not meeting the state mandated diagnostic criteria for eligibility for state funded behavioral health services.","RAND Short Form 36[1] (SF-36) Health Survey","In DY4 and DY5 provider will  improve reported scores on the SF-36 questionnaires completed during the measurement period. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",73635.66,"Yes/No","RHP 1_121988304.3.1_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",73635.66,"Yes/No","RHP 1_121988304.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",79282.035000000003,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",79282.039999999994,"Numeric",42.207547169999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",335573.28,"Numeric",47.207547169999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",37.207549999999998,5916,159,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,42.207547169999998,null,47.207547169999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator was the number of individuals who presented to participate in the intervention prior to starting.  ","The baseline is an adequate representation of the expected population as they enter services with predominately depression symptoms at four times that of the general population.","RAND Short Form 36[1] (SF-36) Health Survey","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.12.2","Scenario 2: Pre Test Only Baseline","RAND Short Form 36[1] (SF-36) Health Survey",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 1_121988304.1.1","RHP 1_121988304.3.1","RHP 1_121988304.1.1_121988304.3.1",{"$f":"COUNTIFS($FI$4:$FI33,FI33)","v":1},"RHP 1_121988304.1.1_1",null,2,1,1,"RHP 1_121988304",{"$f":"COUNTIFS($FR$4:$FR33,FR33)","v":1},"RHP 1_121988304_1"]
["RHP 1","121988304","Lakes Regional MHMR Center","121988304.2.1","121988304.3.2","IT-6.2.a","Client Satisfaction Questionnaire 8 (CSQ-8)","Baseline Approved","Eligible to Report in October DY4","implement integrated Physical services into three existing rural Behavioral Health Centers allowing individuals with need for primary care to choose LRMHMRC as a medical home to improve physical and behavioral health outcomes.","Client Satisfaction Questionnaire 8 (CSQ-8)","In DY4 and DY5 provider will improve the average overall score of all CSQ-8 questionnaires completed during the measurement period. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",23376.400000000001,"Yes/No","RHP 1_121988304.3.2_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",23376.400000000001,"Yes/No","RHP 1_121988304.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",25168.9,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",25168.9,"Numeric",25.169499999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",106531.2,"Numeric",25.529,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",24.81,2481,100,"07/01/14 - 09/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"short",25.169499999999999,null,25.529,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator is the sum of all CSQ-8 total scores and the denominator is the total number of CSQ surveys (100) completed for this baseline. ","The derived baseline rate is the average CSQ-8 score for this baseline sample. It will form the basis for the percentage improvement during DY-4 and DY-5","Client Satisfaction Questionnaire 8 (CSQ-8)","Ambulatory",null,"The sum of the \"overall score\" for all CSQ-8 surveys completed during the measurement period.  ","The total number of CSQ-8 surveys completed during the measurement period. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.15.1","","Client Satisfaction Questionnaire 8 (CSQ-8)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-07-01","2014-09-30",null,null,"RHP 1_121988304.2.1","RHP 1_121988304.3.2","RHP 1_121988304.2.1_121988304.3.2",{"$f":"COUNTIFS($FI$4:$FI34,FI34)","v":1},"RHP 1_121988304.2.1_1",null,2,1,1,"RHP 1_121988304",{"$f":"COUNTIFS($FR$4:$FR34,FR34)","v":2},"RHP 1_121988304_2"]
["RHP 1","121988304","Lakes Regional MHMR Center","121988304.2.2","121988304.3.3","IT-6.2.a","Client Satisfaction Questionnaire 8 (CSQ-8)","Baseline Approved","Eligible to Report in October DY4","Physical health and nutrition awareness and improvement program for individuals with medication stabilized schizophrenia related disorders. ","Client Satisfaction Questionnaire 8 (CSQ-8)","In DY4 and DY5 provider will improve the average overall score of all CSQ-8 questionnaires completed during the measurement period. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",19869.939999999999,"Yes/No","RHP 1_121988304.3.3_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",19869.939999999999,"Yes/No","RHP 1_121988304.3.3_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",21393.564999999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",21393.57,"Numeric",25.388000000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",90551.52,"Numeric",25.736000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",25.04,2504,100,"07/01/14 - 09/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"short",25.388000000000002,null,25.736000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator is the sum of all CSQ-8 total scores and the denominator is the total number of CSQ surveys (100) completed for this baseline","The derived baseline rate is the average CSQ-8 score for this baseline sample. It will form the basis for the percentage improvement during DY-4 and DY-5","Client Satisfaction Questionnaire 8 (CSQ-8)","Ambulatory",null,"The sum of the \"overall score\" for all CSQ-8 surveys completed during the measurement period.  ","The total number of CSQ-8 surveys completed during the measurement period. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.13.1","","Client Satisfaction Questionnaire 8 (CSQ-8)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-07-01","2014-09-30",null,null,"RHP 1_121988304.2.2","RHP 1_121988304.3.3","RHP 1_121988304.2.2_121988304.3.3",{"$f":"COUNTIFS($FI$4:$FI35,FI35)","v":1},"RHP 1_121988304.2.2_1",null,2,1,1,"RHP 1_121988304",{"$f":"COUNTIFS($FR$4:$FR35,FR35)","v":3},"RHP 1_121988304_3"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.1.1","127278302.3.1","IT-7.8","Chronic Disease Patients Accessing Dental Services","Baseline Approved","Eligible to Report in October DY4","UPA/UTHSCT will partner with TJC by recruiting and hiring joint faculty services in dentistry and dental hygiene in order to establish a ready and timely referral mechanism for UPA patients who are underserved or do not have access to dental  preventive services.","Chronic Disease Patients Accessing Dental Services","In DY4 and DY5 provider will improve the number of chronic disease patients who access dental services as the result of a referral out of the total number of referrals for dental services for chronic disease patient by medical providers",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",75166.485000000001,"Yes/No","RHP 1_127278302.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",75166.485000000001,"Yes/No","RHP 1_127278302.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",118771.935,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",118771.94,"Numeric",0.312068966,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",431087.14,"Numeric",0.34827599999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.275862,8,29,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.312068966,null,0.34827599999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Per Compendium document IT-7.8, an electronic report to pull information from the EMR was generated with the required denominator inclusions and exclusions.  The numerator was pulled from data manually entered from an excel spreadsheet detailing patient visits to the dental clinic.  ","During April 1, 2014-September 30, 2014, 27.59% of patients with chronic disease accessed dental services following a referral by their medical provider.","Chronic Disease Patients Accessing Dental Services","ambulatory",null,"Number of chronic disease patients who access dental services as\nthe result of a referral\n","Total number of referrals for dental services for chronic disease\npatients by medical providers\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.8.6 ","","Chronic Disease Patients Accessing Dental Services",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 1_127278302.1.1","RHP 1_127278302.3.1","RHP 1_127278302.1.1_127278302.3.1",{"$f":"COUNTIFS($FI$4:$FI36,FI36)","v":1},"RHP 1_127278302.1.1_1",null,2,1,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR36,FR36)","v":1},"RHP 1_127278302_1"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.1.10","127278302.3.35","IT-11.26.e.ii","Patient Health Questionnaire 15 (PHQ-15)","Baseline not yet reported","Eligible to Report in October DY4","Expand and enhance the infrastructure necessary to build targeted telemental/telehealth capacity within the Northeast Texas region and to support other DSRIP project efforts directed at workforce development for facilitation of these services (trained Community Health Worker presenters) and integration of primary and behavioral health care services.","Patient Health Questionnaire 15 (PHQ-15)","In DY4 and DY5 provider will improve reported scores on the PHQ-15 instruments completed during the measurement period",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",53210.64,"Yes/No","RHP 1_127278302.3.35_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",53210.64,"Yes/No","RHP 1_127278302.3.35_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",168158.2,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",305168.21000000002,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"DY4","TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Patient Health Questionnaire 15 (PHQ-15)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.11.1","","Patient Health Questionnaire 15 (PHQ-15)",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 1_127278302.1.10","RHP 1_127278302.3.35","RHP 1_127278302.1.10_127278302.3.35",{"$f":"COUNTIFS($FI$4:$FI37,FI37)","v":1},"RHP 1_127278302.1.10_1",null,1,1,0,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR37,FR37)","v":2},"RHP 1_127278302_2"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.1.11","127278302.3.36","IT-9.2","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","Baseline Approved","Eligible to Report in October DY4","Implement a Federally Qualified Health Center in partnership with Genesis PrimeCare to provide primary care for the Medicaid, Medicare, and indigent patient population","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","In DY4 and DY5 provider will improve the percent ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older  (See Adult ACSC diagnostic codes ) out of the total number of ED visits during the measurement period at CHRISTUS St. Michael","Facility ","CHRISTUS St. Michael Facility","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",134059.815,"Yes/No","RHP 1_127278302.3.36_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",134059.815,"Yes/No","RHP 1_127278302.3.36_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",211830.36,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",211830.36,"Numeric",0.38819462999999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",768846.13,"Numeric",0.36776300000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.40862599999999999,15339,37538,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.38819462999999998,null,0.36776300000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Per compendium IT -9.2, an electronic report to pull information from the HPM was generated with the required inclusion and exclusion criteria.","IT 9-2:  During DY 3 (10/01/13 – 09/30/14) 40.86% of all ED visits for persons over 18 were for patients presenting with Grand mal, COPD, asthma, heart failure, hypertension, angina diabetes (see list of codes above).","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","ED",null,"Total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1 ","","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_127278302.1.11","RHP 1_127278302.3.36","RHP 1_127278302.1.11_127278302.3.36",{"$f":"COUNTIFS($FI$4:$FI38,FI38)","v":1},"RHP 1_127278302.1.11_1",null,2,1,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR38,FR38)","v":3},"RHP 1_127278302_3"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.1.12","127278302.3.37","IT-9.4.i","Reduce Emergency Department visits for Dental Conditions","Pending Approval","Eligible to Report in October DY4","Implement a dental clinic in partnership with Genesis PrimeCare to provide dental care for the Medicaid, Medicare, and indigent patient population.   ","Reduce Emergency Department visits for Dental Conditions","In DY4 and DY5 provider will improve the rate of total number of ED Visits with a primary or secondary diagnosis of dental conditions for any individual 18 years and older during the measurement period over all total number of ED visits for individuals 18 years or older during the measurement period at CHRISTUS St. Michael's emergency department ","Facility ","CHRISTUS St. Michael's emergency department as the facility of choice.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",127085.605,"Yes/No","RHP 1_127278302.3.37_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",127085.605,"Yes/No","RHP 1_127278302.3.37_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",200810.285,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",200810.285,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",728848.36,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Per compendium IT -9.4 i, an electronic report to pull information from the HPM was generated with the required inclusion and exclusion criteria.","During the six month baseline period (04/01/14 – 09/30/14), 3.12% of all ED visits for persons over 18 were for preventable dental conditions.  ","Reduce Emergency Department visits for Dental Conditions","ED",null,"Total number of ED Visits with a primary or secondary diagnosis of dental conditions for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.8.6 ","","Reduce Emergency Department visits for Dental Conditions",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 1_127278302.1.12","RHP 1_127278302.3.37","RHP 1_127278302.1.12_127278302.3.37",{"$f":"COUNTIFS($FI$4:$FI39,FI39)","v":1},"RHP 1_127278302.1.12_1",null,2,1,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR39,FR39)","v":4},"RHP 1_127278302_4"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.1.13","127278302.3.38","IT-9.4.e","Reduce Emergency Department visits for Behavioral Health/Substance Abuse","Pending Approval","Eligible to Report in October DY4","The crisis stabilization unit will provide short term (up to 48 hour) treatment for behavioral health patients requiring observation and stabilization from acute symptoms of mental illness thus reducing congestion in area emergency departments, decreasing admissions to medical acute care setting and ICU) while providing quicker treatment options for the behavioral health patient in the appropriate care setting. ","Reduce Emergency Department visits for Behavioral Health/Substance Abuse","In DY4 and DY5, provider will decrease the total number of ED visits at Palestine Regional Medical Center with a primary or secondary diagnosis of BH/SA conditions for individuals 18 years and older during the measurement period over all total number of ED visits at PRMC for individuals 18 years and older during the measurement period.  ","Facility ","Palestine Regional Medical Center.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",55793.68,"Yes/No","RHP 1_127278302.3.38_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",55793.68,"Yes/No","RHP 1_127278302.3.38_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",88160.61,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",88160.61,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",319982.2,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PRMC abstracted data from the EMR per Compendium  document IT 9.4.e specifications to generate a manual report  with the required inclusion and exclusion criteria.  ","During DY 3 – October 1, 2013 – March 31, 2014, 3.13% patients visited the Emergency Department for behavioral health/substance abuse issues.","Reduce Emergency Department visits for Behavioral Health/Substance Abuse","ED",null,"Total number of ED Visits with a primary or secondary diagnosis of behavioral health and/or substance abuse for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.13.1","","Reduce Emergency Department visits for Behavioral Health/Substance Abuse",null,null,null,null,null,"2014-04-01","2015-03-31","2015-04-01","2016-03-31","2013-10-01","2014-03-31",null,null,"RHP 1_127278302.1.13","RHP 1_127278302.3.38","RHP 1_127278302.1.13_127278302.3.38",{"$f":"COUNTIFS($FI$4:$FI40,FI40)","v":1},"RHP 1_127278302.1.13_1",null,2,1,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR40,FR40)","v":5},"RHP 1_127278302_5"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.1.4","127278302.3.6","IT-1.11","Diabetes care:  BP control (<140/90mm Hg) ","Baseline Approved","Eligible to Report in October DY4","Working collaboratively with the East Texas Health Education Center (AHEC) and the Department of Labor, UTHSCT will become a certified apprenticeship and continuing education location for training and deploying CHWs. UTHSCT’s goal is to train and certify more CHWs to be deployed into Region 1 to support disease prevention measures, provide peer support to improve self-management, and monitor target populations for early detection of risk for decomposition.  ","Diabetes care:  BP control (<140/90mm Hg) ","In DY4 and DY5 provider will improve the percentage patients whose most recent BP reading is <140/90 mm Hg during the measurement year over all patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",86531.865000000005,"Yes/No","RHP 1_127278302.3.6_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",86531.865000000005,"Yes/No","RHP 1_127278302.3.6_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",136730.57999999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",136730.57999999999,"Numeric",0.62371239099999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",496268.7,"Numeric",0.63823300000000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.60919199999999996,1816,2981,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.62371239099999998,null,0.63823300000000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Per Compendium document IT- 1.11:  Diabetes Care:  BP Control (<140/90 mm Hg), an electronic report to pull information from the EMR was generated with the required inclusion and exclusion criteria.","For IT – 1.11:  During DY3 (10/01/2013 – 09/30/2014) 60.92% of patients 18-75 years of age with Diabetes (type 1 and type 2), most recent blood pressure (BP) reading is <140/90 mm Hg.","Diabetes care:  BP control (<140/90mm Hg) ","ambulatory",null,"Patients whose most recent BP reading is <140/90 mm Hg during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.2.2 ","","Diabetes care:  BP control (<140/90mm Hg) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_127278302.1.4","RHP 1_127278302.3.6","RHP 1_127278302.1.4_127278302.3.6",{"$f":"COUNTIFS($FI$4:$FI41,FI41)","v":1},"RHP 1_127278302.1.4_1",null,2,1,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR41,FR41)","v":6},"RHP 1_127278302_6"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.1.8","127278302.3.28","IT-1.7","Controlling high blood pressure ","Baseline Approved","Eligible to Report in October DY4","Increase access to a poor, largely minority, underserved area of Smith County (75702) by establishing an open access clinic within the community to provide basic care services and a referral channel to patient centered medical homes and specialty providers. ","Controlling high blood pressure ","In DY4 and DY5 provider will improve the percentage of patients in the denominator whose most recent BP is adequately controlled during the measurement year and are receiving services at the UPA-North Tyler Clinic (for patient’s BP to be controlled, both the systolic and diastolic BP must be <140/90 (adequate control). To determine if a patient’s BP is adequately controlled, the representative BP must be identified) over all patients 18 to 85 years of age by the end of the measurement year within the UPA-North Tyler Clinic who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year.","Facility ","UPA-North Tyler clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",105904.675,"Yes/No","RHP 1_127278302.3.28_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",105904.675,"Yes/No","RHP 1_127278302.3.28_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",167341.905,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",167341.91,"Numeric",0.50109999999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",607373.63,"Numeric",0.52010000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.38972200000000001,182,467,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.50109999999999999,null,0.52010000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Per Compendium document IT-1.7, an electronic report was pulled from the electronic medical records with the required inclusion and exclusion criteria. ","IT-1.7: During measurement period (10/01/2013 – 09/30/2014), 63.85% of patient ages 18 to 85 years who had a diagnosis of hypertension had a blood pressure that was adequately controlled (<140/90).","Controlling high blood pressure ","ambulatory",null,"The number of patients in the denominator whose most recent BP is adequately controlled during the measurement year. For a patient’s BP to be controlled, both the systolic and diastolic BP must be <140/90 (adequate control). To determine if a patient’s BP is adequately controlled, the representative BP must be identified.\n","Patients 18 to 85 years of age by the end of the measurement year who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1 ","","Controlling high blood pressure ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_127278302.1.8","RHP 1_127278302.3.28","RHP 1_127278302.1.8_127278302.3.28",{"$f":"COUNTIFS($FI$4:$FI42,FI42)","v":1},"RHP 1_127278302.1.8_1",null,2,1,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR42,FR42)","v":7},"RHP 1_127278302_7"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.1.9","127278302.3.32","IT-1.12","Diabetes care: Retinal eye exam ","Baseline Approved","Eligible to Report in October DY4","Confirm specialty care gaps early and develop/implement a specialty care access plan which addresses targeted gaps in specialty care for this network of clinics as well as potential referrals from the GSMC IMR","Diabetes care: Retinal eye exam ","In DY4 and DY5 provider will improve the percentage of patients who received an eye screening for diabetic retinal disease (including a retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year) over all patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year across the following clinics: Family Medicine, Internal Medicine, UT Physicians- Overton, UT Physicians - North Tyler, UT Physicians - Gladewater and University Health Center. .","Facility ","Primary Care Facilities (6 locations)","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",65953.64,"Yes/No","RHP 1_127278302.3.32_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",65953.64,"Yes/No","RHP 1_127278302.3.32_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",104214.55,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",104214.55,"Numeric",0.45029999999999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",378250.57,"Numeric",0.47499000000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.41715200000000002,1075,2577,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.45029999999999998,null,0.47499000000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Per compendium IT 1.12, an electronic report to pull information from the EMR was generated with the required inclusion and exclusion criteria.","During the twelve month time frame (October 1, 2013-September 30, 2014), 41.72% of patients 18-75 years of age who had a diagnosis of diabetes (type 1 or type 2) received a retinal or dilated eye exam.  ","Diabetes care: Retinal eye exam ","ambulatory",null,"Patients who received an eye screening for diabetic retinal disease. This includes diabetics who had the following:\n- A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year\n\nOR\n\n- A negative retinal exam or dilated eye exam (negative for retinopathy) by an eye care professional in the year prior to the measurement year.\n\nFor exams performed in the year prior to the measurement year, a result must be available.\n\n","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2 ","","Diabetes care: Retinal eye exam ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_127278302.1.9","RHP 1_127278302.3.32","RHP 1_127278302.1.9_127278302.3.32",{"$f":"COUNTIFS($FI$4:$FI43,FI43)","v":1},"RHP 1_127278302.1.9_1",null,2,1,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR43,FR43)","v":8},"RHP 1_127278302_8"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.1.9","127278302.3.33","IT-1.13","Diabetes care:  Foot exam ","Baseline Approved","Eligible to Report in October DY4","Confirm specialty care gaps early and develop/implement a specialty care access plan which addresses targeted gaps in specialty care for this network of clinics as well as potential referrals from the GSMC IMR","Diabetes care:  Foot exam ","In DY4 and DY5 provider will improve the percentage of patients who received a foot exam (visual inspection with either a sensory exam or a pulse exam) during the measurement year over all patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year across the following clinics: Family Medicine, Internal Medicine, UT Physicians- Overton, UT Physicians - North Tyler, UT Physicians - Gladewater and University Health Center. ..","Facility ","Primary Care Facilities (6 locations)","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",65953.64,"Yes/No","RHP 1_127278302.3.33_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",65953.64,"Yes/No","RHP 1_127278302.3.33_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",104214.55,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",104214.55,"Numeric",0.48598676499999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",378250.57,"Numeric",0.51304000000000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.45893299999999998,1179,2569,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.48598676499999999,null,0.51304000000000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Per compendium IT 1.13, an electronic report to pull information from the EMR was generated with the required inclusion and exclusion criteria.","During the twelve month time frame (October 1, 2013-September 30, 2014), 45.89% of patients 18-75 years of age who had a diagnosis of diabetes (type 1 or type 2) received a foot exam. ","Diabetes care:  Foot exam ","ambulatory",null,"Patients who received a comprehensive foot exam (visual inspection with either a sensory exam or a pulse exam) during the measurement year","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2 ","","Diabetes care:  Foot exam ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_127278302.1.9","RHP 1_127278302.3.33","RHP 1_127278302.1.9_127278302.3.33",{"$f":"COUNTIFS($FI$4:$FI44,FI44)","v":2},"RHP 1_127278302.1.9_2",null,2,1,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR44,FR44)","v":9},"RHP 1_127278302_9"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.1.9","127278302.3.34","IT-1.14","Diabetes care: Nephropathy ","Baseline Approved","Eligible to Report in October DY4","Confirm specialty care gaps early and develop/implement a specialty care access plan which addresses targeted gaps in specialty care for this network of clinics as well as potential referrals from the GSMC IMR","Diabetes care: Nephropathy ","In DY4 and DY5 provider will improve the percentage of patients who received a nephropathy screening test or had evidence of nephropathy during the measurement year over all patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year across the following clinics: Family Medicine, Internal Medicine, UT Physicians- Overton, UT Physicians - North Tyler, UT Physicians - Gladewater and University Health Center. ..","Facility ","Primary Care Facilities (6 locations)","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",65953.64,"Yes/No","RHP 1_127278302.3.34_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",65953.64,"Yes/No","RHP 1_127278302.3.34_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",104214.55,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",104214.55,"Numeric",0.73480000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",378250.57,"Numeric",0.74824999999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.57555599999999996,1474,2561,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.73480000000000001,null,0.74824999999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Per compendium IT 1.14, an electronic report to pull information from the EMR was generated with the required inclusion and exclusion criteria.","During the twelve month time frame (October 1, 2013-September 30, 2014), 57.55% of patients 18-75 years of age who had a diagnosis of diabetes (type 1 or type 2) received a nephropathy screening test or had evidence of nephropathy during the measurement period.","Diabetes care: Nephropathy ","ambulatory",null,"Patients who received a nephropathy screening test* or had evidence of nephropathy** during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2 ","","Diabetes care: Nephropathy ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_127278302.1.9","RHP 1_127278302.3.34","RHP 1_127278302.1.9_127278302.3.34",{"$f":"COUNTIFS($FI$4:$FI45,FI45)","v":3},"RHP 1_127278302.1.9_3",null,2,1,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR45,FR45)","v":10},"RHP 1_127278302_10"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.2.1","127278302.3.10","IT-12.1","Breast Cancer Screening","Baseline Approved","Eligible to Report in October DY4","UPA has begun the process of transforming its Family Medicine Center into a Patient Centered Medical Home (PCMH).  The project proposes to enhance this transformation process with team personnel experienced in health care system engineering, and through collaboration, to extend NCQA recognition to other primary care clinics at UTHSCT.","Breast Cancer Screening","In DY4 and DY5 provider will improve the percent of women who had mammogram during the measurement year or the 18 months prior to the measurement year over the women 50-74 years old as of the measurement year who had at least one (1) outpatient encounter in the prior 12-month period at UPA clinics (Internal Medicine, Overton, and University Health). ","Facility ","UPA clinics (Internal Medicine, Overton, and University Health)","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",45805.925000000003,"Yes/No","RHP 1_127278302.3.10_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",45805.925000000003,"Yes/No","RHP 1_127278302.3.10_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",72378.774999999994,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",72378.78,"Numeric",0.476650193,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",262701.44,"Numeric",0.49342200000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.45987800000000001,980,2131,"September 1, 2013 -August 31, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.476650193,null,0.49342200000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Per Compendium document IT-12.1, an electronic report was pulled from the electronic medical records with the required inclusion and exclusion criteria. ","During the baseline period for DY 3 (September 1, 2013 to August 31, 2014), 45.99% of the women 50 to 74 years of age have had a mammogram for breast cancer every two years.","Breast Cancer Screening","ambulatory",null,"Women who had mammogram during the measurement year or the 18 months prior to the measurement year.","Women 50-74 years old as of the measurement year who had at least one (1) outpatient encounter in the prior 12-month period. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.1.1 ","","Breast Cancer Screening",null,null,null,null,null,"2014-09-01","2015-08-31","2015-09-01","2016-08-31","2013-09-01","2014-08-31",null,null,"RHP 1_127278302.2.1","RHP 1_127278302.3.10","RHP 1_127278302.2.1_127278302.3.10",{"$f":"COUNTIFS($FI$4:$FI46,FI46)","v":1},"RHP 1_127278302.2.1_1",null,2,1,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR46,FR46)","v":11},"RHP 1_127278302_11"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.2.1","127278302.3.11","IT-12.4","Pneumonia vaccination status for older adults ","Baseline Approved","Eligible to Report in October DY4","UPA has begun the process of transforming its Family Medicine Center into a Patient Centered Medical Home (PCMH).  The project proposes to enhance this transformation process with team personnel experienced in health care system engineering, and through collaboration, to extend NCQA recognition to other primary care clinics at UTHSCT.","Pneumonia vaccination status for older adults ","In DY4 and DY5 provider will improve the percentage of patients who have ever received a pneumococcal vaccination over all patients 65 years and older at UPA clinics (Internal Medicine, Overton, and University Health). ","Facility ","UPA clinics (Internal Medicine, Overton, and University Health)","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",45805.925000000003,"Yes/No","RHP 1_127278302.3.11_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",45805.925000000003,"Yes/No","RHP 1_127278302.3.11_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",72378.774999999994,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",72378.78,"Numeric",0.73533333300000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",262701.44,"Numeric",0.74474099999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.72592599999999996,1078,1485,"September 1, 2013 -August 31, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.73533333300000003,null,0.74474099999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Per Compendium document IT-12.1, an electronic report was pulled from the electronic medical records with the required inclusion and exclusion criteria. ","During the baseline period for DY 3 (09/01/2013 – 08/31/2014), 72.59% of the patients aged 65 years and older have received a pneumococcal vaccine.","Pneumonia vaccination status for older adults ","Ambulatory/Inpatient",null,"The number of patients in the denominator who responded “Yes” to the question “Have you ever had a pneumonia shot? This shot is usually given only once or twice in the person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.”","The number of patients who responded “Yes” or “No” to the question “Have you ever had a pneumonia shot? This shot is usually given only once or twice in a person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.” ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.1.1 ","","Pneumonia vaccination status for older adults ",null,null,null,null,null,"2014-09-01","2015-08-31","2015-09-01","2016-08-31","2013-09-01","2014-08-31",null,null,"RHP 1_127278302.2.1","RHP 1_127278302.3.11","RHP 1_127278302.2.1_127278302.3.11",{"$f":"COUNTIFS($FI$4:$FI47,FI47)","v":2},"RHP 1_127278302.2.1_2",null,2,1,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR47,FR47)","v":12},"RHP 1_127278302_12"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.2.1","127278302.3.12","IT-1.20","Comprehensive Diabetes Care LDL Screening","Baseline Approved","Eligible to Report in October DY4","UPA has begun the process of transforming its Family Medicine Center into a Patient Centered Medical Home (PCMH).  The project proposes to enhance this transformation process with team personnel experienced in health care system engineering, and through collaboration, to extend NCQA recognition to other primary care clinics at UTHSCT.","Comprehensive Diabetes Care LDL Screening","In DY4 and DY5 provider will improve the percentage of patients who had an LDL-C test performed during the measurement year over the patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year at UPA clinics (Internal Medicine, Overton and University Health). .","Facility ","UPA clinics (Internal Medicine, Overton, and University Health)","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",45805.925000000003,"Yes/No","RHP 1_127278302.3.12_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",45805.925000000003,"Yes/No","RHP 1_127278302.3.12_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",72378.774999999994,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",72378.78,"Numeric",0.70340000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",262701.44,"Numeric",0.71750999999999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.69537800000000005,331,476,"September 1, 2013 -August 31, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.70340000000000003,null,0.71750999999999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Per Compendium document IT-1.20, an electronic report was pulled from the electronic medical records with the required inclusion and exclusion criteria.","During the baseline period for DY 3 (09/01/2013 – 08/31/2014), 69.54% of the patients 18 to 75 years of age with diabetes (type 1 and type 2) received an LDL-C test during the measurement period.","Comprehensive Diabetes Care LDL Screening","ambulatory",null,"Patients who had a low-density cholesterol (LDL-C test) performed during the measurement period.","Patients 18-75 years of age by the end of the measurement period who had a diagnosis of diabetes (type 1 or type 2) during the measurement period or the year prior to the measurement period.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.1.1 ","","Comprehensive Diabetes Care LDL Screening",null,null,null,null,null,"2014-09-01","2015-08-31","2015-09-01","2016-08-31","2013-09-01","2014-08-31",null,null,"RHP 1_127278302.2.1","RHP 1_127278302.3.12","RHP 1_127278302.2.1_127278302.3.12",{"$f":"COUNTIFS($FI$4:$FI48,FI48)","v":3},"RHP 1_127278302.2.1_3",null,2,1,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR48,FR48)","v":13},"RHP 1_127278302_13"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.2.100","127278302.3.100","IT-15.17","Latent Tuberculosis Infection (LTBI) treatment rate ","Baseline Approved","Eligible to Report in October DY4","Utilize nurse case managers, community health workers and other partners to implement this project in RHP 1. The project includes targeted identification and testing for LTBI among high-risk populations, effective treatment of LTBI in order to prevent future active cases, and case identification with referral for appropriate therapy (inpatient or outpatient).","Latent Tuberculosis Infection (LTBI) treatment rate ","In DY4 and DY5 provider will improve the percentage of individuals completing an LTBI regimen over all individuals beginning a LTBI regimen",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",32546.314999999999,"Yes/No","RHP 1_127278302.3.100_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",32546.314999999999,"Yes/No","RHP 1_127278302.3.100_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",51427.025000000001,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",51427.03,"Numeric",0.27918287899999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",186656.29,"Numeric",0.31712099999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.24124499999999999,62,257,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.27918287899999999,null,0.31712099999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Per Compendium document IT-15.17, an electronic report to pull information from the EMR/DSHS was generated with the required inclusion and exclusion criteria.  ","During demonstration year 3 (10/01/2013-09/30/2014) 24.12% of LTBI patients age 18 years and older, who were contacts and presented with a positive, TST, T-Spot, or IGRA, accepted and completed therapy. ","Latent Tuberculosis Infection (LTBI) treatment rate ","Ambulatory/Inpatient",null," Individuals from the denominator that completed a LTBI treatment regimen","Total number of individuals identified with Latent Tuberculosis Infection (LTBI) that initiated (accepted) a LTBI treatment regimen. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.7.1","","Latent Tuberculosis Infection (LTBI) treatment rate ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_127278302.2.100","RHP 1_127278302.3.100","RHP 1_127278302.2.100_127278302.3.100",{"$f":"COUNTIFS($FI$4:$FI49,FI49)","v":1},"RHP 1_127278302.2.100_1",null,2,1,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR49,FR49)","v":14},"RHP 1_127278302_14"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.2.13","127278302.3.31","IT-10.1.a.v","Pediatric Quality of Life Inventory (PedsQL)","Baseline Approved","Eligible to Report in October DY4","Establish a pediatric weight management program","Pediatric Quality of Life Inventory (PedsQL)","In DY4 and DY5 provider will  improve reported scores on the PedsQL among all pediatric patients who complete the instrument during the measurement period. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",16789.764999999999,"Yes/No","RHP 1_127278302.3.31_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",8394.8824999999997,"Yes/No","RHP 1_127278302.3.31_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",13264.91,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",13264.91,"Numeric",80.106585370000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",48145.47,"Numeric",85.106585370000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",75.106589999999997,6158.74,82,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,80.106585370000005,null,85.106585370000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Per compendium document IT-10.1.a.v, data was collected from all surveys administered and manually entered into an excel spreadsheet.  Data for reporting was then extracted from the excel document based on numerator and denominator descriptions. ","During the timeframe October 1, 2013- September 30, 2014, the average score for the Pediatric Quality of Life survey was 75.11.  The test was administered to both parent and child.  ","Pediatric Quality of Life Inventory (PedsQL)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.7.5 ","Scenario 2: Pre Test Only Baseline","Pediatric Quality of Life Inventory (PedsQL)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_127278302.2.13","RHP 1_127278302.3.31","RHP 1_127278302.2.13_127278302.3.31",{"$f":"COUNTIFS($FI$4:$FI50,FI50)","v":1},"RHP 1_127278302.2.13_1",null,2,1,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR50,FR50)","v":15},"RHP 1_127278302_15"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.2.13","127278302.3.500","IT-1.29","Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents","Baseline not yet reported","Eligible to Report in October DY4","Establish a pediatric weight management program","Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents","In DY4 and DY5 provider will increase the percentage of children 3-17 years of age who had an outpatient visit with a primary care physician (PCP) or an OB/GYN and who had evidence of body mass index (BMI) percentile documentation, counseling for nutrition and counseling for physical activity during the measurement year. This measure is reported as 3 rates. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",0,"Yes/No","RHP 1_127278302.3.500_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",8394.8824999999997,"Yes/No","RHP 1_127278302.3.500_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",13264.907499999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- BMI documentation",4421.6358333333328,"Numeric","TBD","AM-1.2","Achievement of DY4 performance goal- Counseling for nutrition",4421.6358333333328,"Numeric","TBD","AM-1.3","Achievement of DY4 performance goal- Counseling for physical activity",4421.6358333333328,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- BMI documentation",16048.49,"Numeric","TBD","AM-2.2","Achievement of DY5 performance goal- Counseling for nutrition",16048.49,"Numeric","TBD","AM-2.3","Achievement of DY5 performance goal- Counseling for physical activity",16048.49,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,3,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,"TBD",null,"TBD",null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,0,0,"Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents","Ambulatory",null,"Children ages 3-17 with evidence of each of the following:\nRate #1: Documented body mass index (BMI) percentile \n","Children 3-17 years of age with at least one outpatient visit with a primary care physician (PCP) or obstetrician-gynecologist (OB-GYN) during the measurement period.","Children ages 3-17 with evidence of each of the following:\nRate #2: Counseling for nutrition \n","Children 3-17 years of age with at least one outpatient visit with a primary care physician (PCP) or obstetrician-gynecologist (OB-GYN) during the measurement period.","Children ages 3-17 with evidence of each of the following:\nRate #3: Counseling for physical activity during the measurement year","Children 3-17 years of age with at least one outpatient visit with a primary care physician (PCP) or obstetrician-gynecologist (OB-GYN) during the measurement period.",null,null,null,null,null,null,null,null,null,"2.7.5 ","","BMI documented","Counseling for Nutrition","Counseling for physical activity ",null,null,null,null,null,null,null,"","",null,null,"RHP 1_127278302.2.13","RHP 1_127278302.3.500","RHP 1_127278302.2.13_127278302.3.500",{"$f":"COUNTIFS($FI$4:$FI51,FI51)","v":2},"RHP 1_127278302.2.13_2",null,4,3,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR51,FR51)","v":16},"RHP 1_127278302_16"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.2.14","127278302.3.39","IT-12.3","Colorectal Cancer Screening ","Baseline Approved","Eligible to Report in October DY4","The implementation of a PCMH within the IMR continuity clinic at Good Shepherd near its inception will allow optimization of delivery of coordinated care to patients.  As residents often seek practice and/or employment opportunities in close proximity to their post-graduate training programs, this also creates an environment for propagating this model of care within the East Texas region. ","Colorectal Cancer Screening ","In DY4 and DY5, provider will improve the percentage of individuals receiving one or more screenings for colorectal cancer over all the individuals 51–75 years of age as of December 31 of the measurement year within the Good Shepherd Internal Medicine Continuity Clinic (GSIMCC).","Facility ","Good Shepherd Internal Medicine Continuity Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",44256.1,"Yes/No","RHP 1_127278302.3.39_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",44256.1,"Yes/No","RHP 1_127278302.3.39_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",69929.87,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",69929.87,"Numeric",0.51,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",253813.05,"Numeric",0.53300000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.27391300000000002,63,230,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.51,null,0.53300000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The GSMC Internal Medicine Continuity Clinic abstracted data from the EMR per Compendium  document IT 12.3 specifications to generate a manual report with the required inclusion and exclusion criteria.  ","During DY 3 (October 1, 2013 – September 30, 2014), 27.39% of the patients 51 – 75 had a colorectal screening completed.  ","Colorectal Cancer Screening ","ambulatory",null,"One or more screenings for colorectal cancer. Any of the following meet the criteria: \n\n• Fecal occult blood test (FOBT) during the measurement year. For administrative data, assume the required number of samples were returned regardless of FOBT type.\n• Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year.\n• Colonoscopy during the measurement year or the nine years prior to the measurement year.\n","Patients 51–75 years of age as of the end of the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.1.1 ","","Colorectal Cancer Screening ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_127278302.2.14","RHP 1_127278302.3.39","RHP 1_127278302.2.14_127278302.3.39",{"$f":"COUNTIFS($FI$4:$FI52,FI52)","v":1},"RHP 1_127278302.2.14_1",null,2,1,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR52,FR52)","v":17},"RHP 1_127278302_17"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.2.14","127278302.3.40","IT-12.4","Pneumonia vaccination status for older adults ","Baseline Approved","Eligible to Report in October DY4","The implementation of a PCMH within the IMR continuity clinic at Good Shepherd near its inception will allow optimization of delivery of coordinated care to patients.  As residents often seek practice and/or employment opportunities in close proximity to their post-graduate training programs, this also creates an environment for propagating this model of care within the East Texas region. ","Pneumonia vaccination status for older adults ","In DY4 and DY5 provider will improve the percentage of patients who have ever received a pneumococcal vaccination over all patients 65 years and older within the Good Shepherd Internal Medicine Continuity Clinic (GSIMCC).","Facility ","Good Shepherd Internal Medicine Continuity Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",44256.1,"Yes/No","RHP 1_127278302.3.40_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",44256.1,"Yes/No","RHP 1_127278302.3.40_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",69929.87,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",69929.87,"Numeric",0.66,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",253813.05,"Numeric",0.67600000000000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.375,27,72,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.66,null,0.67600000000000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The GSMC Internal Medicine Continuity Clinic abstracted data from the EMR per Compendium  document IT 12.4 specifications to generate a manual report with the required inclusion and exclusion criteria.  ","During DY 3 (October 1, 2013 – September 30, 2014), 37.50% of patients 65 years and older had documentation in the medical record of having received a pneumonia vaccination.","Pneumonia vaccination status for older adults ","Ambulatory/Inpatient",null,"The number of patients in the denominator who responded “Yes” to the question “Have you ever had a pneumonia shot? This shot is usually given only once or twice in the person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.”","The number of patients who responded “Yes” or “No” to the question “Have you ever had a pneumonia shot? This shot is usually given only once or twice in a person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.” ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.1.1 ","","Pneumonia vaccination status for older adults ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_127278302.2.14","RHP 1_127278302.3.40","RHP 1_127278302.2.14_127278302.3.40",{"$f":"COUNTIFS($FI$4:$FI53,FI53)","v":2},"RHP 1_127278302.2.14_2",null,2,1,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR53,FR53)","v":18},"RHP 1_127278302_18"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.2.14","127278302.3.41","IT-1.20","Comprehensive Diabetes Care LDL Screening","Baseline Approved","Eligible to Report in October DY4","The implementation of a PCMH within the IMR continuity clinic at Good Shepherd near its inception will allow optimization of delivery of coordinated care to patients.  As residents often seek practice and/or employment opportunities in close proximity to their post-graduate training programs, this also creates an environment for propagating this model of care within the East Texas region. ","Comprehensive Diabetes Care LDL Screening","In DY4 and DY5 provider will improve the percentage of patients who had an LDL-C test performed during the measurement year over all patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year within the Good Shepherd Internal Medicine Continuity Clinic (GSIMCC)..","Facility ","Good Shepherd Internal Medicine Continuity Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",44256.1,"Yes/No","RHP 1_127278302.3.41_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",44256.1,"Yes/No","RHP 1_127278302.3.41_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",69929.87,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",69929.87,"Numeric",0.70340000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",253813.05,"Numeric",0.71750999999999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.6,81,135,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.70340000000000003,null,0.71750999999999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The GSMC Internal Medicine Continuity Clinic abstracted data from the EMR per Compendium  document IT 1.20 specifications to generate a manual report with the required inclusion and exclusion criteria.  ","During DY 3 (October 1, 2013 – September 30, 2014), 60.00% of patients 18 -75 years of age with a diagnosis of diabetes (type 1 or type 2) who received an LDL-C test.  ","Comprehensive Diabetes Care LDL Screening","ambulatory",null,"Patients who had a low-density cholesterol (LDL-C test) performed during the measurement period.","Patients 18-75 years of age by the end of the measurement period who had a diagnosis of diabetes (type 1 or type 2) during the measurement period or the year prior to the measurement period.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.1.1 ","","Comprehensive Diabetes Care LDL Screening",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_127278302.2.14","RHP 1_127278302.3.41","RHP 1_127278302.2.14_127278302.3.41",{"$f":"COUNTIFS($FI$4:$FI54,FI54)","v":3},"RHP 1_127278302.2.14_3",null,2,1,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR54,FR54)","v":19},"RHP 1_127278302_19"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.2.15","127278302.3.42","IT-13.1","Hospice and Palliative Care – Pain assessment ","Pending Approval","Eligible to Report in October DY4","Deploy two multi-disciplinary palliative care teams to demonstrate a re-design of care delivery models for ambulatory and in-patient care.  One team will assess pain levels and treat a cohort of UPA clinic patients who have chronic debilitating diseases; a second team will be based at GSMC to consult on pain assessment/treatment for a population of in-patients.  Primary care physicians will receive training to enhance pain assessment skills and current pharmacology protocols. ","Hospice and Palliative Care – Pain assessment ","In DY4 and DY5 provider will improve the percentage of patients who received a comprehensive clinical assessment to determine the severity, etiology and impact of their pain within 24 hours of screening positive for pain over all patients enrolled in hospice OR receiving palliative care who report pain when pain screening is done on the admission evaluation / initial encounter at all UPA clinics along with hospitals at both UTHSCT and Good Shepherd Medical Center.","Facility ","all UPA clinics along with hospitals at both UTHSCT and Good Shepherd Medical Center.    ","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",59237.735000000001,"Yes/No","RHP 1_127278302.3.42_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",59237.735000000001,"Yes/No","RHP 1_127278302.3.42_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",93602.625,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",93602.625,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",339734.19,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"UTHSCT/GSMC abstracted data from the EMR per Compendium  document IT 13.1 specifications to generate a palliative care  manual report with the required inclusion and exclusion  criteria.  Information was obtained from the newly created  project specific templates  built in the EMR to capture the  required palliative care data elements. ","During DY 3 (October 1, 2013 – September 30, 2014), 100.00% of hospice and palliative care patients who screened positive for pain received a clinical assessment for pain within 24 hours of screening.  ","Hospice and Palliative Care – Pain assessment ","Ambulatory/Inpatient",null,"Patients who received a comprehensive clinical assessment to determine the severity, etiology, and impact of their pain within 24 hours of screening positive for pain","Patients enrolled in hospice or receiving palliative care who report pain when pain screening is done on the admission evaluation/initial encounter",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.10.1","","Hospice and Palliative Care – Pain assessment ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_127278302.2.15","RHP 1_127278302.3.42","RHP 1_127278302.2.15_127278302.3.42",{"$f":"COUNTIFS($FI$4:$FI55,FI55)","v":1},"RHP 1_127278302.2.15_1",null,2,1,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR55,FR55)","v":20},"RHP 1_127278302_20"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.2.15","127278302.3.43","IT-13.2","Hospice and Palliative Care – Treatment Preferences ","Pending Approval","Eligible to Report in October DY4","Deploy two multi-disciplinary palliative care teams to demonstrate a re-design of care delivery models for ambulatory and in-patient care.  One team will assess pain levels and treat a cohort of UPA clinic patients who have chronic debilitating diseases; a second team will be based at GSMC to consult on pain assessment/treatment for a population of in-patients.  Primary care physicians will receive training to enhance pain assessment skills and current pharmacology protocols. ","Hospice and Palliative Care – Treatment Preferences ","In DY4 and DY5 provider will improve the percentage of patients whose medical record includes documentation of life sustaining preferences over all seriously ill patients enrolled in hospice OR receiving specialty palliative care in an acute hospital setting at all UPA clinics along with hospitals at both UTHSCT and Good Shepherd Medical Center.","Facility ","all UPA clinics along with hospitals at both UTHSCT and Good Shepherd Medical Center.    ","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",59237.735000000001,"Yes/No","RHP 1_127278302.3.43_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",59237.735000000001,"Yes/No","RHP 1_127278302.3.43_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",93602.625,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",93602.625,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",339734.19,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"UTHSCT/GSMC abstracted data from the EMR per Compendium  document IT 13.2 specifications to generate a palliative care  manual report with the required inclusion and exclusion  criteria.  Information was obtained from the newly created  project specific templates  built in the EMR to capture the  required palliative care data elements. ","During DY 3 (October 1, 2013 – September 30, 2014), 97.71% of palliative care patients had chart documentation of preferences for life sustaining treatments.","Hospice and Palliative Care – Treatment Preferences ","Ambulatory/Inpatient",null,"Patients whose medical record includes documentation of life sustaining preferences","Seriously ill patients enrolled in hospice OR receiving palliative care in an acute hospital setting",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.10.1","","Hospice and Palliative Care – Treatment Preferences ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_127278302.2.15","RHP 1_127278302.3.43","RHP 1_127278302.2.15_127278302.3.43",{"$f":"COUNTIFS($FI$4:$FI56,FI56)","v":2},"RHP 1_127278302.2.15_2",null,2,1,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR56,FR56)","v":21},"RHP 1_127278302_21"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.2.15","127278302.3.44","IT-13.5","Hospice and Palliative Care – documentation of spiritual/religions concerns ","Pending Approval","Eligible to Report in October DY4","Deploy two multi-disciplinary palliative care teams to demonstrate a re-design of care delivery models for ambulatory and in-patient care.  One team will assess pain levels and treat a cohort of UPA clinic patients who have chronic debilitating diseases; a second team will be based at GSMC to consult on pain assessment/treatment for a population of in-patients.  Primary care physicians will receive training to enhance pain assessment skills and current pharmacology protocols. ","Hospice and Palliative Care – Percentage of patients receiving hospice or palliative care services with documentation in the clinical record of a discussion of spiritual/religions concerns or documentation that the patient/caregiver did not want to discuss ","In DY4 and DY5 provider will improve the percentage of patients with clinical record documentation of spiritual/religious concerns or documentation that the patient/family did not want to discuss over all patient’s discharged from hospice care during the designated reporting period at all UPA clinics along with hospitals at both UTHSCT and Good Shepherd Medical Center.    .","Facility ","all UPA clinics along with hospitals at both UTHSCT and Good Shepherd Medical Center.    ","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",59237.735000000001,"Yes/No","RHP 1_127278302.3.44_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",59237.735000000001,"Yes/No","RHP 1_127278302.3.44_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",93602.625,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",93602.625,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",339734.19,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"UTHSCT/GSMC abstracted data from the EMR per Compendium  document IT 13.5 specifications to generate a palliative care  manual report with the required inclusion and exclusion  criteria.  Information was obtained from the newly created  project specific templates  built in the EMR to capture the  required palliative care data elements. ","During DY 3 (October 1, 2013 – September 30, 2014), 98.55% of palliative care patients had documentation in the clinical record of a discussion of spiritual/religious concerns or documentation that the patient/caregiver did not want to discuss.","Hospice and Palliative Care – documentation of spiritual/religions concerns ","Ambulatory/Inpatient",null,"Number of patient with clinical record documentation of spiritual/religious concerns or documentation that the patient/family did not want to discuss","Total number of patient’s discharged from hospice care and/or palliative care during the designated reporting period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.10.1","","Hospice and Palliative Care – documentation of spiritual/religions concerns ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_127278302.2.15","RHP 1_127278302.3.44","RHP 1_127278302.2.15_127278302.3.44",{"$f":"COUNTIFS($FI$4:$FI57,FI57)","v":3},"RHP 1_127278302.2.15_3",null,2,1,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR57,FR57)","v":22},"RHP 1_127278302_22"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.2.16","127278302.3.45","IT-1.22","Asthma Percent of Opportunity Achieved","Baseline Approved","Eligible to Report in October DY4","Innovative and expanded demonstration project to diagnosis and support self-management skills among their pediatric populations with acute asthma/allergies respiratory episodes in order to reduce ED visits and hospitalizations.  This project will deploy two mobile teams, under the direction of an Immunology/Allergy specialist, to assess children with a history of breathing problems for a diagnosis and treatment plan. Each team will use CHWs to work with patients/families to minimize triggers and reinforce self-management skills.    ","Asthma Percent of Opportunity Achieved","In DY4 and DY5 provider will improve the percentage of the time that recommended Asthma care was provided at UPA Pediatric Mobile Asthma Clinic and CHRISTUS St. Michael Mobile Pediatric Asthma Clinic","Facility ","UPA Pediatric Mobile Asthma Clinic and CHRISTUS St. Michael Mobile Pediatric Asthma Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",108100.26,"Yes/No","RHP 1_127278302.3.45_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",108100.26,"Yes/No","RHP 1_127278302.3.45_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",341622.37,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",341622.37,"Numeric",0.949506454,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1239931.04,"Numeric",0.95216400000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.94684900000000005,1247,1317,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.949506454,null,0.95216400000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Per Compendium IT – 1.22, data was manually extracted from the EMR and placed into an excel document similar to the template provided in the compendium.  The number of times each of the asthma opportunities (processes) were completed/fulfilled were calculated in the manner suggested in the Compendium document.","From April 1, 2014- September 30, 2014, 94.68% of the asthma opportunities (processes) were completed/fulfilled at least once during the measurement year for individuals with asthma.  The opportunities were documentation of action/management plan, severity assessment, controller therapy for those eligible, and documentation of spirometry assessment completed within last two years.","Asthma Percent of Opportunity Achieved","ambulatory",null,"The number of times that each of the asthma opportunities (processes) listed below were completed/fulfilled at least once during the measurement year for all individuals with asthma (any age) :  \n1.) Documentation of Action/Management Plan, \n2.) Severity Assessment\n3.) Controller Therapy for those who are eligible, and \n4.) Documentation of spirometry assessment completed within last two years.\n","The total number of opportunities can be calculated in the following manner-\nFor each individual with an asthma diagnosis assign a count one for each of the four processes that should have been completed (should be 3-4 counts per patient) at least once during the measurement period. \n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.1 ","","Asthma Percent of Opportunity Achieved",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 1_127278302.2.16","RHP 1_127278302.3.45","RHP 1_127278302.2.16_127278302.3.45",{"$f":"COUNTIFS($FI$4:$FI58,FI58)","v":1},"RHP 1_127278302.2.16_1",null,2,1,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR58,FR58)","v":23},"RHP 1_127278302_23"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.2.17","127278302.3.46","IT-3.3","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","Baseline not yet reported","Eligible to Report in October DY4","Four hospital systems will participate in learning collaboratively to acquire knowledge about and practical experience with a variety of quality improvement tools. Using reduction in 30 day readmissions for CHF as a target, the teams will participate in didactic sessions, root cause analysis, QI tool selection and application to a process point along the continuum of prevention of CHF readmission.  Regularly scheduled meetings and site visits will enable all teams to benefit from the experience and lessons learned by other LCT teams to move all towards a culture of quality within their own institutions. ","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","In DY4 and DY5 provider will improve the ratio of actual readmissions to expected readmissions for individuals discharged for a CHF related inpatient stay for patients 18 years of age and older at Hospital Partners including UTHSCT, GSMC, CSM and PRMC","Facility ","Hospital Partners including UTHSCT, GSMC, CSM and PRMC.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",159373.61499999999,"Yes/No","RHP 1_127278302.3.46_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",159373.61499999999,"Yes/No","RHP 1_127278302.3.46_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",251829.155,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- UTHSCT",62957.28875,"Numeric","TBD","AM-1.2","Achievement of DY4 performance goal- PRMC",62957.28875,"Numeric","TBD","AM-1.3","Achievement of DY4 performance goal- CSM",62957.28875,"Numeric","TBD","AM-1.4","Achievement of DY4 performance goal- GSMC",62957.28875,"Numeric","TBD",null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- UTHSCT",228505.81,"Numeric","TBD","AM-2.2","Achievement of DY5 performance goal- PRMC",228505.81,"Numeric","TBD","AM-2.3","Achievement of DY5 performance goal- CSM",228505.81,"Numeric","TBD","AM-2.4","Achievement of DY5 performance goal- GSMC",228505.81,"Numeric","TBD",null,null,null,null,null,4,"ratio",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,"TBD",null,"TBD",null,"TBD",null,"TBD",null,"TBD",null,"TBD",null,null,null,null,null,null,null,0,0,"Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission for CHF during the measurement year \n","Expected (risk-adjusted) rate of readmissions for CHF during the measurement year. \n\n\n","Observed (Actual) rate of readmissions within 30 days following an Index Admission for CHF during the measurement year \n","Expected (risk-adjusted) rate of readmissions for CHF during the measurement year. \n\n\n","Observed (Actual) rate of readmissions within 30 days following an Index Admission for CHF during the measurement year \n","Expected (risk-adjusted) rate of readmissions for CHF during the measurement year. \n\n\n","Observed (Actual) rate of readmissions within 30 days following an Index Admission for CHF during the measurement year \n","Expected (risk-adjusted) rate of readmissions for CHF during the measurement year. \n\n\n",null,null,null,null,null,null,null,"2.8.4 ","","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate",null,null,null,null,"Risk adjustment method not yet reported",null,null,null,null,"","",null,null,"RHP 1_127278302.2.17","RHP 1_127278302.3.46","RHP 1_127278302.2.17_127278302.3.46",{"$f":"COUNTIFS($FI$4:$FI59,FI59)","v":1},"RHP 1_127278302.2.17_1",null,5,4,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR59,FR59)","v":24},"RHP 1_127278302_24"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.2.18","127278302.3.47","IT-1.8","Screening and Treatment Plan for Clinical Depression ","Baseline Approved","Eligible to Report in October DY4","Increase the number of primary care physicians (in practice and in training) who can effectively and routinely include behavioral health screening, counseling, and treatment, including psychopharmacology, to deliver integrated care.","Depression management: Screening and Treatment Plan for Clinical Depression ","In DY4 and DY5 provider will improve the percentages of patients screened for clinical depression is documented and follow up plan is documented over all patients 18 years of age and older receiving services at UPA clinics (Tyler, University Health, Internal Medicine, Center for Health Aging) and Good Shepherd Internal Medicine Residency Continuity Clinic.","Facility ","UPA clinics (Tyler,  University Health, Internal Medicine, Center for Health Aging) and Good Shepherd Internal Medicine Residency Continuity Clinic.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",118690.72500000001,"Yes/No","RHP 1_127278302.3.47_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",118690.72500000001,"Yes/No","RHP 1_127278302.3.47_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",187545.375,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",187545.38,"Numeric",0.103073601,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",680702.89,"Numeric",0.150280254,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",5.5867E-2,608,10883,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.103073601,null,0.150280254,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"UTHSCT/GSMC abstracted data from the EMR per instructions in the IT 1.8 compendium document.  Information regarding the numerator was pulled from the EMR template based upon patient PHQ9 scores and consolidated into the reporting document.  Information regarding the denominator was abstracted from the scheduling template utilizing a custom report.  This information was then validated using a chart audit process.","IT-1.8:  During the calendar year of October 1,2013-September 30-2014, 5.60% patients ages 18 years and older were screened for clinical depression using a standardized tool AND a follow-up plan was documented.  ","Screening and Treatment Plan for Clinical Depression ","Multiple",null,"Patient’s screening for clinical depression using a standardized tool AND follow-up plan is documented","All patients aged 18 years and older",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.15.1","","Screening and Treatment Plan for Clinical Depression ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_127278302.2.18","RHP 1_127278302.3.47","RHP 1_127278302.2.18_127278302.3.47",{"$f":"COUNTIFS($FI$4:$FI60,FI60)","v":1},"RHP 1_127278302.2.18_1",null,2,1,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR60,FR60)","v":25},"RHP 1_127278302_25"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.2.18","127278302.3.48","IT-1.9","Depression Remission at Twelve Months  ","Baseline Approved","Eligible to Report in October DY4","Increase the number of primary care physicians (in practice and in training) who can effectively and routinely include behavioral health screening, counseling, and treatment, including psychopharmacology, to deliver integrated care.","Depression management: Depression Remission at Twelve Months  ","In DY4 and DY5 provider will improve the percentages of adults age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine who achieve remission at twelve months as demonstrated by a twelve month (+/- 30 days) PHQ-9 score of less than five over all adults age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine receiving services at UPA clinics (Tyler, University Health, Internal Medicine, Center for Health Aging) and Good Shepherd Internal Medicine Residency Continuity Clinic..","Facility ","UPA clinics (Tyler, University Health, Internal Medicine, Center for Health Aging) and Good Shepherd Internal Medicine Residency Continuity Clinic.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",118690.72500000001,"Yes/No","RHP 1_127278302.3.48_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",118690.72500000001,"Yes/No","RHP 1_127278302.3.48_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",187545.375,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",187545.38,"Numeric",6.6101695000000002E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",680702.89,"Numeric",0.11525423799999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",1.6948999999999999E-2,2,118,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,6.6101695000000002E-2,null,0.11525423799999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"UTHSCT/GSMC abstracted data from the EMR per instructions in the IT 1.9 compendium document.  Information regarding the numerator was pulled from the EMR template based upon patient PHQ9 scores and consolidated into the reporting document.  Information regarding the denominator was abstracted from the scheduling template utilizing a custom report.  This information was then validated using a chart audit process.","IT-1.9:  During the calendar year of October 1, 2013-September 30-2014, 1.69% of adult patients ages 18 and older with major depression or dysthymia and an initial PHQ-9 score > 9 were targeted for treatment to demonstrate remission of depression at twelve months (plus or minus 30 days) as defined by a PHQ-9 score of less than 5. ","Depression Remission at Twelve Months  ","ambulatory",null,"Adults age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine who achieve remission at twelve months as demonstrated by a twelve month (+/- 30 days) PHQ-9 score of less than five.","Adults age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine (including, patients who do not have a follow-up PHQ-9 score at twelve months (+/- 30 days)",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.15.1","","Depression Remission at Twelve Months  ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_127278302.2.18","RHP 1_127278302.3.48","RHP 1_127278302.2.18_127278302.3.48",{"$f":"COUNTIFS($FI$4:$FI61,FI61)","v":2},"RHP 1_127278302.2.18_2",null,2,1,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR61,FR61)","v":26},"RHP 1_127278302_26"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.2.19","127278302.3.49","IT-9.2","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","Baseline Approved","Eligible to Report in October DY4","UTHSCT’s hospital and primary care clinics will employ 6 teams of chronic disease patient navigators paired with community health workers to enhance the transfer of information and reinforce medical recommendations from the point of hospital discharge and/or medical home visits in order to improve patient adherence and influence patient disease self-management.","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","In DY4 and DY5 provider will improve the rate of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period over all ED visits for individuals 18 years or older during the measurement period at UTHSCT Emergency Department.","Facility ","UTHSCT Emergency Department","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",223949.63500000001,"Yes/No","RHP 1_127278302.3.49_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",223949.63500000001,"Yes/No","RHP 1_127278302.3.49_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",353866.9,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",353866.9,"Numeric",0.115563266,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1284373.02,"Numeric",0.10948099999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.121646,1718,14123,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.115563266,null,0.10948099999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Per Compendium document IT 9.2:  Reduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) per 100,000 an electronic report to pull information from the EMR was generated with the required inclusion and exclusion criteria.  ","For IT-9.2:  During DY3 (10/01/2013–09/30/2014) of all UTHSCT Emergency Department Visits from any individual 18 years or older 12.16% had a primary or secondary Ambulatory Care Sensitive Condition diagnosis.","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","ED",null,"Total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1 ","","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_127278302.2.19","RHP 1_127278302.3.49","RHP 1_127278302.2.19_127278302.3.49",{"$f":"COUNTIFS($FI$4:$FI62,FI62)","v":1},"RHP 1_127278302.2.19_1",null,2,1,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR62,FR62)","v":27},"RHP 1_127278302_27"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.2.20","127278302.3.50","IT-1.10","Diabetes care: HbA1c poor control (>9.0%) ","Baseline Approved","Eligible to Report in October DY4","CHRISTUS St. Michael Health System (CSM) has a goal to create a partnership with a medical home that initiates preventive care and reduces reliance on emergency departments (ED) for primary care. The partnership for medical home coordination of care is with Genesis PrimeCare, an FQHC that operates according to the NCQA Patient Centered Medical standards. ","Diabetes care: HbA1c poor control (>9.0%) ","In DY4 and DY5 provider will decrease the percentage of patients with diabetes whose most recent A1c result is >9% or was not tested during the measurement year at GenesisPrimeCare (Texarkana, Texas)","Facility ","GenesisPrimeCare (Texarkana, Texas)","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",136126.25,"Yes/No","RHP 1_127278302.3.50_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",136126.25,"Yes/No","RHP 1_127278302.3.50_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",215095.57,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",215095.57,"Numeric",0.50700000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",780697.32,"Numeric",0.48525000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.69312200000000002,262,378,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.50700000000000001,null,0.48525000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Per Compendium IT-1.10, the numerator is all FQHC patients between the ages of 18 – 75 with a diagnosis of diabetes that had a test result on Hb1Ac greater than 9%, or whose test was missing. The denominator is all FQHC patients between the ages of 18-75 with a diagnosis of diabetes.","During DY3 (October 1, 2013 – September 30, 2014) the FQHC saw 378 patients with diabetes diagnosis.  During this time frame, 69.31% of patients had a result exceeding 9% on their HbA1C test, or the test was missing/not done.","Diabetes care: HbA1c poor control (>9.0%) ","ambulatory",null,"Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.1.2 ","","Diabetes care: HbA1c poor control (>9.0%) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_127278302.2.20","RHP 1_127278302.3.50","RHP 1_127278302.2.20_127278302.3.50",{"$f":"COUNTIFS($FI$4:$FI63,FI63)","v":1},"RHP 1_127278302.2.20_1",null,2,1,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR63,FR63)","v":28},"RHP 1_127278302_28"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.2.22","127278302.3.52","IT-3.2","Congestive Heart Failure (CHF) 30-day Readmission Rate","Baseline Approved","Eligible to Report in October DY4","Create smooth transitions of care from inpatient to outpatient settings, alternative inpatient settings (e.g., skilled nursing facilities), or home care so that patients being discharged (or responsible party, as appropriate) understand the care regimen, have follow-up care scheduled, and are at reduced risk for avoidable readmissions. This expansion will be implemented using more information to better identify patients needing case management services and increased staff. The piloted approached with be aided by a tablet like product that will help selected patients better manage their weight, needed medications, vital signs, and needed appointments.","Congestive Heart Failure (CHF) 30-day Readmission Rate","In DY4 and DY5 provider will reduce the number of readmissions occurring within 30 days discharge during the measurement year over all the total number of hospital index admissions for Congestive Heart Failure (CHF) during the measurement period at CHRISTUS St. Michael. In addition, in DY5 provider will complete Stretch Activity #3- Outcome Evaluation. ","Facility ","population will be measured at the facility of CHRISTUS St. Michael.  ","P4R","SA-3","PM-8","Submission of Category 3 DY3 Status Report",132768.29500000001,"Yes/No","RHP 1_127278302.3.52_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",132768.29500000001,"Yes/No","RHP 1_127278302.3.52_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",419579.21,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",380719.57,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",380719.57,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.18613099999999999,51,274,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Per compendium IT -3.2, an electronic report to pull information from the HPM was generated with the required inclusion and exclusion criteria.","IT: 3-2 Congestive Heart Failure (CHF) 30 Day Readmission Rate.\nDuring the last six months of DY3 (04/01/14 – 09/30/14) 18.61% of patients discharged with a principal diagnosis of CHF were readmitted within 30 days. ","Congestive Heart Failure (CHF) 30-day Readmission Rate","inpatient",null,"Total number of admissions (index stay) with at least one subsequent readmission (hospital stay) for any reason within 30 days during the measurement year. ","Total number of hospital stays for CHF during the measurement year for patients 18 years and older.",null,null,null,null,null,null,null,null,null,null,"Stretch Activity baseline not reported in DY3",null,null,"2.12.2","","Congestive Heart Failure (CHF) 30-day Readmission Rate",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 1_127278302.2.22","RHP 1_127278302.3.52","RHP 1_127278302.2.22_127278302.3.52",{"$f":"COUNTIFS($FI$4:$FI64,FI64)","v":1},"RHP 1_127278302.2.22_1",null,2,1,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR64,FR64)","v":29},"RHP 1_127278302_29"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.2.23","127278302.3.53","IT-3.15","Risk Adjusted Behavioral Health /Substance Abuse 30-day Readmission Rate ","Baseline not yet reported","Eligible to Report in October DY4","Provide an Intensive Outpatient Program for adult behavioral health.  Patients will be referred to the program at discharge from the inpatient setting, directly from the ER setting, from the crisis stabilization unit, or from other sources, when the patient does not meet inpatient criteria.  Substance abuse counseling is a component of this program. The overall goal is to avoid acute crisis situations by getting the patients into the appropriate setting for the appropriate level of care to decrease unnecessary ED visits, admissions and readmissions. ","Risk Adjusted Behavioral Health /Substance Abuse 30-day Readmission Rate ","In DY4 and DY5 provider will improve the ratio of actual readmissions to expected readmissions for conditions related to behavioral health and/or substance abuse for individuals aged 18-54 at Palestine Regional Medical Center (PRMC). ","Facility, Age ","Individuals age 18 years - 54 years","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",27896.84,"Yes/No","RHP 1_127278302.3.53_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",27896.84,"Yes/No","RHP 1_127278302.3.53_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",44080.305,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",44080.305,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",159991.1,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Risk Adjusted Behavioral Health /Substance Abuse 30-day Readmission Rate ","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission for BH/SA during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk BH/SA admissions during the measurement period.\n","Expected (risk-adjusted) rate of readmissions for BH/SA during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.13.1","","Risk Adjusted Behavioral Health /Substance Abuse 30-day Readmission Rate ",null,null,null,null,"Risk adjustment method not yet reported",null,null,null,null,"","",null,null,"RHP 1_127278302.2.23","RHP 1_127278302.3.53","RHP 1_127278302.2.23_127278302.3.53",{"$f":"COUNTIFS($FI$4:$FI65,FI65)","v":1},"RHP 1_127278302.2.23_1",null,2,1,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR65,FR65)","v":30},"RHP 1_127278302_30"]
["RHP 1","127278302","University Physician Associates (UPA)","127278302.2.5","127278302.3.20","IT-12.16","High-risk Colorectal Cancer Follow-up rate within one year","Pending Approval","Eligible to Report in October DY4","A team will be formed to simultaneously increase access to specialty providers for GI, medical oncology, and surgical oncology while launching an aggressive social marketing campaign  increase colorectal screening among target populations that experience health disparities.  Texas DSHS certified CHWs who are representative of the target population will implement the outreach program to educate and support patient utilization of colon cancer screening procedures.  The CHWs will also serve as patient navigators for patients requiring further diagnostic/treatment services. ","High-risk Colorectal Cancer Follow-up rate within one year","In DY4 and DY5 provider will improve the percentage of patients who undergo follow‐up colonoscopy within one year after initial colonoscopy detection of sessile adenomas that were removed piecemeal and/or rectal or colon cancer over all patients who have sessile adenomas removed piecemeal and/or rectal or colon cancer detected during colonoscopy.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",116495.14,"Yes/No","RHP 1_127278302.3.20_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",116495.14,"Yes/No","RHP 1_127278302.3.20_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",184076.095,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",184076.095,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",668110.99,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Per Compendium document IT-12.16, a manual report to pull information from the EMR was generated with the required inclusions and exclusions criteria. Information was obtained from the newly created project specific templates for capture of required data elements.","During the six month period of April 1, 2013 thru September 30, 2013, 37.50% of patients underwent a follow-up colonoscopy within one year after initial colonoscopy detection of rectal or colon cancer.","High-risk Colorectal Cancer Follow-up rate within one year","ambulatory",null,"The number of patients who undergo follow‐up colonoscopy within one year after initial colonoscopy detection of sessile adenomas that were removed piecemeal and/or rectal or colon cancer.","The number of patients who have sessile adenomas removed piecemeal and/or rectal or colon cancer detected during colonoscopy.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.7.1 ","","High-risk Colorectal Cancer Follow-up rate within one year",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 1_127278302.2.5","RHP 1_127278302.3.20","RHP 1_127278302.2.5_127278302.3.20",{"$f":"COUNTIFS($FI$4:$FI66,FI66)","v":1},"RHP 1_127278302.2.5_1",null,2,1,1,"RHP 1_127278302",{"$f":"COUNTIFS($FR$4:$FR66,FR66)","v":31},"RHP 1_127278302_31"]
["RHP 1","130612806","East Texas Medical Center Jacksonville","130612806.1.1","130612806.3.200","IT-2.21","Ambulatory Care Sensitive Conditions Admissions Rate","Baseline Approved","Eligible to Report in October DY4","This project increases access to healthcare through extended clinic hours on nights and weekends, recruiting an internist and two pediatricians, and adding needed support staff. \n","Ambulatory Care Sensitive Conditions Admissions Rate","In DY4 and DY5 provider will reduce the percentage of admissions for conditions defined as ambulatory care sensitive  for individuals 18 to  75 years of age out of the total number of admssions to ETMC Jacksonville. ","Facility","ETMC - Jacksonville","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",32068.25,"Yes/No","RHP 1_130612806.3.200_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",32068.25,"Yes/No","RHP 1_130612806.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",51458.625,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",51458.625,"Numeric",14902.783915156871,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",246106.3,"Numeric",14118.426866990721,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",15687.140963323023,355,2263,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,14902.783915156871,null,14118.426866990721,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Potentially Preventable Hospitalization Conditions for the hospital for the specific time period (10/1/13-9/30/14)","Total Discharges for the hospital for the specific time period (10/1/13-9/30/14)","Ambulatory Care Sensitive Conditions Admissions Rate","inpatient",null,"Total number of acute care hospitalizations for ambulatory care sensitive conditions younger than age 75 years ","Total mid-measurement period population younger than age 75",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","Ambulatory Care Sensitive Conditions Admissions Rate",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_130612806.1.1","RHP 1_130612806.3.200",{"$f":"A67&\"_\"&D67&\"_\"&E67","v":"RHP 1_130612806.1.1_130612806.3.200"},{"$f":"COUNTIFS($FI$4:$FI67,FI67)","v":1},{"$f":"FI67&\"_\"&FL67","v":"RHP 1_130612806.1.1_1"},null,2,1,1,{"$f":"A67&\"_\"&RIGHT(\"000000000\"&B67,9)","v":"RHP 1_130612806"},{"$f":"COUNTIFS($FR$4:$FR67,FR67)","v":1},"RHP 1_130612806_1"]
["RHP 1","130612806","East Texas Medical Center Jacksonville","130612806.2.1","130612806.3.201","IT-2.21","Ambulatory Care Sensitive Conditions Admissions Rate","Baseline Approved","Eligible to Report in October DY4"," This project is to implement a patient navigation service that shifts non-urgent patients to a more appropriate level of care.  The patient navigators will provide non-urgent patients with a referral to a primary care provider. \n","Ambulatory Care Sensitive Conditions Admissions Rate","In DY4 and DY5 provider will reduce the percentage of admissions for conditions defined as ambulatory care sensitive  for individuals 18 to  75 years of age out of the total number of admssions to ETMC Jacksonville. ","Facility","ETMC - Jacksonville","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",32068.25,"Yes/No","RHP 1_130612806.3.201_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",32068.25,"Yes/No","RHP 1_130612806.3.201_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",51458.625,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",51458.625,"Numeric",14902.783915156871,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",246106.3,"Numeric",14118.426866990721,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",15687.140963323023,355,2263,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,14902.783915156871,null,14118.426866990721,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Potentially Preventable Hospitalization Conditions for the hospital for the specific time period (10/1/13-9/30/14)","Total Discharges for the hospital for the specific time period (10/1/13-9/30/14)","Ambulatory Care Sensitive Conditions Admissions Rate","inpatient",null,"Total number of acute care hospitalizations for ambulatory care sensitive conditions younger than age 75 years ","Total mid-measurement period population younger than age 75",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1 ","","Ambulatory Care Sensitive Conditions Admissions Rate",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,{"$f":"A68&\"_\"&D68","v":"RHP 1_130612806.2.1"},{"$f":"A68&\"_\"&E68","v":"RHP 1_130612806.3.201"},"RHP 1_130612806.2.1_130612806.3.201",{"$f":"COUNTIFS($FI$4:$FI68,FI68)","v":1},"RHP 1_130612806.2.1_1",null,2,{"$f":"IF(DC68=\"\",0,1)+IF(DG68=\"\",0,1)+IF(DK68=\"\",0,1)+IF(DO68=\"\",0,1)+IF(DS68=\"\",0,1)","v":1},1,"RHP 1_130612806",{"$f":"COUNTIFS($FR$4:$FR68,FR68)","v":2},{"$f":"FR68&\"_\"&FS68","v":"RHP 1_130612806_2"}]
["RHP 1","131037704","Hopkins County Memorial Hospital","131037704.1.1","131037704.3.1","IT-6.1.b.i","CG-CAHPS 12-month: Timeliness of Appointments, Care, & Information","Baseline Approved","Eligible to Report in April DY4","This project will expand primary care capacity by hiring two primary care providers to practice in our established Rural Health primary care clinic.","CG-CAHPS 12-month: Timeliness of Appointments, Care, & Information","In DY4 and DY5 provider will improve (increase) the CAHPS scores related to the Timeliness of Appointments, Care, & Information.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",28840.35,"Yes/No","RHP 1_131037704.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",28840.35,"Yes/No","RHP 1_131037704.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",46409.25,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",46409.25,"Numeric",0.661135523,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",221211.3,"Numeric",0.67545379800000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.64681699999999998,315,487,"06/01/12 - 05/31/13",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.661135523,null,0.67545379800000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Surveys were mailed to patients seen by a PCP in Memorial Clinic based on the criteria set by NRC Picker for random sampling.  These surveys were returned to NRC Picker who tabulated the results and electronically sent the aggregate data.","For the Timeliness of Appointments, Care and Information , there are two questions that pertain to this outcome.  The scores were averaged to define the baseline score of  of 64.68% top box response.","CG-CAHPS 12-month: Timeliness of Appointments, Care, & Information","Ambulatory",null,"Patient-mix and survey mode adjusted percent \"top box\" score for a given subdomain as provided by your survey administrator, multiplied by the number of completed CG-CAHPS surveys represented in the \"top box\" score.","The number of CG-CAHPS surveys completed during the measurement period as reported by your survey administrator. The denominator should be the same as the multiplier used in the numerator.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","CG-CAHPS 12-month: Timeliness of Appointments, Care, & Information",null,null,null,null,null,"2013-06-01","2014-05-31","2014-06-01","2015-05-31","2012-06-01","2013-05-31",null,null,"RHP 1_131037704.1.1","RHP 1_131037704.3.1","RHP 1_131037704.1.1_131037704.3.1",{"$f":"COUNTIFS($FI$4:$FI69,FI69)","v":1},"RHP 1_131037704.1.1_1",null,{"$f":"MAX(IF(AC69=\"\",0,1)+IF(AH69=\"\",0,1)+IF(AM69=\"\",0,1)+IF(AR69=\"\",0,1)+IF(AW69=\"\",0,1)+IF(BB69=\"\",0,1),IF(BG69=\"\",0,1)+IF(BL69=\"\",0,1)+IF(BQ69=\"\",0,1)+IF(BV69=\"\",0,1)+IF(CA69=\"\",0,1))","v":2},1,{"$f":"FO69-FP69","v":1},"RHP 1_131037704",{"$f":"COUNTIFS($FR$4:$FR69,FR69)","v":1},"RHP 1_131037704_1"]
["RHP 1","131037704","Hopkins County Memorial Hospital","131037704.1.2","131037704.3.200","IT-9.6","Emergency department (ED) visits where patients left without being seen","Pending Approval","Eligible to Report in October DY4","We will purchase clinic space and hire an additional primary care provider and staff to expand access to primary care. This project will allow HCMH the ability to provide appropriate care in a timely manner in the proper setting to the uninsured and underinsured population who currently seek primary health care in the Emergency Department as Level 1 and Level 2\npatients.","Emergency department (ED) visits where patients left without being seen","In DY4 and DY5 provider will improve (decrease) the percentage of patients presenting to the emergency department (ED) who did not wait after having clinical information documented about their presenting complaint, during the time period.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",10254.344999999999,"Yes/No","RHP 1_131037704.3.200_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",10254.344999999999,"Yes/No","RHP 1_131037704.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",16501.064999999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",16501.064999999999,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",78652.91,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The Meditech EMR  captures the patient time of arrival, departure, disposition, chief complaint and diagnosis in the ER Log report.   This data is transferred  to an excel spreadsheet that calculates times for door to physician, door to triage,and  average LOS for admitted and discharged patients and is then displayed in the ED Daily Score Card.","Baseline was established in DY3  and reported in the April 2014 Report using  information from prior fiscal year.  Have a 2.2% baseline of LWBS","Emergency department (ED) visits where patients left without being seen","ED",null,"Number of patients presenting to the emergency department (ED) who did not wait* after having clinical information documented** about their presenting complaint, during the time period","Total number of patients presenting to the emergency department (ED), during the time period",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2","","Emergency department (ED) visits where patients left without being seen",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 1_131037704.1.2","RHP 1_131037704.3.200","RHP 1_131037704.1.2_131037704.3.200",{"$f":"COUNTIFS($FI$4:$FI70,FI70)","v":1},"RHP 1_131037704.1.2_1",null,2,1,1,"RHP 1_131037704",{"$f":"COUNTIFS($FR$4:$FR70,FR70)","v":2},"RHP 1_131037704_2"]
["RHP 1","131037704","Hopkins County Memorial Hospital","131037704.1.2","131037704.3.201","IT-9.10.a","Median Time from ED Arrival to ED Departure for Discharged ED Patients","Baseline Approved","Eligible to Report in April DY4","We will purchase clinic space and hire an additional primary care provider and staff to expand access to primary care. This project will allow HCMH the ability to provide appropriate care in a timely manner in the proper setting to the uninsured and underinsured population who currently seek primary health care in the Emergency Department as Level 1 and Level 2\npatients.","Median Time from ED Arrival to ED Departure for Discharged ED Patients","In DY4 and DY5 provider will improve (decrease) the median time from emergency department arrival to time of departure from the emergency room for patients discharged from the emergency department",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",10254.344999999999,"Yes/No","RHP 1_131037704.3.201_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",10254.344999999999,"Yes/No","RHP 1_131037704.3.201_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",16501.064999999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",16501.07,"Numeric",112.1,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",78652.91,"Numeric",106.2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"time (minutes)",118,118,1,"DY2: Oct 1st, 2012 - Sept 30th, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,112.1,null,106.2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The Meditech EMR  captures the patient time of arrival, departure, disposition, chief complaint and diagnosis in the ER Log report.   This data is transferred  to an excel spreadsheet that calculates times for door to physician, door to triage,and  average LOS for admitted and discharged patients and is then displayed in the ED Daily Score Card.  ","Baseline was established in DY3  and reported in the April 2014 Report using  information from prior fiscal year.  For the 14,686 patients discharged from our ED, the average time from arrival to discharge was 118 minutes.","Median Time from ED Arrival to ED Departure for Discharged ED Patients","ED",null,"Median Time from ED Arrival to ED Departure for Discharged ED Patients: Continuous Variable Statement: Time (in minutes) from ED arrival to ED departure for patients discharged from the emergency department. ",1,null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2","","Median Time from ED Arrival to ED Departure for Discharged ED Patients",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 1_131037704.1.2","RHP 1_131037704.3.201","RHP 1_131037704.1.2_131037704.3.201",{"$f":"COUNTIFS($FI$4:$FI71,FI71)","v":2},"RHP 1_131037704.1.2_2",null,2,1,1,"RHP 1_131037704",{"$f":"COUNTIFS($FR$4:$FR71,FR71)","v":3},"RHP 1_131037704_3"]
["RHP 1","131037704","Hopkins County Memorial Hospital","131037704.1.2","131037704.3.3","IT-9.10.c","Median time from ED arrival to time of departure from the emergency room for patients admitted to the facility from the ED","Pending Approval","Eligible to Report in October DY4","We will purchase clinic space and hire an additional primary care provider and staff to expand access to primary care. This project will allow HCMH the ability to provide appropriate care in a timely manner in the proper setting to the uninsured and underinsured population who currently seek primary health care in the Emergency Department as Level 1 and Level 2\npatients.","Median time from ED arrival to time of departure from the emergency room for patients admitted to the facility from the ED","In DY4 and DY5 provider will improve (decrease) the median time from emergency department (ED) arrival to time of departure from the emergency room for patients admitted to the facility from the ED.\n\n",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",10254.344999999999,"Yes/No","RHP 1_131037704.3.3_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",10254.344999999999,"Yes/No","RHP 1_131037704.3.3_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",16501.064999999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",16501.064999999999,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",78652.91,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"time (minutes)",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The Meditech EMR  captures the patient time of arrival, departure, disposition, chief complaint and diagnosis in the ER Log report.   This data is transferred  to an excel spreadsheet that calculates times for door to physician, door to triage,and  average LOS for admitted and discharged patients and is then displayed in the ED Daily Score Card.  ","Baseline was established in DY3  and reported in the April 2014 Report using  information from prior fiscal year.  For the 2,779 patients admitted to our hospital, the average time was 213 minutes.","Median time from ED arrival to time of departure from the emergency room for patients admitted to the facility from the ED","ED",null,"Median time from ED arrival to time of departure from the emergency room for patients admitted to the facility from the ED: Continuous variable statement: Time (in minutes) from emergency department (ED) arrival to ED departure for patients admitted to the facility from the ED",1,null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2","","Median time from ED arrival to time of departure from the emergency room for patients admitted to the facility from the ED",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 1_131037704.1.2","RHP 1_131037704.3.3","RHP 1_131037704.1.2_131037704.3.3",{"$f":"COUNTIFS($FI$4:$FI72,FI72)","v":3},"RHP 1_131037704.1.2_3",null,2,1,1,"RHP 1_131037704",{"$f":"COUNTIFS($FR$4:$FR72,FR72)","v":4},"RHP 1_131037704_4"]
["RHP 1","131037704","Hopkins County Memorial Hospital","131037704.2.1","131037704.3.2","IT-5.1.a","Improved Cost Savings: Cost of Illness Analysis","Baseline not yet reported","Eligible to Report in October DY4","This project will implement a cost accounting system to identify unique and specific costs of providing care for the top 25 DRGs by volume.","Improved Cost Savings: Demonstrate cost savings in care delivery - Cost of Illness Analysis","In DY4 and DY5 provider will improve (decrease) the direct inpatient costs associated with the top 25 diagnoses. ","Facility, Comorbid Condition ","top 25 DRGs and reduce the direct inpatient costs using average cost","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",22110.935000000001,"Yes/No","RHP 1_131037704.3.2_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",22110.935000000001,"Yes/No","RHP 1_131037704.3.2_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",35580.425000000003,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",35580.425000000003,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",169595.33,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"$",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Improved Cost Savings: Cost of Illness Analysis","Multiple",null,"Formula: COI = Direct cost + Indirect cost","Total number of patients with the designated illness during the measurement year",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.5.3 ","","Improved Cost Savings: Cost of Illness Analysis",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 1_131037704.2.1","RHP 1_131037704.3.2","RHP 1_131037704.2.1_131037704.3.2",{"$f":"COUNTIFS($FI$4:$FI73,FI73)","v":1},"RHP 1_131037704.2.1_1",null,2,1,1,"RHP 1_131037704",{"$f":"COUNTIFS($FR$4:$FR73,FR73)","v":5},"RHP 1_131037704_5"]
["RHP 1","131037704","Hopkins County Memorial Hospital","131037704.2.2","131037704.3.4","IT-3.3","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","Pending Approval","Eligible to Report in October DY4","This project will develop, implement and evaluate standardized clinical protocols and evidence based care delivery model to improve care transitions focusing on the congestive heart failure patients.","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","In DY4 and DY5 provider will improve the ratio of actual readmissions to expected readmissions for individuals discharged for a CHF related inpatient stay. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",14420.174999999999,"Yes/No","RHP 1_131037704.3.4_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",14420.174999999999,"Yes/No","RHP 1_131037704.3.4_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",23204.625,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",23204.625,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",110605.65,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"When we manually counted the CHF readmits, we were using the DRG codes for CHF.   Now that we have  the 3M software to  run the risk adjusted CHF readmits reports, it uses diagnosis codes rather than DRGs to calculate.  So the baseline changed from 24 readmits of the 88 patients discharged in 2013 to  6 of","The expected readmission rate based on 98 CHF admits for DY2  was 11.54 and our facility's observed rate for DY2 was 7.5.  We are preforming better than expected.","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission for CHF during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk CHF admissions during the measurement period.\n","Expected (risk-adjusted) rate of readmissions for CHF during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc. \n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.12.1","","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate",null,null,null,null,"3M","2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 1_131037704.2.2","RHP 1_131037704.3.4","RHP 1_131037704.2.2_131037704.3.4",{"$f":"COUNTIFS($FI$4:$FI74,FI74)","v":1},"RHP 1_131037704.2.2_1",null,2,1,1,"RHP 1_131037704",{"$f":"COUNTIFS($FR$4:$FR74,FR74)","v":6},"RHP 1_131037704_6"]
["RHP 1","131038504","Hunt Regional Medical Center Greenville","131038504.1.1","131038504.3.200","IT-12.2","Cervical Cancer Screening ","Baseline Approved","Eligible to Report in October DY4","Hunt Regional Medical Center will partner with the Greenville Community Health Service Agency to increase primary care capacity in Hunt County. The project will increase primary care capacity by expanding clinic space, hours and primary care providers.  ","Cervical Cancer Screening ","In DY4 and DY5 provider will improve the percentage of women who were screened for cervical cancer over all women 24-64 years of age as of the end of the measurement year at the Greenville Community Health Center Medicine Clinic.","Facility ","denominator will include women at the Greenville Community Health Center Medicine Clinic.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",20909.965,"Yes/No","RHP 1_131038504.3.200_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",20909.965,"Yes/No","RHP 1_131038504.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",33630.300000000003,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",33630.300000000003,"Numeric",0.68369999999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",160983.53,"Numeric",0.69384000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.68,204,300,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.68369999999999997,null,0.69384000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator and denominator values were calculated using data from the electronic health record. The report specifications matched the inclusion and exclusion criteria as outlined in the IT 12.2 Compendium. Report Specifications:  \n• Date: 10/01/13-09/31/14\n• Location: Greenville Community Health Center\n• Sex: female\n• Age: 21-64\nNumerator Inclusions:\n• Women age 21–64 who had cervical cytology performed every 3 years\nDenominator Inclusion:\n• Women 24-64 years of age as of 09/30/14\nDenominator Exclusion:\n• Documentation of women who had a hysterectomy with no residual cervix (determined through manual chart review) \n","From October 1, 2013 – September 30, 2014, of those patient eligible for cervical cancer screening, 68% of the eligible women received cervical cancer screening as recommended. ","Cervical Cancer Screening ","ambulatory",null,"The number of women who were screened for cervical cancer during the measurement year or the two years prior to the measurement year.","Women 24-64 years of age as of the end of the measurement year ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","Cervical Cancer Screening ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_131038504.1.1","RHP 1_131038504.3.200","RHP 1_131038504.1.1_131038504.3.200",{"$f":"COUNTIFS($FI$4:$FI75,FI75)","v":1},"RHP 1_131038504.1.1_1",null,2,1,1,"RHP 1_131038504",{"$f":"COUNTIFS($FR$4:$FR75,FR75)","v":1},"RHP 1_131038504_1"]
["RHP 1","131038504","Hunt Regional Medical Center Greenville","131038504.1.1","131038504.3.201","IT-12.3","Colorectal Cancer Screening ","Baseline Approved","Eligible to Report in October DY4","Hunt Regional Medical Center will partner with the Greenville Community Health Service Agency to increase primary care capacity in Hunt County. The project will increase primary care capacity by expanding clinic space, hours and primary care providers.  ","Colorectal Cancer Screening ","In DY4 and DY5 provider will improve the percentage of individuals with one or more screenings for colorectal cancer (FOBT, sigmoidoscopy, colonoscopy) over all patients 51–75 years of age as of the end of measurement year at the Greenville Community Health Center Medicine Clinic.","Facility ","patients at the Greenville Community Health Center Medicine Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",20909.965,"Yes/No","RHP 1_131038504.3.201_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",20909.965,"Yes/No","RHP 1_131038504.3.201_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",33630.300000000003,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",33630.300000000003,"Numeric",0.51,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",160983.53,"Numeric",0.53300000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.17,51,300,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.51,null,0.53300000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator and denominator values were calculated using data from the electronic health record and a manual chart review process to determine denominator exclusions. The report specifications matched the inclusion and exclusion criteria as outlined in the IT 12.3 Compendium. Report Specifications:  \n• Date: 10/01/13-09/30/14\n• Location: Greenville Community Health Center\n• Age: 51-75\nNumerator Inclusions:\nOne or more colorectal cancer screenings:\n• Fecal occult blood test (FOBT) \n• Flexible sigmoidoscopy\n• Colonoscopy during the measurement year or the nine years prior to the measurement year.\nDenominator Inclusion:\n• Patients 51–75 years of age as of 09/30/14\nDenominator Exclusion:\n• Documentation of colorectal cancer or total colectomy (chart review)\n","From October 1, 2013 – September 30, 2014, of those patients eligible for colorectal cancer screening, 17% of the eligible individuals received colorectal cancer screening as recommended. ","Colorectal Cancer Screening ","ambulatory",null,"One or more screenings for colorectal cancer. Any of the following meet the criteria: \n\n• Fecal occult blood test (FOBT) during the measurement year. For administrative data, assume the required number of samples were returned regardless of FOBT type.\n• Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year.\n• Colonoscopy during the measurement year or the nine years prior to the measurement year.\n","Patients 51–75 years of age as of the end of the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","Colorectal Cancer Screening ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_131038504.1.1","RHP 1_131038504.3.201","RHP 1_131038504.1.1_131038504.3.201",{"$f":"COUNTIFS($FI$4:$FI76,FI76)","v":2},"RHP 1_131038504.1.1_2",null,2,1,1,"RHP 1_131038504",{"$f":"COUNTIFS($FR$4:$FR76,FR76)","v":2},"RHP 1_131038504_2"]
["RHP 1","131038504","Hunt Regional Medical Center Greenville","131038504.1.1","131038504.3.202","IT-1.1","Third next available appointment ","Baseline Approved","Eligible to Report in October DY4","Hunt Regional Medical Center will partner with the Greenville Community Health Service Agency to increase primary care capacity in Hunt County. The project will increase primary care capacity by expanding clinic space, hours and primary care providers.  ","Third next available appointment ","In DY4 and DY5 provider will improve the average number of days to third next available appointment for an office visit at the Greenville Community Health Center Medicine Clinic.","Facility ","patients/appointments at the Greenville Community Health Center Medicine Clinic.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",20909.965,"Yes/No","RHP 1_131038504.3.202_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",20909.965,"Yes/No","RHP 1_131038504.3.202_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",33630.300000000003,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",33630.300000000003,"Numeric",28.652000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",160983.53,"Numeric",27.143999999999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"time (days)",30.16,180.96,6,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,28.652000000000001,null,27.143999999999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"***The above formula in excel is INCORRECT. This was discovered after the question period. The RATE shoud be calculated as average days to the third next available appointment divided by providers.  The formula is calculating a percent. The CORRECT rate is 5.02.  Question submitted to HHSC box. *** The numerator and denominator values were calculated using data from the scheduling module in the electronic health record system. The report specifications matched the inclusion and exclusion criteria as outlined in the IT 1.1 Compendium. Report Specifications:  \n• Date: 10/01/13-09/30/14\n• Location: Greenville Community Health Center\n• Providers: All (6)\nNumerator Inclusions:\n• Average number of days to third next available appointment for an office visit \nDenominator Inclusion:\n• All office encounters \n","During the period of October 1, 2013 – September 30, 2014, the average days to the third next available appointment was 30.16 and the number of providers was 6 resulting in a rate of third next available appointment rate of 5.02. ","Third next available appointment ","ambulatory",null,"Continuous variable statement: Average number of days to third next available appointment for an office visit for each clinic and/or department MULTIPLED by the value in the denominator.  This will lead to a resulting rate of days to third next available appointment. The measure will take into account calendar days, including weekends, holidays and clinician days off.\n","Number of providers within reported clinics and/or departments included in analysis of this outcome",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","Third next available appointment ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_131038504.1.1","RHP 1_131038504.3.202","RHP 1_131038504.1.1_131038504.3.202",{"$f":"COUNTIFS($FI$4:$FI77,FI77)","v":3},"RHP 1_131038504.1.1_3",null,2,1,1,"RHP 1_131038504",{"$f":"COUNTIFS($FR$4:$FR77,FR77)","v":3},"RHP 1_131038504_3"]
["RHP 1","131038504","Hunt Regional Medical Center Greenville","131038504.1.2","131038504.3.203","IT-3.3","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","Pending Approval","Eligible to Report in October DY4","Implement telehealth to provide remote patient monitoring and outpatient disease management to congestive heart failure patients in the home setting.  ","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","In DY4 and DY5 provider will improve the ratio of actual readmissions to expected readmissions for individuals discharged for a CHF related inpatient stay. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",62729.9,"Yes/No","RHP 1_131038504.3.203_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",62729.9,"Yes/No","RHP 1_131038504.3.203_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",100890.9,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",100890.9,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",482950.6,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"*** The above formula should calculate a percent*** The numerator and denominator values were calculated electronically utilizing ADT and coding/claim data as described above. The report specifications matched the inclusion and exclusion criteria as outlined in the IT 3.3 Compendium. Report Specifications: \n• Date: 10/01/13-03/31/14\n• Location: Greenville \n• Age 18 years and above\nNumerator Inclusions: \n• Service Line CHF (DRG 291, 292, 293)\n• Inpatient readmissions within 30 days of index hospitalization \nNumerator Exclusions:\n• Discharge Disposition- AMA or expired \nDenominator Inclusions:\n• Service Line CHF (DRG 291, 292, 293) 3M APR-DRG methodology \nDenominator Exclusions \n• Discharge Disposition- AMA or expired \n","From October 1, 2013 – March 31, 2014, HRMC had 124 inpatients admitted for CHF. Of those,  21 patients were readmitted within 30 days from the index hospitalization resulting in a 17% rate of risk adjusted CHF 30 day readmission. ","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission for CHF during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk CHF admissions during the measurement period.\n","Expected (risk-adjusted) rate of readmissions for CHF during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc. \n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.7.2 ","","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate",null,null,null,null,"3M APR-DRG grouper ","2014-04-01","2015-03-31","2015-04-01","2016-03-31","2013-10-01","2014-03-31",null,null,"RHP 1_131038504.1.2","RHP 1_131038504.3.203","RHP 1_131038504.1.2_131038504.3.203",{"$f":"COUNTIFS($FI$4:$FI78,FI78)","v":1},"RHP 1_131038504.1.2_1",null,2,1,1,"RHP 1_131038504",{"$f":"COUNTIFS($FR$4:$FR78,FR78)","v":4},"RHP 1_131038504_4"]
["RHP 1","131038504","Hunt Regional Medical Center Greenville","131038504.1.3","131038504.3.5","IT-4.5","Patient Fall Rate","Baseline Approved","Eligible to Report in October DY4","Implement a project to enhance performance improvement and reporting capacity through people, processes and technology.  We will hire two additional quality analysts to collect, analyze and perform performance improvement, purchase and install a data repository and interface to collect real-time data, develop a quality dashboard to measure improvement and select quality indicators including potentially preventable complications for rapid improvement. ","Patient Fall Rate","In DY4 and DY5 provider will reduce the total number of all documented falls, with or without injury, experienced by patients on eligible unit types in a measurement period. Reported as Total Falls per 1,000 Patient Days and Unassisted Falls per 1000 Patient Days.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",62729.9,"Yes/No","RHP 1_131038504.3.5_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",31364.95,"Yes/No","RHP 1_131038504.3.5_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",50445.45,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- Total Falls",25222.724999999999,"Numeric",6.1247985260000002,"AM-1.2","Achievement of DY4 performance goal- Unassisted Falls",25222.724999999999,"Numeric",5.5998159999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- Total Falls",120737.65,"Numeric",5.802441,"AM-2.2","Achievement of DY5 performance goal- Unassisted Falls",120737.65,"Numeric",5.3050889999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"number per 1K",6.447156343541331,140,21715,"DY3: Oct 1st, 2013- Sept 30th, 2014",5.8945429426663596,128,21715,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,6.1247985260000002,null,5.802441,null,5.5998159999999997,null,5.3050889999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"***The above formula in excel is INCORRECT. This was discovered after the question period. The fall rate SHOULD be calculated as falls divided by patient days multiplied by 1000. The formula is multiplying by 100 instead. Question submitted to HHSC box. *** \nThe numerator and denominator values were calculated using data from HRMC occurrence reporting software and the electronic health record as described above. The report specifications matched the inclusion and exclusion criteria as outlined in the IT 4.5Compendium. Report Specifications:  \n• Date: 10/01/13-09/31/14\n• Location: Greenville \nNumerator Inclusions: \nTotal Falls: All patient falls including: ICU, Telemetry East (Observation), Telemetry West (ICU step down), Surgical and acute rehab. \nTotal Unassisted Falls: all unassisted falls including: ICU, Telemetry East (Observation), Telemetry West (ICU step down), Surgical and acute rehab. \nDenominator Inclusions: Inpatient days from ICU, Telemetry East (Observation), Telemetry West (ICU step down), Surgical and acute rehab\nDenominator Exclusions: Inpatient days from obstetrics, nursery, NICU, Behavioral Health ","From October 1, 2013 – September 30, 2014, HRMC had 21, 715 inpatient days from included units with 140 total and 128 unassisted patient falls. The total patient fall rate is 6.4 falls/1000 patient days and unassisted patient fall rate is 5.9 falls/1000 patient days.","Patient Fall Rate","inpatient",null,"Rate #1 (Total Falls): Total number of patient falls (with or without injury to the patient and whether or not assisted by a staff member) by hospital unit during the measurement period","Patient days by hospital unit ","Rate #2 (Total Unassisted Falls): Total number of patient falls (with or without injury to the patient) that were not not assisted by a staff member by hospital unit during the measurement period","Patient days by hospital unit ",null,null,null,null,null,null,null,null,null,null,null,"1.10.2","","Total Falls","Unassisted Falls",null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_131038504.1.3","RHP 1_131038504.3.5","RHP 1_131038504.1.3_131038504.3.5",{"$f":"COUNTIFS($FI$4:$FI79,FI79)","v":1},"RHP 1_131038504.1.3_1",null,3,2,1,"RHP 1_131038504",{"$f":"COUNTIFS($FR$4:$FR79,FR79)","v":5},"RHP 1_131038504_5"]
["RHP 1","131038504","Hunt Regional Medical Center Greenville","131038504.1.3","131038504.3.500","IT-4.19","Falls: Screening, Risk-Assessment, and Plan of Care to Prevent Future Falls","Baseline Approved","Eligible to Report in October DY4","Implement a project to enhance performance improvement and reporting capacity through people, processes and technology.  We will hire two additional quality analysts to collect, analyze and perform performance improvement, purchase and install a data repository and interface to collect real-time data, develop a quality dashboard to measure improvement and select quality indicators including potentially preventable complications for rapid improvement. ","Falls: Screening, Risk-Assessment, and Plan of Care to Prevent Future Falls","In DY4 and DY5 provider will increase assessment of fall prevention in older adults. The measure has three rates:\n\nA) Screening for Future Fall Risk:\nPercentage of patients aged 65 years of age and older who were screened for future fall risk at least once within 12 months\n\nB) Falls: Risk Assessment:\nPercentage of patients aged 65 years of age and older with a history of falls who had a risk assessment for falls completed within 12 months\n\nC) Plan of Care for Falls:\nPercentage of patients aged 65 years of age and older with a history of falls who had a plan of care for falls documented within 12 months.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",0,"Yes/No","RHP 1_131038504.3.500_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",31364.95,"Yes/No","RHP 1_131038504.3.500_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",50445.45,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- Screening",16815.149999999998,"Numeric",0.72583034099999999,"AM-1.2","Achievement of DY4 performance goal- Risk Assessment",16815.149999999998,"Numeric",0.94567800000000002,"AM-1.3","Achievement of DY4 performance goal- Plan of Care",16815.149999999998,"Numeric",0.82819100000000001,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- Screening",80491.766666666663,"Numeric",0.74026000000000003,"AM-2.2","Achievement of DY5 performance goal- Risk Assessment",80491.766666666663,"Numeric",0.94853699999999996,"AM-2.3","Achievement of DY5 performance goal- Plan of Care",80491.766666666663,"Numeric",0.83723400000000003,null,null,null,null,null,null,null,null,null,null,3,"%",0.71140000000000003,1585,2228,"DY3: Oct 1st, 2013- Sept 30th, 2014",0.94281899999999996,709,752,"DY3: Oct 1st, 2013- Sept 30th, 2014",0.81914893600000005,616,752,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0.72583034099999999,null,0.74026000000000003,null,0.94567800000000002,null,0.94853699999999996,null,0.82819100000000001,null,0.83723400000000003,null,null,null,null,null,null,null,null,null,null,null,"The numerator and denominator values were calculated using data from Meditech, the electronic health record. The report specifications matched the inclusion and exclusion criteria as outlined in the IT 4.19 Compendium. Report Specifications:  \n• Date: 10/01/13-09/31/14\n• Location: Greenville \n• Age 65 years old and older \n\nNumerator Inclusions (documented in the nursing fall risk assessment on admission): \n• Rate 1: Patients who were screened for future fall risk at last once within 12 months\n• Rate 2: Patients at risk of future fall who had a multifactorial risk assessment for falls completed within 12 months.\n• Rate 3: Patients at risk of future fall having had had 2 or more falls in the past year or any fall with injury in the past year. \nDenominator Inclusions:\n• Rate 1:  All patients aged 65 years and older.\n• Rate 2 & 3: All patients aged 65 years and older with a history of falls (history of falls is defined as 2 or more falls in the past year or any fall with injury in the past year).\n","From October 1, 2013 – September 30, 2014, HRMC had 2,228 individuals aged 65 and over and 752 patients aged 65 and over who were assessed with a history of falls. Of these, 1585 individuals or 71% (rate 1) were screened for their future fall risk within the previous 12 months, 709 individuals or 94% (rate2) received a multifactorial risk assessment for falls and 616 individuals or 82% (rate 3) of patients at risk of a future fall had a plan of care for fall prevention documented within the previous 12 months. ","Falls: Screening, Risk-Assessment, and Plan of Care to Prevent Future Falls","BOTH",null,"Rate #1: Patients who were screened for future fall* risk** at last once within 12 months","Rate #1:  All patients aged 65 years and older.","Rate #2: Patients at risk* of future fall** who had a multifactorial risk\nassessment*** for falls completed within 12 months\n","All patients aged 65 years and older with a history of falls (history of falls is defined as 2 or more falls in the past year or any fall with injury in the past year).","Rate #3: Patients at risk* of future fall** with a plan of care**** for falls prevention documented within 12 months.","All patients aged 65 years and older with a history of falls (history of falls is defined as 2 or more falls in the past year or any fall with injury in the past year).",null,null,null,null,null,null,null,null,null,"1.10.2","","Screening","Risk Assessment ","Plan of Care",null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_131038504.1.3","RHP 1_131038504.3.500","RHP 1_131038504.1.3_131038504.3.500",{"$f":"COUNTIFS($FI$4:$FI80,FI80)","v":2},"RHP 1_131038504.1.3_2",null,4,3,1,"RHP 1_131038504",{"$f":"COUNTIFS($FR$4:$FR80,FR80)","v":6},"RHP 1_131038504_6"]
["RHP 1","131038504","Hunt Regional Medical Center Greenville","131038504.2.1","131038504.3.2","IT-9.2","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","Baseline Approved","Eligible to Report in October DY4","Implement a patient navigation program in the Emergency Department to patients with high medical and social needs.  The patient navigation program will use community health workers to conduct home visits and nurse/social worker navigators to perform intensive case management and disease self-management patient education. ","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","In DY4 and DY5 provider will improve the rate of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period over all ED visits for individuals 18 years or older during the measurement period for patients treated at Hunt Regional Medical Center, Greenville. ","Facility ","ED patients treated at Hunt Regional Medical Center, Greenville","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",62729.9,"Yes/No","RHP 1_131038504.3.2_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",62729.9,"Yes/No","RHP 1_131038504.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",100890.9,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",100890.9,"Numeric",0.14279382600000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",482950.6,"Numeric",0.13527800000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.150309,4714,31362,"10/01/13 - 07/31/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.14279382600000001,null,0.13527800000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator and denominator values were calculated electronically utilizing ADT and coding/claims data as described above. The report specifications matched the inclusion and exclusion criteria as outlined in the IT 9.2 Compendium. Report Specifications:  \n• Date: 10/01/13-07/31/14\n• Location: Greenville \n• Age 18 years and above\nNumerator Inclusions: \nTotal ED visits with a primary or secondary ACSC diagnosis including (ICD9 methodology):\n• Grand mal status and other epileptic convulsions: 345\n• COPD: 466.0 (with a secondary diagnosis of 491, 492, 494, 496, 496), 491, 492, 494, 496\n• Asthma: 493\n• Heart failure and pulmonary edema: 402.01, 402.11, 402.91, 428, 518.4\n• Hypertension: 401.0, 401.9, 402.00, 402.10, 402.90\n• Angina: 411.1, 411.8, 413\n• Diabetes: 250.0, 250.1, 250.2, 250.3, 250.8, 250.9\n Numerator Exclusions:\n• Heart failure and pulmonary edema: procedure codes 36.01, 36.02, 36.05, 36.1, 37.5, 37.7\n• Hypertension: procedure codes 36.01, 36.02, 36.05, 36.1, 37.5, 37.7\n• Angina: procedure codes 01-86.99\n• Diabetes: 250.4, 250.5, 250.6, 250.7\nDenominator Inclusions:\n• Total ED visits\n","From October 1, 2013 – July 31, 2014, HRMC had 31,362 ED visits with patients 18 years old and older.  Of those, 4,717 had an ambulatory care sensitive condition resulting in a 15.03% rate of ED visits for ambulatory care sensitive conditions. ","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","ED",null,"Total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1 ","","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ",null,null,null,null,null,"2014-08-01","2015-07-31","2015-08-01","2016-07-31","2013-10-01","2014-07-31",null,null,"RHP 1_131038504.2.1","RHP 1_131038504.3.2","RHP 1_131038504.2.1_131038504.3.2",{"$f":"COUNTIFS($FI$4:$FI81,FI81)","v":1},"RHP 1_131038504.2.1_1",null,2,1,1,"RHP 1_131038504",{"$f":"COUNTIFS($FR$4:$FR81,FR81)","v":7},"RHP 1_131038504_7"]
["RHP 1","131038504","Hunt Regional Medical Center Greenville","131038504.2.2","131038504.3.3","IT-3.22","Risk Adjusted All-Cause Readmission","Pending Approval","Eligible to Report in October DY4","Implement a care transitions program to create a smooth, coordinated hospital discharge.  Interventions will include implementing Project RED (Re-Engineered Discharge) to perform discharge planning, education, medication management and coordinate outpatient follow-up.  ","Risk Adjusted All-Cause Readmission","In DY4 and DY5 provider will improve the ratio of actual readmissions to expected readmissions for individuals discharged with a diagnosis of COPD, CHF, HTN, CVA/TIA, Asthma, Chest Pain or Diabetes. ","Comorbid Condition ","Inpatients discharged with a diagnosis of COPD, CHF, HTN, CVA/TIA, Asthma, Chest Pain or Diabetes. ","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",62729.9,"Yes/No","RHP 1_131038504.3.3_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",62729.9,"Yes/No","RHP 1_131038504.3.3_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",100890.9,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",100890.9,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",482950.6,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"*** The above formula should calculate a percent*** The numerator and denominator values were calculated electronically utilizing ADT and coding/claims data as described above. The report specifications matched the inclusion and exclusion criteria as outlined in the IT 3.22 Compendium. Report Specifications: \n• Date: 10/01/13-03/31/14\n• Location: Greenville \n• Age 18 years and above\nNumerator Inclusions: \n• Inpatient readmissions within 30 days of index hospitalization \nNumerator Exclusions:\n• Discharge Disposition- AMA or expired \nDenominator Subset Inclusions (using ICD9 methodology):\n• COPD: 490, 491, 492, 496\n• CHF: 398.91, 425, 428, 429.3\n• HTN: 401, 402\n• CVA/TIA: 434, 435\n• Asthma: 493\n• Chest pain, cardiovascular disease: 786, 429.89, 429.9\n• Diabetes: 250\nDenominator Exclusions \n• Discharge Disposition- AMA or expired \n","From October 1, 2013 – March 31, 2014, HRMC had 1540 inpatients with a chronic condition including COPD, CHF, HTN, CVA/TIA, Asthma, chest pain/cardiovascular disease, and diabetes.  Of those, 222 patients were readmitted within 30 days from the index hospitalization resulting in a 14.42%% rate of risk adjusted all cause readmission. ","Risk Adjusted All-Cause Readmission","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk admissions during the measurement period.","Expected (risk-adjusted) rate of readmissions for all-causes during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.12.1","","Risk Adjusted All-Cause Readmission",null,null,null,null,"3M APR-DRG grouper","2014-04-01","2015-03-31","2015-04-01","2016-03-31","2013-10-01","2014-03-31",null,null,"RHP 1_131038504.2.2","RHP 1_131038504.3.3","RHP 1_131038504.2.2_131038504.3.3",{"$f":"COUNTIFS($FI$4:$FI82,FI82)","v":1},"RHP 1_131038504.2.2_1",null,2,1,1,"RHP 1_131038504",{"$f":"COUNTIFS($FR$4:$FR82,FR82)","v":8},"RHP 1_131038504_8"]
["RHP 1","136367307","Burke Center","136367307.1.1","136367307.3.1","IT-11.5","Adherence to Antipsychotic Medications for Individuals with Schizophrenia ","Baseline not yet reported","Eligible to Report in October DY4","Expand primary behavioral health for children and adults. Services include psychiatric care, therapy, medication services and patient education as needed.","Adherence to Antipsychotic Medications for Individuals with Schizophrenia ","In DY4 and DY5 provider will increase the percentage of adults with   schizophrenia or schizoaffective disorder with a Proportion of Days Covered for antipsychotic medications of at least .8, out of all adults with schizoaffective disorder with at least two claims for antipsychotic medication during the measurement period receiving services at Houston County Mental Health Clinic","Facility ","Houston County Mental Health Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",17326.5,"Yes/No","RHP 1_136367307.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",8663.25,"Yes/No","RHP 1_136367307.3.1_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",9267.5,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",9267.5,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",40294,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Adherence to Antipsychotic Medications for Individuals with Schizophrenia ","ambulatory",null,"Individuals with schizophrenia or schizoaffective disorder who filled at least two prescriptions for any antipsychotic medication and have a Proportion of Days Covered (PDC) for antipsychotic medications of at least 0.8","Individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder with at least two claims for any antipsychotic medication during the measurement period (12 consecutive months)",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.12.2","","Adherence to Antipsychotic Medications for Individuals with Schizophrenia ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 1_136367307.1.1","RHP 1_136367307.3.1","RHP 1_136367307.1.1_136367307.3.1",{"$f":"COUNTIFS($FI$4:$FI83,FI83)","v":1},"RHP 1_136367307.1.1_1",null,2,1,1,"RHP 1_136367307",{"$f":"COUNTIFS($FR$4:$FR83,FR83)","v":1},"RHP 1_136367307_1"]
["RHP 1","136367307","Burke Center","136367307.1.1","136367307.3.500","IT-1.1","Third next available appointment ","Baseline not yet reported","Eligible to Report in October DY4","Expand primary behavioral health for children and adults. Services include psychiatric care, therapy, medication services and patient education as needed.","Third next available appointment ","In DY4 and DY5 provider will reduce the average number of days to third next available appointment for an office visit for Houston County Mental Health Clinic","Facility ","Houston County Mental Health Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",0,"Yes/No","RHP 1_136367307.3.500_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",8663.25,"Yes/No","RHP 1_136367307.3.500_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",9267.5,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",9267.5,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",40294,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"time (days)",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Third next available appointment ","ambulatory",null,"Continuous variable statement: Average number of days to third next available appointment for an office visit for each clinic and/or department MULTIPLED by the value in the denominator.  This will lead to a resulting rate of days to third next available appointment. The measure will take into account calendar days, including weekends, holidays and clinician days off.\n","Number of providers within reported clinics and/or departments included in analysis of this outcome",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.12.2","","Third next available appointment ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 1_136367307.1.1","RHP 1_136367307.3.500","RHP 1_136367307.1.1_136367307.3.500",{"$f":"COUNTIFS($FI$4:$FI84,FI84)","v":2},"RHP 1_136367307.1.1_2",null,2,1,1,"RHP 1_136367307",{"$f":"COUNTIFS($FR$4:$FR84,FR84)","v":2},"RHP 1_136367307_2"]
["RHP 1","137921608","Community Healthcore","137921608.1.1","137921608.3.1","IT-1.18","Follow-Up After Hospitalization for Mental Illness ","Baseline not yet reported","Eligible to Report in October DY4","Regional Crisis Response Center in Atlanta Texas covering the northeast Texas area serving as a short-term alternative to inpatient psychiatric hospitalization. Included are 6 beds for stabilization (locked) and 12 beds for intensive residential services (unlocked). Clinical services include emergency crisis screening, physician examination and psychiatric assessment (via telemedicine).","Follow-Up After Hospitalization for Mental Illness ","In DY4 and DY5 provider will improve the percentage of discharges for patients 18 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported: \n\n- The percentage of discharges for which the patient received follow-up within 30 days of discharge \n- The percentage of discharges for which the patient received follow-up within 7 days of discharge.","Age ","Individuals 18 and over ","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",137183,"Yes/No","RHP 1_137921608.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",137183,"Yes/No","RHP 1_137921608.3.1_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",125855.75,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- 7 day follow-up",62927.875,"Numeric","TBD","AM-1.2","Achievement of DY4 performance goal- 30 day follow-up",62927.875,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- 7 day follow-up",247257.375,"Numeric","TBD","AM-2.2","Achievement of DY5 performance goal- 30 day follow-up",247257.375,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Follow-Up After Hospitalization for Mental Illness ","ambulatory",null,"Rate #1: 7-Day Follow-Up: An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 7 days after discharge. ","Patients 6 years and older as of the date of discharge who were discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal diagnosis of mental illness during the first 11 months of the measurement year. ","Rate #2: 30-Day Follow-Up: An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 30 days after discharge. ","Patients 6 years and older as of the date of discharge who were discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal diagnosis of mental illness during the first 11 months of the measurement year. ",null,null,null,null,null,null,null,null,null,null,null,"1.13.1","","7 day follow-up","30 day follow-up",null,null,null,null,null,null,null,null,"","",null,null,"RHP 1_137921608.1.1","RHP 1_137921608.3.1","RHP 1_137921608.1.1_137921608.3.1",{"$f":"COUNTIFS($FI$4:$FI85,FI85)","v":1},"RHP 1_137921608.1.1_1",null,3,2,1,"RHP 1_137921608",{"$f":"COUNTIFS($FR$4:$FR85,FR85)","v":1},"RHP 1_137921608_1"]
["RHP 1","137921608","Community Healthcore","137921608.1.3","137921608.3.3","IT-11.8","Initiation and Engagement of Alcohol and Other Drug Dependence Treatment ","Baseline not yet reported","Eligible to Report in October DY4","Ambulatory detoxification clinic in a non-residential setting co-located with the University of Texas Health Science Center-Tyler primary care clinic.","Initiation and Engagement of Alcohol and Other Drug Dependence Treatment ","In DY4 and DY5 provider will improve the percentage of individuals 18 years or greater with a new episode of alcohol or other drug (AOD) dependence who received the following. a. Initiation of AOD Treatment. The percentage of individuals who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis. b. Engagement of AOD Treatment. ","Age ","Individuals 18 years and older ","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",137183,"Yes/No","RHP 1_137921608.3.3_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",137183,"Yes/No","RHP 1_137921608.3.3_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",125855.75,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- Initiation of AOD treatment",62927.875,"Numeric","TBD","AM-1.2","Achievement of DY4 performance goal- Engagement of AOD treatment",62927.875,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- Initiation of AOD treatment",247257.375,"Numeric","TBD","AM-2.2","Achievement of DY5 performance goal- Engagement of AOD treatment",247257.375,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Initiation and Engagement of Alcohol and Other Drug Dependence Treatment ","Ambulatory/Inpatient",null,"Initiation of AOD Treatment: Initiation of AOD treatment through an inpatient admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of diagnosis.","Patients age 13 years of age and older who were diagnosed with a new episode of alcohol and drug dependency (AOD) during the first 10 and ½ months of the measurement year (e.g., January 1-November 15).","Engagement of AOD Treatment: Initiation of AOD treatment and two or more inpatient admissions, outpatient visits, intensive outpatient encounters or partial hospitalizations with any AOD diagnosis within 30 days after the date of the Initiation encounter (inclusive). ","Patients age 13 years of age and older who were diagnosed with a new episode of alcohol and drug dependency (AOD) during the first 10 and ½ months of the measurement year (e.g., January 1-November 15).",null,null,null,null,null,null,null,null,null,null,null,"1.9.2 ","","Initiation ","Engagement",null,null,null,null,null,null,null,null,"","",null,null,"RHP 1_137921608.1.3","RHP 1_137921608.3.3","RHP 1_137921608.1.3_137921608.3.3",{"$f":"COUNTIFS($FI$4:$FI86,FI86)","v":1},"RHP 1_137921608.1.3_1",null,3,2,1,"RHP 1_137921608",{"$f":"COUNTIFS($FR$4:$FR86,FR86)","v":2},"RHP 1_137921608_2"]
["RHP 1","137921608","Community Healthcore","137921608.1.4","137921608.3.6","IT-1.18","Follow-Up After Hospitalization for Mental Illness ","Baseline not yet reported","Eligible to Report in October DY4","Regional Crisis Response Center in the Longview/Gregg County area serving as a short-term alternative to inpatient psychiatric hospitalization. Included are 6 beds for stabilization (locked) and 12 beds for intensive residential services (unlocked). Clinical services include emergency cri","Follow-Up After Hospitalization for Mental Illness ","In DY4 and DY5 provider will improve the percentage of discharges for patients 18 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported: \n\n- The percentage of discharges for which the patient received follow-up within 30 days of discharge \n- The percentage of discharges for which the patient received follow-up within 7 days of discharge.","Age ","Individuals 18 and over","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",137183,"Yes/No","RHP 1_137921608.3.6_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",137183,"Yes/No","RHP 1_137921608.3.6_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",125855.75,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- 7 day follow-up",62927.875,"Numeric","TBD","AM-1.2","Achievement of DY4 performance goal- 30 day follow-up",62927.875,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- 7 day follow-up",247257.375,"Numeric","TBD","AM-2.2","Achievement of DY5 performance goal- 30 day follow-up",247257.375,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Follow-Up After Hospitalization for Mental Illness ","ambulatory",null,"Rate #1: 7-Day Follow-Up: An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 7 days after discharge. ","Patients 6 years and older as of the date of discharge who were discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal diagnosis of mental illness during the first 11 months of the measurement year. ","Rate #2: 30-Day Follow-Up: An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 30 days after discharge. ","Patients 6 years and older as of the date of discharge who were discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal diagnosis of mental illness during the first 11 months of the measurement year. ",null,null,null,null,null,null,null,null,null,null,null,"1.13.1","","7 day follow-up","30 day follow-up",null,null,null,null,null,null,null,null,"","",null,null,"RHP 1_137921608.1.4","RHP 1_137921608.3.6","RHP 1_137921608.1.4_137921608.3.6",{"$f":"COUNTIFS($FI$4:$FI87,FI87)","v":1},"RHP 1_137921608.1.4_1",null,3,2,1,"RHP 1_137921608",{"$f":"COUNTIFS($FR$4:$FR87,FR87)","v":3},"RHP 1_137921608_3"]
["RHP 1","137921608","Community Healthcore","137921608.2.1","137921608.3.4","IT-1.7","Controlling high blood pressure ","Baseline not yet reported","Eligible to Report in October DY4","Integrate primary and behavioral healthcare services. Community Healthcore will collaborate with Good Shepherd Medical Center and the local FQHC in the Longview area. Coordinated care to include routine screening for behavioral health concerns conducted in primary care settings; primary care screening in behavioral health settings; referral processes to establish co-located services and develop protocols for integrated services located together with a single treatment plan for the target population.  ","Controlling high blood pressure ","In DY4 and DY5 provider will increase the number of adults with an outpatient encounter diagnosis of hypertension during the first six months of the measurement year whose most recent BP is adequately controlled during the measurement year, out of all adults who had an outpatient encounter diagnosis of hypertension during the first six months of the measurement year and also have comorbidities of serious mental illness and co-occurring hypertension and/or diabetes . ","Comorbid Condition ","Adults with serious mental illness and co-occurring hypertension and/or diabetes ","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",68591.5,"Yes/No","RHP 1_137921608.3.4_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",68591.5,"Yes/No","RHP 1_137921608.3.4_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",62927.875,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",62927.875,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",247257.38,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Controlling high blood pressure ","ambulatory",null,"The number of patients in the denominator whose most recent BP is adequately controlled during the measurement year. For a patient’s BP to be controlled, both the systolic and diastolic BP must be <140/90 (adequate control). To determine if a patient’s BP is adequately controlled, the representative BP must be identified.\n","Patients 18 to 85 years of age by the end of the measurement year who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.15.1","","Controlling high blood pressure ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 1_137921608.2.1","RHP 1_137921608.3.4","RHP 1_137921608.2.1_137921608.3.4",{"$f":"COUNTIFS($FI$4:$FI88,FI88)","v":1},"RHP 1_137921608.2.1_1",null,2,1,1,"RHP 1_137921608",{"$f":"COUNTIFS($FR$4:$FR88,FR88)","v":4},"RHP 1_137921608_4"]
["RHP 1","137921608","Community Healthcore","137921608.2.1","137921608.3.5","IT-1.21","Adult Body Mass Index (BMI) Assessment ","Baseline not yet reported","Eligible to Report in October DY4","Integrate primary and behavioral healthcare services. Community Healthcore will collaborate with Good Shepherd Medical Center and the local FQHC in the Longview area. Coordinated care to include routine screening for behavioral health concerns conducted in primary care settings; primary care screening in behavioral health settings; referral processes to establish co-located services and develop protocols for integrated services located together with a single treatment plan for the target population.  ","Adult Body Mass Index (BMI) Assessment ","In DY4 and DY5 provider will increase the 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 and also have comorbidities of serious mental illness and co-occurring hypertension and/or diabetes .                                                               \n  Normal Parameters: Age 65 years and older BMI 23 and 30\nAge 18 – 64 years BMI 18.5 and 25","Comorbid Condition ","Adults with serious mental illness and co-occurring hypertension and/or diabetes ","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",68591.5,"Yes/No","RHP 1_137921608.3.5_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",68591.5,"Yes/No","RHP 1_137921608.3.5_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",62927.875,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",62927.875,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",247257.38,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Adult Body Mass Index (BMI) Assessment ","both",null,"Patients with BMI calculated within the past six months or during the current visit and a follow-up plan is documented within the last six months or during the current visit if the BMI is outside of normal parameters.\n\nDefinitions:\n\nBMI – Body mass index (BMI) is expressed as weight/height (BMI; kg/m2) and is commonly used to classify weight categories.\n\nCalculated BMI – Requires an eligible professional or their staff to measure both the height and weight. Self-reported values cannot be used. BMI is calculated either as weight in pounds divided by height in inches squared multiplied by 703, or as weight in kilograms divided by height in meters squared.\n\nFollow-up Plan – Proposed outline of treatment to be conducted as a result of a BMI out of normal parameters. Such follow-up may include but is not limited to: documentation of a future appointment, education, referral (such as, a registered dietician, nutritionist, occupational therapist, physical therapist, primary care provider, exercise physiologist, mental health professional or surgeon), pharmacological interventions, dietary supplements, exercise counseling or nutrition counseling.\n","Patients age 18 years as of the first day of the 12-month period prior to the measurement period to 74 years as of last day of the measurement period who had an outpatient visit during the measurement period or the 12-month period prior to the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.15.1","","Adult Body Mass Index (BMI) Assessment ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 1_137921608.2.1","RHP 1_137921608.3.5","RHP 1_137921608.2.1_137921608.3.5",{"$f":"COUNTIFS($FI$4:$FI89,FI89)","v":2},"RHP 1_137921608.2.1_2",null,2,1,1,"RHP 1_137921608",{"$f":"COUNTIFS($FR$4:$FR89,FR89)","v":5},"RHP 1_137921608_5"]
["RHP 1","138360606","Northeast Texas Public Health District","138360606.2.1","138360606.3.1","IT-10.3.e","Problem Areas in Diabetes (PAID) Scale","Baseline Approved","Eligible to Report in October DY4","Health education will be provided including: diabetic management classes, tobacco cessation programs, nutrition counseling, access to WIC and immunization services, health coaching and health education media campaigns.  Screenings such as mobile mammography, blood pressure, blood glucose, cholesterol, weight and BMI will be provided, through partnerships with other performing providers in Region 1, as outlined and selected as project option 2.6.2.","Problem Areas in Diabetes (PAID) Scale","In DY4 and DY5 provider will improve reported scores on the Problem Areas in Diabetes (PAID) Scale over all completed surveys. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",16500,"Yes/No","RHP 1_138360606.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",16500,"Yes/No","RHP 1_138360606.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",16500,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",16500,"Numeric",22.29555921,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",55000,"Numeric",21.903618420000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",22.6875,907.5,40,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,22.29555921,null,21.903618420000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator is equal to the sum of all scores of pre and post PAID surveys of only participants who completed both the pre and the post surveys.    The denominator is equal to the total number of surveys (including pre and post) completed by participants who completed both surevys. ","The baseline rate is the average of all of the pre-test and post-test scores for individuals who completed both pre and post surveys.","Problem Areas in Diabetes (PAID) Scale","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.6.2 ","Scenario 1: Pre/Posttest Baseline","Problem Areas in Diabetes (PAID) Scale",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 1_138360606.2.1","RHP 1_138360606.3.1","RHP 1_138360606.2.1_138360606.3.1",{"$f":"COUNTIFS($FI$4:$FI90,FI90)","v":1},"RHP 1_138360606.2.1_1",null,2,1,1,"RHP 1_138360606",{"$f":"COUNTIFS($FR$4:$FR90,FR90)","v":1},"RHP 1_138360606_1"]
["RHP 1","138374715","East Texas Medical Center Pittsburg","138374715.1.1","138374715.3.1","IT-4.4","Surgical site infections (SSI) rates","Pending Approval","Eligible to Report in October DY4","This project increases access to specialty healthcare through recruiting a full-time general surgeon and orthopedic surgeon to establish specialty clinics. \n","Surgical site infections (SSI) rates","In DY4 and DY5 provider will reduce the rate of Surgical Site Infections for all patients as described by the IQR criteria. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",71879.475000000006,"Yes/No","RHP 1_138374715.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",71879.475000000006,"Yes/No","RHP 1_138374715.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",115341.2,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",115341.2,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",551633.19999999995,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator is all general surgery patients at ETMC Pittsburg and the numerator was the General surgery SSI for ETMC Pittsburg. ","The denominator of 261 is all general surgery patients at ETMC Pittsburg and the numerator of 1 was the General surgery SSI for ETMC Pittsburg. Therefore the SSI infection rate for General Surgery at ETMC Pittsburg is .38","Surgical site infections (SSI) rates","inpatient",null,"Number of surgical site infections occurring within thirty days after the operative procedure if no implant is left in place or with one year if an implant is in place in patients who had an NHSN operative procedure performed during a specified time period and the infection appears to be related to the operative procedure. Infections are identified on original admission or upon readmission to the facility of original operative procedure within the relevant time frame (30 days for no implants; within 1 year for implants).","Number of NHSN operative procedures performed during a specified time period stratified by:\n\n• Type of NHSN operative procedure\nand\n• NNIS SSI risk index: \nEvery patient having the selected procedure is assigned one (1) risk point for each of the following three factors: \no Surgical wound classification = clean contaminated or dirty\no American Society of Anesthesiologists (ASA) preoperative severity of illness score = 3, 4, or 5\no Duration of operation >t hours, where t varies by type of NHSN operative procedure and is the approximate 75th percentile of the duration of the procedure rounded to the nearest whole number of hours. \n\nNote: For operative procedures performed using lapyroscopes and endoscopes the use of a lapyroscope is an additional factor that modifies the risk index.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2 ","","Surgical site infections (SSI) rates",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_138374715.1.1","RHP 1_138374715.3.1","RHP 1_138374715.1.1_138374715.3.1",{"$f":"COUNTIFS($FI$4:$FI91,FI91)","v":1},"RHP 1_138374715.1.1_1",null,2,1,1,"RHP 1_138374715",{"$f":"COUNTIFS($FR$4:$FR91,FR91)","v":1},"RHP 1_138374715_1"]
["RHP 1","138913209","Titus Regional Medical Center","138913209.1.1","138913209.3.1","IT-1.7","Controlling high blood pressure ","Baseline not yet reported","Eligible to Report in October DY4","This project will build a new Family Care Center in an underserved location of Mount Pleasant\nand provide the community an alternative to the Emergency Room.","Controlling high blood pressure ","In DY4 and DY5 provider will improve the number of  adults diagnosed with hypertension who had their blood pressure under control out of all adults with hypertension",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",45316.71,"Yes/No","RHP 1_138913209.3.1_PM-8","Metric Carried Forward in October DY3","PM-9","Validation and submission of baseline performance",45316.71,"Yes/No","RHP 1_138913209.3.1_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",72878.565000000002,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",72878.565000000002,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",348848.71,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Controlling high blood pressure ","ambulatory",null,"The number of patients in the denominator whose most recent BP is adequately controlled during the measurement year. For a patient’s BP to be controlled, both the systolic and diastolic BP must be <140/90 (adequate control). To determine if a patient’s BP is adequately controlled, the representative BP must be identified.\n","Patients 18 to 85 years of age by the end of the measurement year who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1 ","","Controlling high blood pressure ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 1_138913209.1.1","RHP 1_138913209.3.1","RHP 1_138913209.1.1_138913209.3.1",{"$f":"COUNTIFS($FI$4:$FI92,FI92)","v":1},"RHP 1_138913209.1.1_1",null,2,1,1,"RHP 1_138913209",{"$f":"COUNTIFS($FR$4:$FR92,FR92)","v":1},"RHP 1_138913209_1"]
["RHP 1","138913209","Titus Regional Medical Center","138913209.1.2","138913209.3.4","IT-3.5","Risk Adjusted Diabetes 30-day Readmission Rate ","Baseline not yet reported","Eligible to Report in October DY4","This project will recruit an endocrinologist to Titus County and increase the number of patients seen by the Diabetes Self-Management Education Program Team.","Risk Adjusted Diabetes 30-day Readmission Rate ","In DY4 and DY5 provider will improve the ratio of actual readmissions to expected readmissions for individuals discharged for a diabetes related inpatient stay. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",8541.3700000000008,"Yes/No","RHP 1_138913209.3.4_PM-8","Metric Carried Forward in October DY3","PM-9","Validation and submission of baseline performance",8541.3700000000008,"Yes/No","RHP 1_138913209.3.4_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",13736.275,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",13736.275,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",65751.59,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Risk Adjusted Diabetes 30-day Readmission Rate ","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission for Diabetes during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk Diabetes admissions during the measurement period.\n","Expected (risk-adjusted) rate of readmissions for Diabetes during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2 ","","Risk Adjusted Diabetes 30-day Readmission Rate ",null,null,null,null,"Risk adjustment method not yet reported",null,null,null,null,"","",null,null,"RHP 1_138913209.1.2","RHP 1_138913209.3.4","RHP 1_138913209.1.2_138913209.3.4",{"$f":"COUNTIFS($FI$4:$FI93,FI93)","v":1},"RHP 1_138913209.1.2_1",null,2,1,1,"RHP 1_138913209",{"$f":"COUNTIFS($FR$4:$FR93,FR93)","v":2},"RHP 1_138913209_2"]
["RHP 1","138913209","Titus Regional Medical Center","138913209.1.3","138913209.3.204","IT-4.17","Stroke - Thrombolytic Therapy  ","Baseline not yet reported","Eligible to Report in October DY4","This project increases the capacity of specialty healthcare in Northeast Texas through TRMC achieving the Texas certification as a Level II Primary Stroke Center and  the recruitment of a full-time neurologist to establish a specialty clinic location. ","Stroke - Thrombolytic Therapy  ","In DY4 and DY5 provider will improve the number of adults who receive stroke therapy within 2 hours of arriving at hospital out of all stroke patients arriving at hospital.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",22658.355,"Yes/No","RHP 1_138913209.3.204_PM-8","Metric Carried Forward in October DY3","PM-9","Validation and submission of baseline performance",22658.355,"Yes/No","RHP 1_138913209.3.204_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",36439.285000000003,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",36439.285000000003,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",174424.36,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Stroke - Thrombolytic Therapy  ","inpatient",null,"Acute ischemic stroke patients for whom IV thrombolytic therapy was initiated at this hospital within 3 hours (less than or equal to 180 minutes) of time last known well.","Acute ischemic stroke patients whose time of arrival is within 2 hours (greater than or equal to 120 minutes) of time last known well. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.1","","Stroke - Thrombolytic Therapy  ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 1_138913209.1.3","RHP 1_138913209.3.204","RHP 1_138913209.1.3_138913209.3.204",{"$f":"COUNTIFS($FI$4:$FI94,FI94)","v":1},"RHP 1_138913209.1.3_1",null,2,1,1,"RHP 1_138913209",{"$f":"COUNTIFS($FR$4:$FR94,FR94)","v":3},"RHP 1_138913209_3"]
["RHP 1","138913209","Titus Regional Medical Center","138913209.1.3","138913209.3.6","IT-3.13","Risk Adjusted Stroke (CVA) 30-day Readmission Rate ","Pending Approval","Eligible to Report in October DY4","This project increases the capacity of specialty healthcare in Northeast Texas through TRMC achieving the Texas certification as a Level II Primary Stroke Center and  the recruitment of a full-time neurologist to establish a specialty clinic location. ","Risk Adjusted Stroke (CVA) 30-day Readmission Rate ","In DY4 and DY5 provider will improve the ratio of actual readmissions to expected readmissions for individuals discharged for a Stroke/CVA related inpatient stay. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",22658.355,"Yes/No","RHP 1_138913209.3.6_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",22658.355,"Yes/No","RHP 1_138913209.3.6_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",36439.285000000003,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",36439.285000000003,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",174424.36,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"APR DRG and indexing medical records for readmission with similar diagnosis within 30 days.","Actual patient volume is to small for interpreation.","Risk Adjusted Stroke (CVA) 30-day Readmission Rate ","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission for CVD during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk CVD admissions during the measurement period.\n","Expected (risk-adjusted) rate of readmissions for CVD during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.1","","Risk Adjusted Stroke (CVA) 30-day Readmission Rate ",null,null,null,null,"Not Risk Adjusted due to small encounter  set, used APR DRG","2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_138913209.1.3","RHP 1_138913209.3.6","RHP 1_138913209.1.3_138913209.3.6",{"$f":"COUNTIFS($FI$4:$FI95,FI95)","v":2},"RHP 1_138913209.1.3_2",null,2,1,1,"RHP 1_138913209",{"$f":"COUNTIFS($FR$4:$FR95,FR95)","v":4},"RHP 1_138913209_4"]
["RHP 1","138913209","Titus Regional Medical Center","138913209.2.1","138913209.3.3","IT-5.2","Per Episode Cost of Care","Pending Approval","Eligible to Report in October DY4","The project will implement processes and systems needed to identify, analyze and lower the cost of care to patients, employers, and the government while maintaining \nhigh quality outcomes.","Per Episode Cost of Care","In DY4 and DY5 provider will improve the per episode cost of care out of all episodes of care in the year.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",45316.71,"Yes/No","RHP 1_138913209.3.3_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",45316.71,"Yes/No","RHP 1_138913209.3.3_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",72878.565000000002,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",72878.565000000002,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",348848.69999999995,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"$",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Total cost and total patient encountersfor 10/01/2013 and 09/30/2014","Unknown how the rate above is a reflection on performance on cost.","Per Episode Cost of Care","Multiple",null,"Total cost for episode of care","Total number of episodes during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.5.3 ","","Per Episode Cost of Care",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_138913209.2.1","RHP 1_138913209.3.3","RHP 1_138913209.2.1_138913209.3.3",{"$f":"COUNTIFS($FI$4:$FI96,FI96)","v":1},"RHP 1_138913209.2.1_1",null,2,1,1,"RHP 1_138913209",{"$f":"COUNTIFS($FR$4:$FR96,FR96)","v":5},"RHP 1_138913209_5"]
["RHP 1","138913209","Titus Regional Medical Center","138913209.2.2","138913209.3.202","IT-9.10.b","Median time from admit decision time to time of departure from the ED for ED patients admitted to inpatient status","Pending Approval","Eligible to Report in October DY4","This project will focus on the implementation of a process improvement methodology to improve safety, quality, patient experience and efficiency.  TRMC will use the Lean process improvement methodology in our Emergency Room in a relentless pursuit of the perfect process through waste elimination.  TRMC expects this process will lead to improvements in available and prompt care, better patient outcomes, increased patient satisfaction, improved financial viability, improved patient throughput, improved publicly reported information, and higher employee involvement and satisfaction.  ","Median time from admit decision time to time of departure from the ED for ED patients admitted to inpatient status","In DY4 and DY5 provider will improve median time from admit decision to ED departure for any condition, excluding psychiatric patients.","Comorbid Condition "," Psychiatric Patients be excluded","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",15105.57,"Yes/No","RHP 1_138913209.3.202_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",15105.57,"Yes/No","RHP 1_138913209.3.202_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",24292.855,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",24292.855,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",116282.9,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"time (minutes)",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"All ED Visits excluding PSYCH, ED visits with admissions to Inpatient or observation services excluding PSYCH","7.45% of ED patient population had an length of stay pending status waiting for admission to nursing floor 56 minutes. (100.685/1778=56.628)","Median time from admit decision time to time of departure from the ED for ED patients admitted to inpatient status","ED",null,"Median time from admit decision time to time of departure from the ED for ED patients admitted to inpatient status: Continuous variable statement: Time (in minutes) from admit decision time to time of departure from the emergency department (ED) for ED patients admitted to inpatient status",1,null,null,null,null,null,null,null,null,null,null,null,null,null,"2.8.1 ","","Median time from admit decision time to time of departure from the ED for ED patients admitted to inpatient status",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_138913209.2.2","RHP 1_138913209.3.202","RHP 1_138913209.2.2_138913209.3.202",{"$f":"COUNTIFS($FI$4:$FI97,FI97)","v":1},"RHP 1_138913209.2.2_1",null,2,1,1,"RHP 1_138913209",{"$f":"COUNTIFS($FR$4:$FR97,FR97)","v":6},"RHP 1_138913209_6"]
["RHP 1","138913209","Titus Regional Medical Center","138913209.2.2","138913209.3.203","IT-9.10.c","Median time from ED arrival to time of departure from the emergency room for patients admitted to the facility from the ED","Pending Approval","Eligible to Report in October DY4","This project will focus on the implementation of a process improvement methodology to improve safety, quality, patient experience and efficiency.  TRMC will use the Lean process improvement methodology in our Emergency Room in a relentless pursuit of the perfect process through waste elimination.  TRMC expects this process will lead to improvements in available and prompt care, better patient outcomes, increased patient satisfaction, improved financial viability, improved patient throughput, improved publicly reported information, and higher employee involvement and satisfaction.  ","Median time from ED arrival to time of departure from the emergency room for patients admitted to the facility from the ED","In DY4 and DY5 provider will improve median time from ED arrival to ED departure for admitted patients from ED for any condition, excluding psychiatric patients.","Comorbid Condition "," Psychiatric Patients be excluded","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",15105.57,"Yes/No","RHP 1_138913209.3.203_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",15105.57,"Yes/No","RHP 1_138913209.3.203_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",24292.855,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",24292.855,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",116282.9,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"time (minutes)",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"All ED Visits excluding PSYCH, ED visits with admissions to Inpatient or observation services excluding PSYCH","7.45% of ED patient population had a total length of stay before for admission to nursing floor 237 minutes. (423115/1778=237.97)","Median time from ED arrival to time of departure from the emergency room for patients admitted to the facility from the ED","ED",null,"Median time from ED arrival to time of departure from the emergency room for patients admitted to the facility from the ED: Continuous variable statement: Time (in minutes) from emergency department (ED) arrival to ED departure for patients admitted to the facility from the ED",1,null,null,null,null,null,null,null,null,null,null,null,null,null,"2.8.1 ","","Median time from ED arrival to time of departure from the emergency room for patients admitted to the facility from the ED",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_138913209.2.2","RHP 1_138913209.3.203","RHP 1_138913209.2.2_138913209.3.203",{"$f":"COUNTIFS($FI$4:$FI98,FI98)","v":2},"RHP 1_138913209.2.2_2",null,2,1,1,"RHP 1_138913209",{"$f":"COUNTIFS($FR$4:$FR98,FR98)","v":7},"RHP 1_138913209_7"]
["RHP 1","138913209","Titus Regional Medical Center","138913209.2.2","138913209.3.5","IT-9.10.a","Median Time from ED Arrival to ED Departure for Discharged ED Patients","Pending Approval","Eligible to Report in October DY4","This project will focus on the implementation of a process improvement methodology to improve safety, quality, patient experience and efficiency.  TRMC will use the Lean process improvement methodology in our Emergency Room in a relentless pursuit of the perfect process through waste elimination.  TRMC expects this process will lead to improvements in available and prompt care, better patient outcomes, increased patient satisfaction, improved financial viability, improved patient throughput, improved publicly reported information, and higher employee involvement and satisfaction.  ","Median Time from ED Arrival to ED Departure for Discharged ED Patients","In DY4 and DY5 provider will improve median time from ED arrival to ED departure for any condition, excluding psychiatric patients.","Comorbid Condition "," Psychiatric Patients be excluded","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",15105.57,"Yes/No","RHP 1_138913209.3.5_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",15105.57,"Yes/No","RHP 1_138913209.3.5_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",24292.855,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",24292.855,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",116282.9,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"time (minutes)",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ALL ED visits excluding PSYCH patients; ED visits that were discharged from ED not admitted or transferred","83.6% of ED patient Encounters had an average length of stay of 131 minutes before departure.  (2620263/19958=131.289)","Median Time from ED Arrival to ED Departure for Discharged ED Patients","ED",null,"Median Time from ED Arrival to ED Departure for Discharged ED Patients: Continuous Variable Statement: Time (in minutes) from ED arrival to ED departure for patients discharged from the emergency department. ",1,null,null,null,null,null,null,null,null,null,null,null,null,null,"2.8.1 ","","Median Time from ED Arrival to ED Departure for Discharged ED Patients",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_138913209.2.2","RHP 1_138913209.3.5","RHP 1_138913209.2.2_138913209.3.5",{"$f":"COUNTIFS($FI$4:$FI99,FI99)","v":3},"RHP 1_138913209.2.2_3",null,2,1,1,"RHP 1_138913209",{"$f":"COUNTIFS($FR$4:$FR99,FR99)","v":8},"RHP 1_138913209_8"]
["RHP 1","139173209","East Texas Medical Center Athens","139173209.1.1","139173209.3.200","IT-2.21","Ambulatory Care Sensitive Conditions Admissions Rate","Pending Approval","Eligible to Report in October DY4","This project increases access to healthcare through establishing a new primary care clinic on the ETMC Athens campus.  This project is not duplicative of 139173209.1.2 – Expand Primary Care Capacity, as these clinics are at separate locations and serving different target populations. ","Ambulatory Care Sensitive Conditions Admissions Rate","In DY4 and DY5 provider will reduce the percentage of admissions for conditions defined as ambulatory care sensitive  for individuals 18 to  75 years of age out of the total number of admissions to ETMC Athens.","Facility","ETMC-Athens","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",49217.94,"Yes/No","RHP 1_139173209.3.200_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",49217.94,"Yes/No","RHP 1_139173209.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",78977.34,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",78977.34,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",377718.3,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ETMC understands that this project measures the age-standardized acute care hospitalization rate for conditions where appropriate ambulatory care prevents or reduces the need for admission to the hospital, per 100,000 population under age 75 years. ETMC understands that depending on the population that, depending on the population size, a random sample may be used. ETMC also understands that the population is derived from patients who present the primary condition codes of the following: • Grand mal status and other epileptic convulsions \n• Chronic obstructive pulmonary diseases \n• Asthma \n• Heart failure and pulmonary edema \n• Hypertension \n• Angina, or \n• Diabetes ","ETMC's understanding is that Henderson Co. had 1324 admissions who's primary diagnosis code fell into a \"preventable\" range (numerator). Denominator is simply the population of Henderson Co .  Our original understanding of this measure is that denominator would be the total number of hospital admissoins from all Henderson Co. residents, not, the total number of Henderson County residents","Ambulatory Care Sensitive Conditions Admissions Rate","inpatient",null,"Total number of acute care hospitalizations for ambulatory care sensitive conditions younger than age 75 years ","Total mid-measurement period population younger than age 75",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1 ","","Ambulatory Care Sensitive Conditions Admissions Rate",null,null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 1_139173209.1.1","RHP 1_139173209.3.200","RHP 1_139173209.1.1_139173209.3.200",{"$f":"COUNTIFS($FI$4:$FI100,FI100)","v":1},"RHP 1_139173209.1.1_1",null,2,1,1,"RHP 1_139173209",{"$f":"COUNTIFS($FR$4:$FR100,FR100)","v":1},"RHP 1_139173209_1"]
["RHP 1","139173209","East Texas Medical Center Athens","139173209.1.2","139173209.3.201","IT-2.21","Ambulatory Care Sensitive Conditions Admissions Rate","Pending Approval","Eligible to Report in October DY4","This project increases access to healthcare through recruiting four primary care providers adding needed support staff.  ","Ambulatory Care Sensitive Conditions Admissions Rate","In DY4 and DY5 provider will reduce the percentage of admissions for conditions defined as ambulatory care sensitive  for individuals 18 to  75 years of age out of the total number of admissions to ETMC Athens.","Facility","ETMC-Athens","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",103904.54,"Yes/No","RHP 1_139173209.3.201_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",103904.54,"Yes/No","RHP 1_139173209.3.201_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",166729.94,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",166729.94,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",797405.3,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ETMC understands that this project measures the age-standardized acute care hospitalization rate for conditions where appropriate ambulatory care prevents or reduces the need for admission to the hospital, per 100,000 population under age 75 years. ETMC understands that depending on the population that, depending on the population size, a random sample may be used. ETMC also understands that the population is derived from patients who present the primary condition codes of the following: • Grand mal status and other epileptic convulsions \n• Chronic obstructive pulmonary diseases \n• Asthma \n• Heart failure and pulmonary edema \n• Hypertension \n• Angina, or \n• Diabetes ","ETMC's understanding is that Henderson Co. had 1324 admissions who's primary diagnosis code fell into a \"preventable\" range (numerator). Denominator is simply the population of Henderson Co .  Our original understanding of this measure is that denominator would be the total number of hospital admissoins from all Henderson Co. residents, not, the total number of Henderson County residents","Ambulatory Care Sensitive Conditions Admissions Rate","inpatient",null,"Total number of acute care hospitalizations for ambulatory care sensitive conditions younger than age 75 years ","Total mid-measurement period population younger than age 75",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","Ambulatory Care Sensitive Conditions Admissions Rate",null,null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 1_139173209.1.2","RHP 1_139173209.3.201","RHP 1_139173209.1.2_139173209.3.201",{"$f":"COUNTIFS($FI$4:$FI101,FI101)","v":1},"RHP 1_139173209.1.2_1",null,2,1,1,"RHP 1_139173209",{"$f":"COUNTIFS($FR$4:$FR101,FR101)","v":2},"RHP 1_139173209_2"]
["RHP 1","139173209","East Texas Medical Center Athens","139173209.2.1","139173209.3.202","IT-2.21","Ambulatory Care Sensitive Conditions Admissions Rate","Pending Approval","Eligible to Report in October DY4","This project is to implement a patient navigation service that shifts non-urgent patients to a more appropriate level of care.  The patient navigators will provide non-urgent patients with a referral to a primary care provider. ","Ambulatory Care Sensitive Conditions Admissions Rate","In DY4 and DY5 provider will reduce the percentage of admissions for conditions defined as ambulatory care sensitive  for individuals 18 to  75 years of age out of the total number of admissions to ETMC Athens.","Facility","ETMC-Athens","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",62889.59,"Yes/No","RHP 1_139173209.3.202_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",62889.59,"Yes/No","RHP 1_139173209.3.202_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",100915.49,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",100915.49,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",482640.05,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ETMC understands that this project measures the age-standardized acute care hospitalization rate for conditions where appropriate ambulatory care prevents or reduces the need for admission to the hospital, per 100,000 population under age 75 years. ETMC understands that depending on the population that, depending on the population size, a random sample may be used. ETMC also understands that the population is derived from patients who present the primary condition codes of the following: • Grand mal status and other epileptic convulsions \n• Chronic obstructive pulmonary diseases \n• Asthma \n• Heart failure and pulmonary edema \n• Hypertension \n• Angina, or \n• Diabetes ","ETMC's understanding is that Henderson Co. had 1324 admissions who's primary diagnosis code fell into a \"preventable\" range (numerator). Denominator is simply the population of Henderson Co .  Our original understanding of this measure is that denominator would be the total number of hospital admissoins from all Henderson Co. residents, not, the total number of Henderson County residents","Ambulatory Care Sensitive Conditions Admissions Rate","inpatient",null,"Total number of acute care hospitalizations for ambulatory care sensitive conditions younger than age 75 years ","Total mid-measurement period population younger than age 75",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1 ","","Ambulatory Care Sensitive Conditions Admissions Rate",null,null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 1_139173209.2.1","RHP 1_139173209.3.202","RHP 1_139173209.2.1_139173209.3.202",{"$f":"COUNTIFS($FI$4:$FI102,FI102)","v":1},"RHP 1_139173209.2.1_1",null,2,1,1,"RHP 1_139173209",{"$f":"COUNTIFS($FR$4:$FR102,FR102)","v":3},"RHP 1_139173209_3"]
["RHP 1","139173209","East Texas Medical Center Athens","139173209.2.2","139173209.3.203","IT-3.3","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","Pending Approval","Eligible to Report in October DY4","This project is to implement the re-engineered discharge (RED) design for congestive heart failure (CHF) patients.  Newly established discharge protocol will create smooth transitions of care from inpatient to outpatient settings by providing care management during this time period. ","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","In DY4 and DY5 provider will improve the ratio of actual readmissions to expected readmissions for individuals discharged for a CHF related inpatient stay. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",27343.3,"Yes/No","RHP 1_139173209.3.203_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",27343.3,"Yes/No","RHP 1_139173209.3.203_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",43876.3,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",43876.3,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",209843.5,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"\"ETMC understands that this project measures Risk adjusted rate of hospital admissions (stays) for Congestive Heart Failure (CHF) with a subsequent readmission for any reason within 30 days of discharge for patients 18 years of age and older. \n\nA readmission is a subsequent hospital admission in the same hospital within 30 days following an original admission. The discharge date for the index admission must occur within the time period defined as one month prior to the beginning of the measurement period and ending one month prior to the end of the measurement year to allow for the 30-day follow-up period for readmissions within the measurement year\n\"ETMC understands that this project measures Risk adjusted rate of hospital admissions (stays) for Congestive Heart Failure (CHF) with a subsequent readmission for any reason within 30 days of discharge for patients 18 years of age and older. \n\nA readmission is a subsequent hospital admission in the same hospital within 30 days following an original admission. The discharge date for the index admission must occur within the time period defined as one month prior to the beginning of the measurement period and ending one month prior to the end of the measurement year to allow for the 30-day follow-up period for readmissions within the measurement year","using this methodolgy, ETMC believes that  4.43% of eligible CHF patients are re-admitted within 30 days.","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission for CHF during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk CHF admissions during the measurement period.\n","Expected (risk-adjusted) rate of readmissions for CHF during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc. \n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.12.1","","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate",null,null,null,null,"\"ETMC understands that this project measures Risk adjusted rate of hospital admissions (stays) for Congestive Heart Failure (CHF) with a subsequent readmission for any reason within 30 days of discharge for patients 18 years of age and older. \n\nA readmission is a subsequent hospital admission in the same hospital within 30 days following an original admission. The discharge date for the index admission must occur within the time period defined as one month prior to the beginning of the measurement period and ending one month prior to the end of the measurement year to allow for the 30-day follow-up period for readmissions within the measurement year\n\"ETMC understands that this project measures Risk adjusted rate of hospital admissions (stays) for Congestive Heart Failure (CHF) with a subsequent readmission for any reason within 30 days of discharge for patients 18 years of age and older. \n\nA readmission is a subsequent hospital admission in the same hospital within 30 days following an original admission. The discharge date for the index admission must occur within the time period defined as one month prior to the beginning of the measurement period and ending one month prior to the end of the measurement year to allow for the 30-day follow-up period for readmissions within the measurement year","2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_139173209.2.2","RHP 1_139173209.3.203","RHP 1_139173209.2.2_139173209.3.203",{"$f":"COUNTIFS($FI$4:$FI103,FI103)","v":1},"RHP 1_139173209.2.2_1",null,2,1,1,"RHP 1_139173209",{"$f":"COUNTIFS($FR$4:$FR103,FR103)","v":4},"RHP 1_139173209_4"]
["RHP 1","139173209","East Texas Medical Center Athens","139173209.2.3","139173209.3.204","IT-6.1.a.ix","HCAHPS Overall Hospital Rating","Baseline Approved","Eligible to Report in April DY4","This project is to develop and implement a patient experience improvement plan in order to improve how the patient experiences care and the patient’s satisfaction with the care provided. \n","HCAHPS Overall Hospital Rating","In DY4 and DY5 provider will improve patient satisfaction as demonstrated through the increasing percentage of 'top box' scores on HCAHPS - Overall Rating.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",30077.63,"Yes/No","RHP 1_139173209.3.204_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",30077.63,"Yes/No","RHP 1_139173209.3.204_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",48263.93,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",48263.93,"Numeric",0.64,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",230827.85,"Numeric",0.65600000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.63619400000000004,682,1072,"09/01/13 - 11/30/13",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.64,null,0.65600000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Survey data provided by 3rd party.","69% of people surveyed rated hospital as 9 or 10 out of 10 on survery","HCAHPS Overall Hospital Rating","Inpatient",null,"Patient-mix and survey mode adjusted percent \"top box\" score for a given subdomain as provided by your survey administrator, multiplied by the number of completed surveys represented in the \"top box\" score.","The number of HCAHPS surveys completed during the measurement period as reported by your survey administrator. The denominator should be the same as the multiplier used in the numerator. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.4.1 ","","HCAHPS Overall Hospital Rating",null,null,null,null,null,"2013-12-01","2014-11-30","2014-12-01","2015-11-30","2013-09-01","2013-11-30",null,null,"RHP 1_139173209.2.3","RHP 1_139173209.3.204","RHP 1_139173209.2.3_139173209.3.204",{"$f":"COUNTIFS($FI$4:$FI104,FI104)","v":1},"RHP 1_139173209.2.3_1",null,2,1,1,"RHP 1_139173209",{"$f":"COUNTIFS($FR$4:$FR104,FR104)","v":5},"RHP 1_139173209_5"]
["RHP 1","140425362","Paris‐Lamar County Health Department","140425362.1.1","140425362.3.1","IT-1.7","Controlling high blood pressure ","Baseline Approved","Eligible to Report in October DY4","The Paris-Lamar County Health Department proposes to extend clinic hours from 9a-4p Monday-Thursday to 7a-6p Monday-Thursday. The primary goal is to increase Paris Lamar County Health Department’s primary care capacity by 20% over the 4 year waiver period. ","Controlling high blood pressure ","In DY4 and DY5 provider will improve the percentage of patients 18 to 85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90) during the measurement year.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",18750,"Yes/No","RHP 1_140425362.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",18750,"Yes/No","RHP 1_140425362.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",18750,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",18750,"Numeric",0.53793129299999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",75000,"Numeric",0.55495000000000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.52091299999999996,137,263,"January 1, 2014 - September 30, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.53793129299999998,null,0.55495000000000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator: Notation of diagnosed hypertension in patient medical record during the measurment year.  Numerator: Chart review done to indentify patients within the denominator whose bloodpressure fell within the parameters identified in the compendium document"," 52% of patients identified as having a diagnosis of hypertension meet the definition of adequately controlled with a rate of (>140/90) during measurement year","Controlling high blood pressure ","ambulatory",null,"The number of patients in the denominator whose most recent BP is adequately controlled during the measurement year. For a patient’s BP to be controlled, both the systolic and diastolic BP must be <140/90 (adequate control). To determine if a patient’s BP is adequately controlled, the representative BP must be identified.\n","Patients 18 to 85 years of age by the end of the measurement year who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","Controlling high blood pressure ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-01-01","2014-09-30",null,null,"RHP 1_140425362.1.1","RHP 1_140425362.3.1","RHP 1_140425362.1.1_140425362.3.1",{"$f":"COUNTIFS($FI$4:$FI105,FI105)","v":1},"RHP 1_140425362.1.1_1",null,2,1,1,"RHP 1_140425362",{"$f":"COUNTIFS($FR$4:$FR105,FR105)","v":1},"RHP 1_140425362_1"]
["RHP 1","177870603","Red River Regional Hospital","177870603.1.100","177870603.3.203","IT-2.21","Ambulatory Care Sensitive Conditions Admissions Rate","Pending Approval","Eligible to Report in October DY4","Provide specialty physician consultations in select specialties through the use of telemedicine. Types of specialties will include cardiology, pulmonology, and neurology.","Ambulatory Care Sensitive Conditions Admissions Rate","In DY4 and DY5 provider will reduce the percentage of admissions for conditions as defined in the measure as ambulatory care sensitive  for individuals less then 75 years of age out of the total metro area or county population age 18 years and older.  ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",32829.425000000003,"Yes/No","RHP 1_177870603.3.203_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",32829.425000000003,"Yes/No","RHP 1_177870603.3.203_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",53578.81,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",53578.81,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",254086.05,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator is the total number of acute care hospitalizations for ambulatory care sensitive conditions younger than age 75 years.  Denominator is the population in Fannin County, age 18 years and older.","In 2012 there were 1.65% acute care hospitalizations for ambulatory care sensitive conditions per Fannin County population 18 years and older.","Ambulatory Care Sensitive Conditions Admissions Rate","inpatient",null,"Total number of acute care hospitalizations for ambulatory care sensitive conditions younger than age 75 years ","Total mid-measurement period population younger than age 75",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.7.1","","Ambulatory Care Sensitive Conditions Admissions Rate",null,null,null,null,null,"2013-01-01","2013-12-31","2014-01-01","2014-12-31","2012-01-01","2012-12-31",null,null,"RHP 1_177870603.1.100","RHP 1_177870603.3.203","RHP 1_177870603.1.100_177870603.3.203",{"$f":"COUNTIFS($FI$4:$FI106,FI106)","v":1},"RHP 1_177870603.1.100_1",null,2,1,1,"RHP 1_177870603",{"$f":"COUNTIFS($FR$4:$FR106,FR106)","v":1},"RHP 1_177870603_1"]
["RHP 1","177870603","Red River Regional Hospital","177870603.1.101","177870603.3.204","IT-2.21","Ambulatory Care Sensitive Conditions Admissions Rate","Pending Approval","Eligible to Report in October DY4","Recruit a full-time orthopedic surgeon to establish a specialty clinic.","Ambulatory Care Sensitive Conditions Admissions Rate","In DY4 and DY5 provider will reduce the percentage of admissions for conditions as defined in the measure as ambulatory care sensitive  for individuals less then 75 years of age out of the total metro area or county population age 18 years and older.  ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",21257.365000000002,"Yes/No","RHP 1_177870603.3.204_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",21257.365000000002,"Yes/No","RHP 1_177870603.3.204_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",34692.79,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",34692.79,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",164523.15,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator is the total number of acute care hospitalizations for ambulatory care sensitive conditions younger than age 75 years.  Denominator is the population in Fannin County, age 18 years and older.","In 2012 there were 1.65% acute care hospitalizations for ambulatory care sensitive conditions per Fannin County population 18 years and older.","Ambulatory Care Sensitive Conditions Admissions Rate","inpatient",null,"Total number of acute care hospitalizations for ambulatory care sensitive conditions younger than age 75 years ","Total mid-measurement period population younger than age 75",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2","","Ambulatory Care Sensitive Conditions Admissions Rate",null,null,null,null,null,"2013-01-01","2013-12-31","2014-01-01","2014-12-31","2012-01-01","2012-12-31",null,null,"RHP 1_177870603.1.101","RHP 1_177870603.3.204","RHP 1_177870603.1.101_177870603.3.204",{"$f":"COUNTIFS($FI$4:$FI107,FI107)","v":1},"RHP 1_177870603.1.101_1",null,2,1,1,"RHP 1_177870603",{"$f":"COUNTIFS($FR$4:$FR107,FR107)","v":2},"RHP 1_177870603_2"]
["RHP 1","177870603","Red River Regional Hospital","177870603.1.2","177870603.3.202","IT-2.21","Ambulatory Care Sensitive Conditions Admissions Rate","Pending Approval","Eligible to Report in October DY4","Extend clinic hours on nights  and  weekends,  recruit  a  family  practice  physician  and  a  physician  assistant,  and add needed support staff.","Ambulatory Care Sensitive Conditions Admissions Rate","In DY4 and DY5 provider will reduce the percentage of admissions for conditions as defined in the measure as ambulatory care sensitive  for individuals less then 75 years of age out of the total metro area or county population age 18 years and older.  ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",34716.175000000003,"Yes/No","RHP 1_177870603.3.202_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",34716.175000000003,"Yes/No","RHP 1_177870603.3.202_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",56658.05,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",56658.05,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",268688.69,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator is the total number of acute care hospitalizations for ambulatory care sensitive conditions younger than age 75 years.  Denominator is the population in Fannin County, age 18 years and older.","In 2012 there were 1.65% acute care hospitalizations for ambulatory care sensitive conditions per Fannin County population 18 years and older.","Ambulatory Care Sensitive Conditions Admissions Rate","inpatient",null,"Total number of acute care hospitalizations for ambulatory care sensitive conditions younger than age 75 years ","Total mid-measurement period population younger than age 75",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","Ambulatory Care Sensitive Conditions Admissions Rate",null,null,null,null,null,"2013-01-01","2013-12-31","2014-01-01","2014-12-31","2012-01-01","2012-12-31",null,null,"RHP 1_177870603.1.2","RHP 1_177870603.3.202","RHP 1_177870603.1.2_177870603.3.202",{"$f":"COUNTIFS($FI$4:$FI108,FI108)","v":1},"RHP 1_177870603.1.2_1",null,2,1,1,"RHP 1_177870603",{"$f":"COUNTIFS($FR$4:$FR108,FR108)","v":3},"RHP 1_177870603_3"]
["RHP 1","177870603","Red River Regional Hospital","177870603.2.2","177870603.3.200","IT-6.1.a.ix","HCAHPS Overall Hospital Rating","Baseline Approved","Eligible to Report in October DY4","Develop and implement a patient experience improvement plan ","HCAHPS Overall Hospital Rating","In DY4 and DY5 provider will improve (increase) the positive scores for Overall Hospital Rating from RRRH inpatients",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",13458.805,"Yes/No","RHP 1_177870603.3.200_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",13458.805,"Yes/No","RHP 1_177870603.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",21965.26,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",21965.26,"Numeric",0.64,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",104165.54,"Numeric",0.65600000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.45,27,60,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.64,null,0.65600000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator is the number of surveys that are completed and returned.  The numerator is the number of \"top box\" responses from those returned surveys.","Based on a random sampling survey process, 45.00% of our inpatients would give us an overall rating of 9 or 10.","HCAHPS Overall Hospital Rating","Inpatient",null,"Patient-mix and survey mode adjusted percent \"top box\" score for a given subdomain as provided by your survey administrator, multiplied by the number of completed surveys represented in the \"top box\" score.","The number of HCAHPS surveys completed during the measurement period as reported by your survey administrator. The denominator should be the same as the multiplier used in the numerator. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.4.1 ","","HCAHPS Overall Hospital Rating",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_177870603.2.2","RHP 1_177870603.3.200","RHP 1_177870603.2.2_177870603.3.200",{"$f":"COUNTIFS($FI$4:$FI109,FI109)","v":1},"RHP 1_177870603.2.2_1",null,2,1,1,"RHP 1_177870603",{"$f":"COUNTIFS($FR$4:$FR109,FR109)","v":4},"RHP 1_177870603_4"]
["RHP 1","177870603","Red River Regional Hospital","177870603.2.3","177870603.3.201","IT-11.26.e.i","Patient Health Questionnaire 9 (PHQ-9)","Baseline not yet reported","Eligible to Report in October DY4","Red River Regional Hospital will provide a structured outpatient program (SOP) for geriatric, behavioral health patients.  ","Patient Health Questionnaire 9 (PHQ-9)","In DY4 and DY5 provider will improve the reported score of PHQ-9 assessments out of all surveys administered during the measurement period. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",11949.405000000001,"Yes/No","RHP 1_177870603.3.201_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",11949.405000000001,"Yes/No","RHP 1_177870603.3.201_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",19501.865000000002,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",19501.865000000002,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",92483.43,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Patient Health Questionnaire 9 (PHQ-9)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.13.1","","Patient Health Questionnaire 9 (PHQ-9)",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 1_177870603.2.3","RHP 1_177870603.3.201","RHP 1_177870603.2.3_177870603.3.201",{"$f":"COUNTIFS($FI$4:$FI110,FI110)","v":1},"RHP 1_177870603.2.3_1",null,2,1,1,"RHP 1_177870603",{"$f":"COUNTIFS($FR$4:$FR110,FR110)","v":5},"RHP 1_177870603_5"]
["RHP 1","177870603","Red River Regional Hospital","177870603.2.4","177870603.3.6","IT-1.10","Diabetes care: HbA1c poor control (>9.0%) ","Baseline not yet reported","Eligible to Report in October DY4","Develop and implement an evidence‐based diabetes management program","Diabetes care: HbA1c poor control (>9.0%) ","In DY4 and DY5 provider will improve (decrease) the percentage of patients 18-75 years of age with diabetes (type 1 and type 2) whose most recent HbA1c level during the measurement year was greater than 9.0% (poor control) or was missing a result, or if an HbA1c test was not done during the measurement year.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",11572.06,"Yes/No","RHP 1_177870603.3.6_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",11572.06,"Yes/No","RHP 1_177870603.3.6_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",18886.014999999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",18886.014999999999,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",89562.9,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Diabetes care: HbA1c poor control (>9.0%) ","ambulatory",null,"Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.6.2 ","","Diabetes care: HbA1c poor control (>9.0%) ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 1_177870603.2.4","RHP 1_177870603.3.6","RHP 1_177870603.2.4_177870603.3.6",{"$f":"COUNTIFS($FI$4:$FI111,FI111)","v":1},"RHP 1_177870603.2.4_1",null,2,1,1,"RHP 1_177870603",{"$f":"COUNTIFS($FR$4:$FR111,FR111)","v":6},"RHP 1_177870603_6"]
["RHP 1","208843701","East Texas Medical Center Henderson","208843701.1.1","208843701.3.200","IT-2.21","Ambulatory Care Sensitive Conditions Admissions Rate","Baseline Approved","Eligible to Report in October DY4","This project increases access to healthcare through extended clinic hours on nights and weekends and adding needed physician and support hours.","Ambulatory Care Sensitive Conditions Admissions Rate","In DY4 and DY5 provider will reduce the percentage of admissions for conditions defined as ambulatory care sensitive  for individuals 18 to  75 years of age out of the total number of  admissions to ETMC Henderson.","Facility","ETMC-Henderson","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",10739.465,"Yes/No","RHP 1_208843701.3.200_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",10739.465,"Yes/No","RHP 1_208843701.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",17233.075000000001,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",17233.075000000001,"Numeric",18034.462616822431,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",82419.25,"Numeric",17085.280373831774,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",18983.644859813085,325,1712,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,18034.462616822431,null,17085.280373831774,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Potentially Preventable Hospitalization Conditions for the hospital for the specific time period (10/1/13-9/30/14)","Total Discharges for the hospital for the specific time period (10/1/13-9/30/14)","Ambulatory Care Sensitive Conditions Admissions Rate","inpatient",null,"Total number of acute care hospitalizations for ambulatory care sensitive conditions younger than age 75 years ","Total mid-measurement period population younger than age 75",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","Ambulatory Care Sensitive Conditions Admissions Rate",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_208843701.1.1","RHP 1_208843701.3.200","RHP 1_208843701.1.1_208843701.3.200",{"$f":"COUNTIFS($FI$4:$FI112,FI112)","v":1},"RHP 1_208843701.1.1_1",null,2,1,1,"RHP 1_208843701",{"$f":"COUNTIFS($FR$4:$FR112,FR112)","v":1},"RHP 1_208843701_1"]
["RHP 1","208843701","East Texas Medical Center Henderson","208843701.1.2","208843701.3.2","IT-4.4","Surgical site infections (SSI) rates","Pending Approval","Eligible to Report in October DY4","This project increases access to specialty healthcare through recruiting a full-time general surgeon to establish a specialty clinic location.","Surgical site infections (SSI) rates","In DY4 and DY5 provider will reduce the rate of Surgical Site Infections for all patients as described by the IQR criteria. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",32218.39,"Yes/No","RHP 1_208843701.3.2_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",32218.39,"Yes/No","RHP 1_208843701.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",51699.224999999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",51699.224999999999,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",247257.75,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator consists of all cases of surgical site infections as designated by IQR criteria. The denominator consists of all general surgeries from 10/1/13 to 9/30/14.","There were zero site infections in general surgery from 10/1/13 to 9/30/14.","Surgical site infections (SSI) rates","inpatient",null,"Number of surgical site infections occurring within thirty days after the operative procedure if no implant is left in place or with one year if an implant is in place in patients who had an NHSN operative procedure performed during a specified time period and the infection appears to be related to the operative procedure. Infections are identified on original admission or upon readmission to the facility of original operative procedure within the relevant time frame (30 days for no implants; within 1 year for implants).","Number of NHSN operative procedures performed during a specified time period stratified by:\n\n• Type of NHSN operative procedure\nand\n• NNIS SSI risk index: \nEvery patient having the selected procedure is assigned one (1) risk point for each of the following three factors: \no Surgical wound classification = clean contaminated or dirty\no American Society of Anesthesiologists (ASA) preoperative severity of illness score = 3, 4, or 5\no Duration of operation >t hours, where t varies by type of NHSN operative procedure and is the approximate 75th percentile of the duration of the procedure rounded to the nearest whole number of hours. \n\nNote: For operative procedures performed using lapyroscopes and endoscopes the use of a lapyroscope is an additional factor that modifies the risk index.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2 ","","Surgical site infections (SSI) rates",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_208843701.1.2","RHP 1_208843701.3.2","RHP 1_208843701.1.2_208843701.3.2",{"$f":"COUNTIFS($FI$4:$FI113,FI113)","v":1},"RHP 1_208843701.1.2_1",null,2,1,1,"RHP 1_208843701",{"$f":"COUNTIFS($FR$4:$FR113,FR113)","v":2},"RHP 1_208843701_2"]
["RHP 1","751281410","Andrews Center","751281410.1.1","751281410.3.200","IT-11.26.e.iv","Patient Health Questionnaire 4 (PHQ-4)","Baseline Approved","Eligible to Report in October DY4","This project will implement a crisis intervention program consisting of a location where individuals in crisis could be brought for a period of 4 to 23 hours in order to allow for stabilization and planning for optimal placement. \n","Patient Health Questionnaire 4 (PHQ-4)","In DY4 and DY5 provider will improve reported scores on PHQ-4 instruments completed during the measurement period ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",36078.5,"Yes/No","RHP 1_751281410.3.200_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",36078.5,"Yes/No","RHP 1_751281410.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",38553.9,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",38553.9,"Numeric",8.1229090910000004,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",166593.07999999999,"Numeric",8.0640000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",8.1818179999999998,270,33,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,8.1229090910000004,null,8.0640000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Low number of valid responses allowed for a double-verified manual count.","Baseline rate is somewhat skewed by low client compliance and poor staff compliance with proper administration of the post-test.  The average post test score was 4, based on nine valid post-test records.  There were 25 pre-test valid records.  In addition there were 11 invalid pre-test records and 5 invalid post-test records.  Assuming a more equal distribution of valid tests the baseline rate would very likely have been lower, an estimated 6.16 using internal methodology.","Patient Health Questionnaire 4 (PHQ-4)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.13.1","Scenario 1: Pre/Posttest Baseline","Patient Health Questionnaire 4 (PHQ-4)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 1_751281410.1.1","RHP 1_751281410.3.200","RHP 1_751281410.1.1_751281410.3.200",{"$f":"COUNTIFS($FI$4:$FI114,FI114)","v":1},"RHP 1_751281410.1.1_1",null,2,1,1,"RHP 1_751281410",{"$f":"COUNTIFS($FR$4:$FR114,FR114)","v":1},"RHP 1_751281410_1"]
["RHP 1","751281410","Andrews Center","751281410.2.1","751281410.3.2","IT-9.1","Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons","Pending Approval","Eligible to Report in October DY4","Implement a jail diversion program to intercept behavioral health patients from several points within the justice system and move them to a system geared to dealing with their behavioral health needs. \n","Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons","In DY4 and DY5 provider will improve on the percentage of individuals receiving the project intervention who had a potentially preventable admission to a criminal justice setting within the measurement period over individuals receiving the project intervention.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",36078.5,"Yes/No","RHP 1_751281410.3.2_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",36078.5,"Yes/No","RHP 1_751281410.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",38553.9,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",38553.9,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",166593.07999999999,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Potential project interventions result from the activities of direct project supported counselors, police officers trained via project provided classes, and from Crisis Intervention Team deputies hired through project.  As stated above, the sum total of individuals who are exposed to project interventions, regardless of source, is added up.  Along with the count we obtain the disposition of the encounter, and record if the individual was either incarcerated or admitted to a mental health inpatient facility of any kind.","We feel we were extraordinarlity successful as in the early stages of project efforts the participants tend to focus on \"low hanging fruit\" or those individuals most likely to be a good candidate for interventions. ","Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons","ambulatory",null,"The number of individuals receiving project intervention(s) who had a potentially preventable admission/readmission to a criminal justice setting (e.g. jail, prison, etc.) within the measurement period.","Number of individuals receiving project intervention(s)",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.13.1","","Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_751281410.2.1","RHP 1_751281410.3.2","RHP 1_751281410.2.1_751281410.3.2",{"$f":"COUNTIFS($FI$4:$FI115,FI115)","v":1},"RHP 1_751281410.2.1_1",null,2,1,1,"RHP 1_751281410",{"$f":"COUNTIFS($FR$4:$FR115,FR115)","v":2},"RHP 1_751281410_2"]
["RHP 1","751281410","Andrews Center","751281410.2.100","751281410.3.203","IT-10.1.a.iv","Assessment of Quality of Life (AQoL-8D) ","Pending Approval","Eligible to Report in October DY4","This project will significantly increase outpatient therapy services in Henderson County, providing an estimated 3,000 additional outpatient therapy appointments over the span of the program.  ","Assessment of Quality of Life (AQoL-8D) ","In DY4 and DY5 provider will  improve reported scores on the AQoL-8 instruments completed during the measurement from facilities in Henderson County. ","Facility ","Patients served in Henderson County, excluding our other four counties of service.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",36078.5,"Yes/No","RHP 1_751281410.3.203_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",36078.5,"Yes/No","RHP 1_751281410.3.203_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",38553.9,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",38553.9,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",166593.07999999999,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Each individual participating in project-sponsored outpatient cognitive behavioral therapy is asked to complete the AQoL instrument at the conclusion of each session.  The denominator consists of all scores collected, and may include multiple scores across several sessions for a given client.  If the client declines to participate at a given session, a score is not obtained.  If the client does not fully complete the instrument in a given session the partial score is discarded.  The numerator is the sum of all scored instruments.","There was a markedly lower client participation rate that we are investigating, but may be due to project staff training.  We do feel that there are enough scores, however, for the baseline to be valid.","Assessment of Quality of Life (AQoL-8D) ","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.13.1","Scenario 3: Average Score","Assessment of Quality of Life (AQoL-8D) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 1_751281410.2.100","RHP 1_751281410.3.203","RHP 1_751281410.2.100_751281410.3.203",{"$f":"COUNTIFS($FI$4:$FI116,FI116)","v":1},"RHP 1_751281410.2.100_1",null,2,1,1,"RHP 1_751281410",{"$f":"COUNTIFS($FR$4:$FR116,FR116)","v":3},"RHP 1_751281410_3"]
["RHP 1","751281410","Andrews Center","751281410.2.2","751281410.3.201","IT-1.7","Controlling high blood pressure ","Baseline Approved","Eligible to Report in October DY4","This project will improve the integration of behavioral health and primary care services at various potential locations in Region 1, primarily through primary care clinic services\nin the behavioral health setting.","Controlling high blood pressure ","In DY4 and DY5 provider will improve on the number of patients in the denominator whose most recent BP is adequately controlled during the measurement year over patients 18 to 85 years of age by the end of the measurement year who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",36078.5,"Yes/No","RHP 1_751281410.3.201_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",36078.5,"Yes/No","RHP 1_751281410.3.201_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",38553.9,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",38553.9,"Numeric",0.52572764699999996,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",166593.07999999999,"Numeric",0.54410199999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.50735300000000005,138,272,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.52572764699999996,null,0.54410199999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Custom MS Access filters were developed to display only those individuals with a HTN diagnosis, this provided the denominator.  These results were then subjected to further filters to bring out only the most recent blood pressure reading for that particular individual, and then again to count those within controlled limits.","The result is well within our expected ranges, and gives us a formidable but worthy challenge to provide the care, education, and support required to bring more individuals into controlled ranges.","Controlling high blood pressure ","ambulatory",null,"The number of patients in the denominator whose most recent BP is adequately controlled during the measurement year. For a patient’s BP to be controlled, both the systolic and diastolic BP must be <140/90 (adequate control). To determine if a patient’s BP is adequately controlled, the representative BP must be identified.\n","Patients 18 to 85 years of age by the end of the measurement year who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.15.1","","Controlling high blood pressure ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 1_751281410.2.2","RHP 1_751281410.3.201","RHP 1_751281410.2.2_751281410.3.201",{"$f":"COUNTIFS($FI$4:$FI117,FI117)","v":1},"RHP 1_751281410.2.2_1",null,2,1,1,"RHP 1_751281410",{"$f":"COUNTIFS($FR$4:$FR117,FR117)","v":4},"RHP 1_751281410_4"]
["RHP 1","751281410","Andrews Center","751281410.2.3","751281410.3.202","IT-10.1.a.iv","Assessment of Quality of Life (AQoL-8D) ","Pending Approval","Eligible to Report in October DY4","Increase therapy services in Smith, Henderson, Van Zandt, Wood, and Rains counties by expanding an intensive therapy program for the behavioral health population.","Assessment of Quality of Life (AQoL-8D) ","In DY4 and DY5 provider will improve reported scores on the AQoL-8 instruments completed during the measurement period from facilities in the following counties: Smith, Van Zandt, Wood, and Rains","Facility ","Patients seen within our Smith, Van Zandt, Wood, and Rains County facilities, excluding Henderson County.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",36078.5,"Yes/No","RHP 1_751281410.3.202_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",36078.5,"Yes/No","RHP 1_751281410.3.202_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",38553.9,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",38553.9,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",166593.07999999999,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Each individual participating in project-sponsored outpatient cognitive behavioral therapy is asked to complete the AQoL instrument at the conclusion of each session.  The denominator consists of all scores collected, and may include multiple scores across several sessions for a given client.  If the client declines to participate at a given session, a score is not obtained.  If the client does not fully complete the instrument in a given session the partial score is discarded.  The numerator is the sum of all scored instruments.","This baselien is within our expected results.  We are pleased with the participation rate and look forward to demonstrating the efficacy of our intervention going forward via improved average scores.","Assessment of Quality of Life (AQoL-8D) ","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.13.1","Scenario 3: Average Score","Assessment of Quality of Life (AQoL-8D) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 1_751281410.2.3","RHP 1_751281410.3.202","RHP 1_751281410.2.3_751281410.3.202",{"$f":"COUNTIFS($FI$4:$FI118,FI118)","v":1},"RHP 1_751281410.2.3_1",null,2,1,1,"RHP 1_751281410",{"$f":"COUNTIFS($FR$4:$FR118,FR118)","v":5},"RHP 1_751281410_5"]
["RHP 10","020950401","Medical Center of Arlington","020950401.2.1","020950401.3.1","IT-6.1.a.ix","HCAHPS Overall Hospital Rating","Baseline Approved","Eligible to Report in April DY4","Implement process improvement plans that target specific patient experiences.","HCAHPS Overall Hospital Rating","In DY4 and DY5 provider will increase the percentage of top box scores on the HCAHPS survey- Overall Hospital Rating domain. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",45140.9,"Yes/No","RHP 10_020950401.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",45140.9,"Yes/No","RHP 10_020950401.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",48290.34,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",48290.34,"Numeric",0.68300000000000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",230953.24,"Numeric",0.69599999999999995,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.67,807.35,1205,"DY2: Oct 1st, 2012 - Sept 30th, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.68300000000000005,null,0.69599999999999995,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The Numerator is the total number of surveys administered in the period provided by our survery administrator Gallup patient mix and mode adjusted by CMS multiplies times top box score for Overall Hospital Rating. The Denomintor is the number of suverys adminstered by Gallup for the period obtained from you Gallup website","The baseline rate above is 67% top box score for Overall Hospital Rating for the period 2012 Q4 to 2013 Q3. Top Box score is % of survey responses that rated the hospital a 9 or 10 on a scale 0-10 (0 being worst to 10 being best).","HCAHPS Overall Hospital Rating","Inpatient",null,"Patient-mix and survey mode adjusted percent \"top box\" score for a given subdomain as provided by your survey administrator, multiplied by the number of completed surveys represented in the \"top box\" score.","The number of HCAHPS surveys completed during the measurement period as reported by your survey administrator. The denominator should be the same as the multiplier used in the numerator. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.4.1 ","","HCAHPS Overall Hospital Rating",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 10_020950401.2.1","RHP 10_020950401.3.1","RHP 10_020950401.2.1_020950401.3.1",{"$f":"COUNTIFS($FI$4:$FI119,FI119)","v":1},"RHP 10_020950401.2.1_1",null,2,1,1,"RHP 10_020950401",{"$f":"COUNTIFS($FR$4:$FR119,FR119)","v":1},"RHP 10_020950401_1"]
["RHP 10","020950401","Medical Center of Arlington","020950401.2.2","020950401.3.2","IT-4.10","Sepsis bundle  (NQF 0500)","Baseline Approved","Eligible to Report in October DY4","This project will implement process improvement methodologies in a sepsis evidenced based care program ","Sepsis bundle  (NQF 0500)"," In DY 4 and DY 5 provider will increase the percentage of patients that receive care compliant with the sepsis identification and management bundle for patients with severe sepsis and/or septic shock excluding patients who fall in to denominator exclusions A) thru E) where as PICC Line placement are also alternatives for Central lines for patient access for treatment\n",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",88669.625,"Yes/No","RHP 10_020950401.3.2_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",88669.625,"Yes/No","RHP 10_020950401.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",94856.024999999994,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",94856.024999999994,"Numeric",8.1147541000000004E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",453658.15,"Numeric",0.12950800000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",3.2786999999999997E-2,4,122,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,8.1147541000000004E-2,null,0.12950800000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator was the number of patients  that meet the 3 hour metric for treatment or 6 hour bundle metric if they should have received these additional sepsis treatments. If a patient was eligible to receive the 3 and 6 hours treatment bundles based on their diagnosis and response to initial treatment but did not meet 3 hour time metric or documentation was not clear that treament met the time metric, the patient claim was not in the numerator. The denominator was a sample of claims with as diagnosis fo severe sepsis or septic shock selected with a sampling process. ","The baseline rate represents 3% of patients received the bundle treatment in time measurement s 3 hours and 6 hours.  Often the patients receive the bundle treatment but they are not timely. Processes need to be improved to impact the timeliness of treament,","Sepsis bundle  (NQF 0500)","inpatient",null,"Patients from the denominator who received all the following: A, B, C, and D within 3 hours of time of presentation†, \nAND, \nIF septic shock is present (as either defined as hypotension* or lactate >=4 mmol/L) who also received E, ,F and G within 6 hours of time of presentation\n\nTo be completed within 3 hours:\nA. measure lactate level\nB. obtain blood cultures prior to antibiotics\nC. administer broad spectrum antibiotics\nD. administer 30 ml/kg crystalloid (bolus) for hypotension or lactate >=4 mmol/L\n\nTo be completed within 6 hours (or if septic shock is present):\nE. apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure >= 65)\nF. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate >=4 mmol/L (36 mg/dl) the resuscitation is objectively monitored using a method such as lactate clearance, ScvO2 monitoring or CVP monitoring\nG. re-measure lactate if initial lactate is elevated\n","Number of patients presenting with severe sepsis or septic shock.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.8.11","","Sepsis bundle  (NQF 0500)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 10_020950401.2.2","RHP 10_020950401.3.2","RHP 10_020950401.2.2_020950401.3.2",{"$f":"COUNTIFS($FI$4:$FI120,FI120)","v":1},"RHP 10_020950401.2.2_1",null,2,1,1,"RHP 10_020950401",{"$f":"COUNTIFS($FR$4:$FR120,FR120)","v":2},"RHP 10_020950401_2"]
["RHP 10","020950401","Medical Center of Arlington","020950401.2.3","020950401.3.200","IT-9.9","Transition Record with Specified Elements Received by Inpatient Discharge Patients","Baseline Approved","Eligible to Report in October DY4","Implement a Care Transitions Program  to improve care transitions and coordination of care from inpatient to outpatient, post‐acute care, and home care settings","Transition Record with Specified Elements Received by Discharged Patients (Inpatient Discharges to Home/Self Care or Any Other Site of Care)","In DY4 and DY5 provider will improve (increase) the percentage of CHF patients, regardless of age, discharged from an inpatient facility (e.g. hospital inpatient or observation, skilled nursing facility, or rehabilitation facility) to home or any other site of care, or their caregiver(s), who received a transition record (and with whom a review of all included information was documented) at the time of discharge including, at a minimum, all of the specified elements","Comorbid Condition ","CHF patients","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",9135.66,"Yes/No","RHP 10_020950401.3.200_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",9135.66,"Yes/No","RHP 10_020950401.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",9773.0450000000001,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",9773.0499999999993,"Numeric",0.90890411000000004,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",46740.54,"Numeric",0.91369900000000004,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.90410999999999997,66,73,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.90890411000000004,null,0.91369900000000004,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator are those heart failure  patients whose transtion record gievn to patient was documented with specified elements and denominator were all possible heart failure patients who should have received transition record","90.4% of heart falure patients received transition record.","Transition Record with Specified Elements Received by Inpatient Discharge Patients","Inpatient/Ambulatory",null,"Patients or their caregiver(s) who received a transition record (and with whom a review of all included information was documented) at the time of discharge including, at a minimum, all of the following elements:\n \nInpatient Care\n•Reason for inpatient admission, AND \n•Major procedures and tests performed during inpatient stay and summary of results, AND \n•Principal diagnosis at discharge \n\nPost-Discharge/Patient Self-Management\n•Current medication list, AND \n•Studies pending at discharge (e.g., laboratory, radiological), AND \n•Patient instructions \n\nAdvance Care Plan\n•Advance directives or surrogate decision maker documented, OR\n•Documented reason for not providing advance care plan \n\nContact Information/Plan for Follow-up Care\n•24-hour/7-day contact information including physician for emergencies related to inpatient stay, AND \n•Contact information for obtaining results of studies pending at discharge, AND \n•Plan for follow-up care, AND \n•Primary physician, other health care professional, or site designated for follow-up care\n","All patients, regardless of age, discharged from an inpatient facility (e.g., hospital inpatient or observation, skilled nursing facility, or rehabilitation facility) to home/self-care or any other site of care",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.12.2","","Transition Record with Specified Elements Received by Inpatient Discharge Patients",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 10_020950401.2.3","RHP 10_020950401.3.200","RHP 10_020950401.2.3_020950401.3.200",{"$f":"COUNTIFS($FI$4:$FI121,FI121)","v":1},"RHP 10_020950401.2.3_1",null,2,1,1,"RHP 10_020950401",{"$f":"COUNTIFS($FR$4:$FR121,FR121)","v":3},"RHP 10_020950401_3"]
["RHP 10","020950401","Medical Center of Arlington","020950401.2.3","020950401.3.201","IT-9.10.a","Median Time from ED Arrival to ED Departure for Discharged ED Patients","Baseline Approved","Eligible to Report in October DY4","Implement a Care Transitions Program  to improve care transitions and coordination of care from inpatient to outpatient, post‐acute care, and home care settings","Median Time from ED Arrival to ED Departure for Discharged ED Patients","In DY4 and DY5 provider will improve (decrease) the median time from hospital-based emergency department arrival to time of departure from the emergency room for patients discharged from the hospital-based emergency department","Facility ","Hospital based Emergency Room","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",9135.66,"Yes/No","RHP 10_020950401.3.201_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",9135.66,"Yes/No","RHP 10_020950401.3.201_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",9773.0450000000001,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",9773.0499999999993,"Numeric",148.19999999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",46740.54,"Numeric",140.4,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"time (minutes)",156,156,1,"September 1, 2013 -August 31, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,148.19999999999999,null,140.4,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The ED median time is  156 minutes.  These were  37,858 ED cases for the subset in the measurement period. Total minutes were 7242595.  Median time was 156 minutes and average  time from arrival to departure from ED was 191 minutes. ","The  time from arrival at the ED to the time patients is departed (physically left the ED to home/transfer) mid point of all times recorded is 156 minutes so basically 50% of times are below 156  minutes and 50% of times are greater than 156 minutes. However the average time is 191 which takes into account lower and higher times","Median Time from ED Arrival to ED Departure for Discharged ED Patients","ED",null,"Median Time from ED Arrival to ED Departure for Discharged ED Patients: Continuous Variable Statement: Time (in minutes) from ED arrival to ED departure for patients discharged from the emergency department. ",1,null,null,null,null,null,null,null,null,null,null,null,null,null,"2.12.2","","Median Time from ED Arrival to ED Departure for Discharged ED Patients",null,null,null,null,null,"2014-09-01","2015-08-31","2015-09-01","2016-08-31","2013-09-01","2014-08-31",null,null,"RHP 10_020950401.2.3","RHP 10_020950401.3.201","RHP 10_020950401.2.3_020950401.3.201",{"$f":"COUNTIFS($FI$4:$FI122,FI122)","v":2},"RHP 10_020950401.2.3_2",null,2,1,1,"RHP 10_020950401",{"$f":"COUNTIFS($FR$4:$FR122,FR122)","v":4},"RHP 10_020950401_4"]
["RHP 10","020950401","Medical Center of Arlington","020950401.2.3","020950401.3.4","IT-9.8","Care Transition: Transition Record with Specified Elements Received by ED Discharged Patients","Baseline Approved","Eligible to Report in October DY4","Implement a Care Transitions Program  to improve care transitions and coordination of care from inpatient to outpatient, post‐acute care, and home care settings","Care Transition: Transition Record with Specified Elements Received by Discharged Patients (Emergency Department Discharges to Ambulatory Care [Home/Self Care] or Home Health Care)","In DY4 and DY5 provider will improve (increase) the percentage of CHF patients, regardless of age, discharged from an emergency department (ED) to ambulatory care or home health care, or their caregiver(s), who received a transition record at the time of ED discharge including, at a minimum, all of the specified elements.","Comorbid Condition ","CHF Patients in Hospital Based Emergency room","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",9135.66,"Yes/No","RHP 10_020950401.3.4_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",9135.66,"Yes/No","RHP 10_020950401.3.4_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",9773.0450000000001,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",9773.0450000000001,"Numeric",0.97978723400000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",46740.54,"Numeric",0.98085100000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.97872300000000001,46,47,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.97978723400000001,null,0.98085100000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator is the number of Heart Failure patients whose ED  transition record given to  the patient and documented contains the 5 elements of the transition record if applicable. The denominator were all ED claims with Heart Failure diagnosis in 6 month period Apr 2014 to Sept 2014 (56 claims) less 9 excluded patients (AMA, transfer, expired) for a total denominator of 47.","97.8% of patients received an appropriate transition record","Care Transition: Transition Record with Specified Elements Received by ED Discharged Patients","ED/Ambulatory",null,"Patients or their caregiver(s) who received a transition record at the time of emergency department (ED) discharge including, at a minimum, all of the following elements:\n•Summary of major procedures and tests performed during ED visit, AND \n•Principal clinical diagnosis at discharge which may include the presenting chief complaint, AND \n•Patient instructions, AND \n•Plan for follow-up care (OR statement that none required), including primary physician, other health care professional, or site designated for follow-up care, AND \n•List of new medications and changes to continued medications that patient should take after ED discharge, with quantity prescribed and/or dispensed (OR intended duration) and instructions for each\n\n","All patients, regardless of age, discharged from an emergency department (ED) to ambulatory care (home/self-care) or home health care",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.12.2","","Care Transition: Transition Record with Specified Elements Received by ED Discharged Patients",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 10_020950401.2.3","RHP 10_020950401.3.4","RHP 10_020950401.2.3_020950401.3.4",{"$f":"COUNTIFS($FI$4:$FI123,FI123)","v":3},"RHP 10_020950401.2.3_3",null,2,1,1,"RHP 10_020950401",{"$f":"COUNTIFS($FR$4:$FR123,FR123)","v":5},"RHP 10_020950401_5"]
["RHP 10","021184901","Cook Children's Medical Center","021184901.1.1","021184901.3.1","IT-9.3.a","Pediatric Emergency Department (ED) visits per 100,000","Baseline Approved","Eligible to Report in October DY4","This project establishes another pediatric primary care clinic in an area where 42% of the families are below 200% of the Federal Poverty Level","Pediatric Emergency Department (ED) visits per 100,000","In DY4 and DY5 provider will improve (decrease) the rate of ED utilization for Pediatric Ambulatory Care Sensitive Conditions (Pediatric Quality Indicators #14, #15, #16, and #18) out of the total number of pediatric ED visits for children age 0-14 years. ","Age ","Age 0 - 14 years","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",207977.5,"Yes/No","RHP 10_021184901.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",207977.5,"Yes/No","RHP 10_021184901.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",222487.33499999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",222487.34,"Numeric",26129.610682617138,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1064071,"Numeric",24754.368015110973,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",27504.853350123303,104843,442314,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,26129.610682617138,null,24754.368015110973,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Since Cook Children's Medical Center and this project are exclusively pediatric in nature, we believe a more relevant age range to measure any impact at the population level would be from Birth to 14 years of age.","The numerator was calculated from records housed in our EMR to determine the exact number of distinct visits in which care was rendered in the emergency department (patients who elopped, left without being seen, left against medical advice or were transferred to another facility were not included) between 10/01/2013 and 9/30/2014 for patients between birth and 14 years of age.   The denominator (population of children between birth and 14 years of age in Tarrant County) was gathered through the product Market Expert by Truven Health Analytics. ","About 23.7 children (0 to 14 years of age) presented to Cook Children's Emergency Department out of every 100 children (0 to 14 years of age) that reside in Tarrant County between October 1, 2013 and September 30, 2014.","Pediatric Emergency Department (ED) visits per 100,000","ED",null,"Total number of ED Visits during the measurement period for patients aged 6 – 17 years ","Population in Metro Area or county , age 6 – 17 years",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1 ","","Pediatric Emergency Department (ED) visits per 100,000",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 10_021184901.1.1","RHP 10_021184901.3.1","RHP 10_021184901.1.1_021184901.3.1",{"$f":"COUNTIFS($FI$4:$FI124,FI124)","v":1},"RHP 10_021184901.1.1_1",null,2,1,1,"RHP 10_021184901",{"$f":"COUNTIFS($FR$4:$FR124,FR124)","v":1},"RHP 10_021184901_1"]
["RHP 10","021184901","Cook Children's Medical Center","021184901.1.2","021184901.3.2","IT-9.3.a","Pediatric Emergency Department (ED) visits per 100,000","Baseline Approved","Eligible to Report in October DY4","This project establishes another pediatric urgent care clinic in an area where 14% of the families, regardless of household income rate access to urgent care as “difficult.”","Pediatric Emergency Department (ED) visits per 100,000","In DY4 and DY5 provider will improve (decrease) the rate of ED utilization for Pediatric Ambulatory Care Sensitive Conditions (Pediatric Quality Indicators #14, #15, #16, and #18) out of the total number of pediatric ED visits for children age 0-14 years. ","Age ","Age 0 - 14 years","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",207977.5,"Yes/No","RHP 10_021184901.3.2_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",207977.5,"Yes/No","RHP 10_021184901.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",222487.33499999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",222487.34,"Numeric",22518.131915336166,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1064071,"Numeric",21332.967077686892,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",23703.296752985436,104843,442314,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,22518.131915336166,null,21332.967077686892,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Since Cook Children's Medical Center and this project are exclusively pediatric in nature, we believe a more relevant age range to measure any impact at the population level would be from Birth to 14 years of age.","The numerator was calculated from records housed in our EMR to determine the exact number of distinct visits in which care was rendered in the emergency department (patients who elopped, left without being seen, left against medical advice or were transferred to another facility were not included) between 10/01/2013 and 9/30/2014 for patients between birth and 14 years of age.   The denominator (population of children between birth and 14 years of age in Tarrant County) was gathered through the product Market Expert by Truven Health Analytics. ","About 23.7 children (0 to 14 years of age) presented to Cook Children's Emergency Department out of every 100 children (0 to 14 years of age) that reside in Tarrant County between October 1, 2013 and September 30, 2014.","Pediatric Emergency Department (ED) visits per 100,000","ED",null,"Total number of ED Visits during the measurement period for patients aged 6 – 17 years ","Population in Metro Area or county , age 6 – 17 years",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1 ","","Pediatric Emergency Department (ED) visits per 100,000",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 10_021184901.1.2","RHP 10_021184901.3.2","RHP 10_021184901.1.2_021184901.3.2",{"$f":"COUNTIFS($FI$4:$FI125,FI125)","v":1},"RHP 10_021184901.1.2_1",null,2,1,1,"RHP 10_021184901",{"$f":"COUNTIFS($FR$4:$FR125,FR125)","v":2},"RHP 10_021184901_2"]
["RHP 10","021184901","Cook Children's Medical Center","021184901.1.3","021184901.3.3","IT-7.2","Cavities: Children","Pending Approval","Eligible to Report in October DY4","This project establishes a pediatric dental clinic in an area where the families ranked access to pediatric dental care as one of the top five priorities.  ","Cavities: Children","In DY4 and DY5 provider will improve (decrease) the percentage of children with untreated dental caries",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",207977.5,"Yes/No","RHP 10_021184901.3.3_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",207977.5,"Yes/No","RHP 10_021184901.3.3_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",222487.33499999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",222487.33499999999,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1064071,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numberator and denominator data was obtained from Bill Devine, DDS who works with John Peter Smith Hospital (see attached email).  The denominator is the number of children in Tarrant County enrolled in Fort Worth ISD,  grades pre-kindergarten through 4th grade, who were screened for untreated dental decay by the dental health program at John Peter Smith Hospital.  The numerator is the total number of children from this population who were referred to a dentist because of untreated dental decay found during the screening. ","For every 1,000 children enrolled in Pre-Kindergarten through 4th grade there are about 44 children with untreated dental cavities/tooth decay.","Cavities: Children","ambulatory",null,"Number of children with untreated dental caries","Total number of children that have seen a dental provider within the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.8.6 ",null,"Cavities: Children",null,null,null,null,null,"2014-10-29","2015-10-28","2015-10-29","2016-10-28","2013-10-01","2014-10-28",null,null,"RHP 10_021184901.1.3","RHP 10_021184901.3.3","RHP 10_021184901.1.3_021184901.3.3",{"$f":"COUNTIFS($FI$4:$FI126,FI126)","v":1},"RHP 10_021184901.1.3_1",null,2,1,1,"RHP 10_021184901",{"$f":"COUNTIFS($FR$4:$FR126,FR126)","v":3},"RHP 10_021184901_3"]
["RHP 10","022817305","Tarrant County Public Health","022817305.1.1","022817305.3.1","IT-5.1.a","Improved Cost Savings: Cost of Illness Analysis","Baseline not yet reported","Eligible to Report in October DY4","The project involves a two-way flow of data between TCPH and the North Texas Accountable Healthcare Partnership’s (NTAHP) regional HIE which will be used to analyze, assess and impact population health covering various health conditions and/or chronic diseases. Health conditions/disease states include notifiable/reportable disease such as sexually transmitted infections or tuberculosis as well as pregnancy or chronic diseases such as obesity, diabetes, hypertension, congestive heart failure and asthma. This data will be analyzed to characterize the conditions in special populations (e.g., racial/ethnic groups or groups based on primary language or health literacy status). TCPH developed and maintains a syndromic surveillance reporting network featuring aggregate, de-identified data that soon will be more robust as additional providers send data to the regional HIE to obtain incentives for achieving Meaningful Use (MU) requirements. TCPH and providers will use this data (and individual, private health data on reportable conditions that TCPH maintains) to identify health conditions and disease state “hot spots” and/or disproportionately-affected groups and to direct resources appropriately, meaning in ways that are specific to and will best address each participant’s populations, findings and needs.  ","Improved Cost Savings: Demonstrate cost savings in care delivery - Cost of Illness Analysis","In DY4 and DY5 provider will demonstrate improvement by improving cost savings for individuals with pertussis whose health data is collected in the HIE. ","Facility, Comorbid Condition ","All Pertussis case data received through the HIE","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",101739.66,"Yes/No","RHP 10_022817305.3.1_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",101739.66,"Yes/No","RHP 10_022817305.3.1_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",217825.92000000001,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",473534.04,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"$",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"dy4","TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Improved Cost Savings: Cost of Illness Analysis","Multiple",null,"Formula: COI = Direct cost + Indirect cost","Total number of patients with the designated illness during the measurement year",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.10.2","","Improved Cost Savings: Cost of Illness Analysis",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 10_022817305.1.1","RHP 10_022817305.3.1","RHP 10_022817305.1.1_022817305.3.1",{"$f":"COUNTIFS($FI$4:$FI127,FI127)","v":1},"RHP 10_022817305.1.1_1",null,1,1,0,"RHP 10_022817305",{"$f":"COUNTIFS($FR$4:$FR127,FR127)","v":1},"RHP 10_022817305_1"]
["RHP 10","022817305","Tarrant County Public Health","022817305.1.2","022817305.3.15","IT-15.17","Latent Tuberculosis Infection (LTBI) treatment rate ","Baseline Approved","Eligible to Report in April DY4","The primary purpose for this project is to provide non-traditional service hours to improve compliance of treatment of latent TB infection, reducing active TB in the pop. The project is an expansion to current TB Clinic.","Latent Tuberculosis Infection (LTBI) treatment rate ","In DY4 and DY5 provider will increase the percentage of patients that complete the treatment regimen for LTBI out of all patients that initiate treatment at Tarrant County Public Health Department outreach clinic. ","Facility ","All LTBI patients that have started treatment through the Tarrant County Public Health Department.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",84783.05,"Yes/No","RHP 10_022817305.3.15_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",84783.05,"Yes/No","RHP 10_022817305.3.15_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",90760.8,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",90760.8,"Numeric",0.63147853700000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",394611.7,"Numeric",0.65087399999999995,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.61208300000000004,385,629,"CY 2013: Jan 1st, 2013 - Dec 31st, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.63147853700000001,null,0.65087399999999995,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Clients who last had a medication refill during the measurement period were included in the baseline as this would either be their completion or failure year (the measure is calculating a rate for those eligible to complete in 2013). This is because there are multiple LTBI treatment regimens with varying durations. The LTBI regimens used during the baseline period include Rifampin for 4 months and Isoniazid for 6 or 9 months. It is preferred that a client take Isoniazid for 9 months, but 6 months is considered adequate therapy and also was in establishing the baseline.","61% of all patients in our population completed therapy.","Latent Tuberculosis Infection (LTBI) treatment rate ","Ambulatory/Inpatient",null," Individuals from the denominator that completed a LTBI treatment regimen","Total number of individuals identified with Latent Tuberculosis Infection (LTBI) that initiated (accepted) a LTBI treatment regimen. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","Latent Tuberculosis Infection (LTBI) treatment rate ",null,null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 10_022817305.1.2","RHP 10_022817305.3.15","RHP 10_022817305.1.2_022817305.3.15",{"$f":"COUNTIFS($FI$4:$FI128,FI128)","v":1},"RHP 10_022817305.1.2_1",null,2,1,1,"RHP 10_022817305",{"$f":"COUNTIFS($FR$4:$FR128,FR128)","v":2},"RHP 10_022817305_2"]
["RHP 10","022817305","Tarrant County Public Health","022817305.2.1","022817305.3.19","IT-8.12","Pre-term birth rate ","Baseline not yet reported","Eligible to Report in October DY4","Implement the use of antenatal steroids to prevent preterm birth in women with a history of spontaneous preterm birth.","Pre-term birth rate ","In DY4 and DY5 provider will demonstrate improvement by reducing the percentage of pre-term births (<37 weeks gestation) out of all women enrolled in the community based antenatal steroids education program who also have a history of prior preterm birth. ","Facility, Comorbid Condition ","We are requesting two population subsets: 1)Denominator will be limited to patients that are educated by our project (facility) and; 2) only women with a history of preterm birth (targeted comorbid condition).  ","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",84783.05,"Yes/No","RHP 10_022817305.3.19_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",84783.05,"Yes/No","RHP 10_022817305.3.19_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",181521.6,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",394611.7,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"dy4","TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Pre-term birth rate ","Multiple",null,"Number of singleton livebirths delivered with less than 37 completed weeks of gestation. \n","All live births. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.7.4 ","","Pre-term birth rate ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 10_022817305.2.1","RHP 10_022817305.3.19","RHP 10_022817305.2.1_022817305.3.19",{"$f":"COUNTIFS($FI$4:$FI129,FI129)","v":1},"RHP 10_022817305.2.1_1",null,1,1,0,"RHP 10_022817305",{"$f":"COUNTIFS($FR$4:$FR129,FR129)","v":3},"RHP 10_022817305_3"]
["RHP 10","022817305","Tarrant County Public Health","022817305.2.100","022817305.3.100","IT-10.1.h","CDC Health-Related Quality of Life (HRQoL) Measures","Baseline not yet reported","Eligible to Report in October DY4","Implementation of the evidence-based, award-winning, Matter of Balance Fall Management Program.  The program is designed to teach clients the necessary fall-management techniques that will help them reduce and manage falls and improve quality of life.  \n\nDuring the class, participants learn to:\n\n• View falls as controllable\n• Set goals for increasing activity\n• Make changes to reduce fall risk at home\n• Exercise to increase strength and balance\n• Fall in a way that eliminates or minimizes injury\n• Improve health related quality of life\n\nThe program will be implemented with the cooperation of the providers within the Texas Health Resources system, and other select providers in Tarrant County.  This is a new initiative for Tarrant County Public Health, but will augment a small initiative being led by Senior Citizen Services of Tarrant County.  TCPH intends to hire 5 new staff members to implement the program – 1 supervisory community health worker and 4 non-supervisory community health workers.  \n","CDC Health-Related Quality of Life (HRQoL) Measures","In DY4 and DY5 provider will improve reported scores on the  HRQoL out of all surveys completed during the measurement period by patients receiving fall prevention curriculum. ","Facility ","All individuals enrolled in our project training classes.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",94957.014999999999,"Yes/No","RHP 10_022817305.3.100_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",94957.014999999999,"Yes/No","RHP 10_022817305.3.100_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",203304.19,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",441965.1,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"dy4","TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"CDC Health-Related Quality of Life (HRQoL) Measures","Ambulatory",null,"The overall score as defined by selected reporting scenario, multiplied by the number of completed CDC-HRQOL surveys represented in the overall score. ","The total number of CDC-HRQOL surveys aggregated to create the overall score as defined by selected reporting scenario\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.6.2","","CDC Health-Related Quality of Life (HRQoL) Measures",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 10_022817305.2.100","RHP 10_022817305.3.100","RHP 10_022817305.2.100_022817305.3.100",{"$f":"COUNTIFS($FI$4:$FI130,FI130)","v":1},"RHP 10_022817305.2.100_1",null,1,1,0,"RHP 10_022817305",{"$f":"COUNTIFS($FR$4:$FR130,FR130)","v":4},"RHP 10_022817305_4"]
["RHP 10","022817305","Tarrant County Public Health","022817305.2.2","022817305.3.5","IT-15.15","High Intensity Behavioral Counseling to prevent STIs","Baseline Approved","Eligible to Report in October DY4","Evidence-based Intervention designed to inform and educate youth about Sexually Transmitted Diseases and how to make appropriate choices regarding sexual activities. This is a new project for the Arlington, Texas area.","High Intensity Behavioral Counseling to prevent STIs for all sexually active adolescents and for adults at increased risk for STIs ","In DY4 and DY5 provider will report the percentage of sexually active adolescents that receive HIBC for STDs out of all sexually active adolescents, residing in Arlington, Texas, aged 15 to 19 years. In addition, in DY5 provider will complete Stretch Activity #3 (SA3)- Outcome Evaluation.","Age ","Our population consists of adolescents age 15-19 years old.","P4R","SA3","PM-8","Submission of Category 3 DY3 Status Report",101739.66,"Yes/No","RHP 10_022817305.3.5_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",101739.66,"Yes/No","RHP 10_022817305.3.5_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",217825.92000000001,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",236767.02,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",236767.02,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",1.1898000000000001E-2,153.30000000000001,12885,"3/1/2014-8/31/2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Since sexual activity among teens is not a variable that is collected among Arlington residents or PRIDE\nattendees. Hence a proxy measure was used based on the proportion of Texas high school students\nwho reported ‘ever having sex’ from Texas Youth Risk Behavior Survey (Tx YRBS) conducted by the Texas\nDepartment of State Health Services.\n-Based on the 2013 Tx YRBS, 45.9% of Texas high school students reported ‘ever having sex’\n-There were 472 PRIDE enrollees aged 15‐19 years from March 1, 2014 through August 31, 2014;\n334 of them were considered to be 100% completers of the PRIDE curriculum.\n-Numerator: Once data collection was completed for DY3, the numerator was extrapolated using\nthe aforementioned proxy. The estimated number of PRIDE enrollees aged 15‐19 years who are\nsexually active would be 45.9% of PRIDE enrollees aged 15‐19 years OR in other words\n(334)*(45.9%) = 153.3.  Denominator: The denominator was extrapolated using the aforementioned proxy and the Census data for Arlington. Per US Census data, there were 28,072 Arlington residents aged\n15‐19 years. So the estimated number of Arlington residents aged 15‐19 years who are sexually\nactive would be 45.9% of the Arlington residents aged 15‐19 years OR in other words\n(28,072)*(45.9%) = 12,885.\nThe proportion of sexually active Arlington residents aged 15‐19 years old who have attended the PRIDE\nProgram = (153.3/12,885)*100 = 1.2%","1.2% of the sexually active (ages 15-19) have received HIBC.","High Intensity Behavioral Counseling to prevent STIs","ambulatory",null,"Number of persons undergoing High Intensity Behavioral Counseling (HIBC) identified at increased risk for STI","Total number of persons at increased risk for STI infection",null,null,null,null,null,null,null,null,null,null,"AIM: To assess the change in the knowledge pertaining to Sexually Transmitted Diseases (STDs) among\nPRIDE program enrollees.\nPRIDE program is an evidence based community program designed to inform and educate adolescents &\nyoung adults about STIs by using current group leaders/youth leaders in teen clubs and community\norganizations as facilitators and conduits of information to the youth. The selected facilitators are\ntrained by Tarrant County Public Health staff in how to communicate STI information, specifically\nregarding STD acquisition, symptoms, prevention and treatment. The PRIDE program participants are\nconsidered to be program completers upon completing the required PRIDE curriculum which is imparted\nin a class room setting.\nA 10‐question Pride Knowledge Assessment questionnaire is administered to PRIDE\nenrollees at the time of enrollment (Pre‐test) to assess their knowledge of STD terminology,\ntransmission, signs/symptoms, treatment, and prevention. At the time of completion of the PRIDE\ncurriculum, the enrollees are once again administered the same 10‐question Pride Knowledge\nAssessment questionnaire (Post‐test) that was administered at the time of the enrollment to assess\ntheir knowledge of STD terminology, transmission, signs/symptoms, treatment, and prevention.\nAll pre‐ and post‐tests were scored by a PRIDE Program staff member and the scores were entered into\na secure SPSS database. The measurement scale used to score the pre‐ and post‐tests was ordinal.\nVariables tracked in the database included:\no Location of education session (agency name)\no Enrollee name\no Enrollee unique ID number\no Date enrolled (session start date)\no Session end date\no Enrollee grade\no Enrollee age\no Total number of sessions in the education program\no Number of sessions attended by the enrollee\no Enrollee responses to each of the pre‐ and post‐test questions\nSign test for related samples was used to assess significant difference between the pre‐ and post‐tests\nscores. All data analyses were performed using SPSS 19.0.\nResults through September 30, 2014: There were 395 pre‐ and 399 post‐test completed by PRIDE enrollees from March 1, 2014 – September 30, 2014. Pre‐ and Post‐tests that could not be matched or traced back to a particular enrollee were\nexcluded from the analyses. Three hundred and seventy six pre‐ and post‐tests were included in the\nanalyses (attachment 2).  The Pre‐test scores ranged from 10‐100 with a mean of 75.5. The Post‐test scores ranged from\n0‐100 with a mean of 88.7. Twenty seven enrollees scored the maximum score of 100 on the Pre and\nthe Post test. 260 of the 376 participants (69%) had an increase in knowledge (post‐test score higher\nthan pre‐test score). There was statistically significant median difference between paired or matched\n(pre‐test & post‐test) observations (Z=12.3, p < 0.001); the post‐test scores were significantly higher to\nthe pre‐test scores for the paired observations.  This tool will continue to be utilized to optimize the transfer of education to the participant and help refine best practices for implementation.",null,null,"2.6.1","","High Intensity Behavioral Counseling to prevent STIs",null,null,null,null,null,"2014-09-01","2015-08-31","2015-09-01","2016-08-31","2014-03-01","2014-08-31",null,null,"RHP 10_022817305.2.2","RHP 10_022817305.3.5",{"$f":"A131&\"_\"&D131&\"_\"&E131","v":"RHP 10_022817305.2.2_022817305.3.5"},{"$f":"COUNTIFS($FI$4:$FI131,FI131)","v":1},{"$f":"FI131&\"_\"&FL131","v":"RHP 10_022817305.2.2_1"},null,2,1,1,{"$f":"A131&\"_\"&RIGHT(\"000000000\"&B131,9)","v":"RHP 10_022817305"},{"$f":"COUNTIFS($FR$4:$FR131,FR131)","v":5},"RHP 10_022817305_5"]
["RHP 10","022817305","Tarrant County Public Health","022817305.2.3","022817305.3.6","IT-15.11","Follow-up after Treatment for Primary or Secondary Syphilis ","Baseline Approved","Eligible to Report in October DY4","Reduce syphilis, gonorrhea, chlamydia and HIV infection in the City of Arlington, through increased availability of clinical and epidemiological services. This is an expansion of STD services for the Arlington, Texas area.","Follow-up after Treatment for Primary or Secondary Syphilis ","In DY4 and DY5 provider will increase the percentage of individuals who undergo 6 month follow up testing for primary or secondary syphilis out of all individuals who initiate treatment. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",47478.51,"Yes/No","RHP 10_022817305.3.6_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",47478.51,"Yes/No","RHP 10_022817305.3.6_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",50826.05,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",50826.05,"Numeric",0.165151515,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",220982.55,"Numeric",0.209091,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.121212,4,33,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.165151515,null,0.209091,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator was developed by selecting all Arlington patients that were dx with primary or secondary syphilis.  The numerator represents all of these patients that received follow-up treatment 5-7 months post dx.","12.12% of patients diagnosed with primary or secondary syphilis in our target population received follow-up treatment within 5-7 months of diagnosis.  (All documents initially submitted (in the portal) during the October 2014 reporting period, for this baseline, should be disregarded.)","Follow-up after Treatment for Primary or Secondary Syphilis ","ambulatory",null,"The number of individuals who have undergone treatment for primary or secondary syphilis and complete clinical and/or serologic testing at 6 months","Total number of individuals who have undergone treatment for primary or secondary syphilis.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.7.1","","Follow-up after Treatment for Primary or Secondary Syphilis ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,{"$f":"A132&\"_\"&D132","v":"RHP 10_022817305.2.3"},{"$f":"A132&\"_\"&E132","v":"RHP 10_022817305.3.6"},"RHP 10_022817305.2.3_022817305.3.6",{"$f":"COUNTIFS($FI$4:$FI132,FI132)","v":1},"RHP 10_022817305.2.3_1",null,2,{"$f":"IF(DC132=\"\",0,1)+IF(DG132=\"\",0,1)+IF(DK132=\"\",0,1)+IF(DO132=\"\",0,1)+IF(DS132=\"\",0,1)","v":1},1,"RHP 10_022817305",{"$f":"COUNTIFS($FR$4:$FR132,FR132)","v":6},{"$f":"FR132&\"_\"&FS132","v":"RHP 10_022817305_6"}]
["RHP 10","022817305","Tarrant County Public Health","022817305.2.3","022817305.3.7","IT-15.14","Follow-up testing for N. gonorrhoeae among recently infected men and women","Baseline Approved","Eligible to Report in October DY4","Reduce syphilis, gonorrhea, chlamydia and HIV infection in the City of Arlington, through increased availability of clinical and epidemiological services. This is an expansion of STD services for the Arlington, Texas area.","Follow-up testing for N. gonorrhoeae among recently infected men and women","In DY4 and DY5 provider will increase the percentage of individuals who receive follow-up testing at 3 months for gonorrhea out of all individuals who initiate treatment for gonorrhea. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",47478.51,"Yes/No","RHP 10_022817305.3.7_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",47478.51,"Yes/No","RHP 10_022817305.3.7_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",50826.05,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",50826.05,"Numeric",9.4186046999999995E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",220982.55,"Numeric",0.14186000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",4.6511999999999998E-2,12,258,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,9.4186046999999995E-2,null,0.14186000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator was developed by selecting all Arlington patients that were dx with uncomplicated gonorrhea.  The numerator represents all of these patients that received follow-up treatment 2-4 months post dx.","4.65% of patients diagnosed with uncomplicated gonorrhea in our target population received follow-up treatment.  (All documents initially submitted (in the portal) during the October 2014 reporting period, for this baseline, should be disregarded.)","Follow-up testing for N. gonorrhoeae among recently infected men and women","ambulatory",null,"The number of individuals who undergo follow-up testing for uncomplicated Gonorrhea 3-months after treatment.","Total number of individuals treated for uncomplicated Gonorrhea.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.7.1","","Follow-up testing for N. gonorrhoeae among recently infected men and women",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 10_022817305.2.3","RHP 10_022817305.3.7","RHP 10_022817305.2.3_022817305.3.7",{"$f":"COUNTIFS($FI$4:$FI133,FI133)","v":2},"RHP 10_022817305.2.3_2",null,{"$f":"MAX(IF(AC133=\"\",0,1)+IF(AH133=\"\",0,1)+IF(AM133=\"\",0,1)+IF(AR133=\"\",0,1)+IF(AW133=\"\",0,1)+IF(BB133=\"\",0,1),IF(BG133=\"\",0,1)+IF(BL133=\"\",0,1)+IF(BQ133=\"\",0,1)+IF(BV133=\"\",0,1)+IF(CA133=\"\",0,1))","v":2},1,{"$f":"FO133-FP133","v":1},"RHP 10_022817305",{"$f":"COUNTIFS($FR$4:$FR133,FR133)","v":7},"RHP 10_022817305_7"]
["RHP 10","022817305","Tarrant County Public Health","022817305.2.4","022817305.3.8","IT-10.1.h","CDC Health-Related Quality of Life (HRQoL) Measures","Baseline Approved","Eligible to Report in October DY4","The program will teach clients the necessary self-management techniques that will help the clients to control blood pressure and manage their diabetes. This is a new initiative for Tarrant County Public Health .","CDC Health-Related Quality of Life (HRQoL) Measures","In DY4 and DY5 provider will improve reported scores on the  HRQoL out of all surveys completed during the measurement period by patients receiving self management services (CDSMP curriculum). ","Facility ","All individuals that are enrolled in our project training classes.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",94957.014999999999,"Yes/No","RHP 10_022817305.3.8_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",94957.014999999999,"Yes/No","RHP 10_022817305.3.8_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",101652.095,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",101652.1,"Numeric",68.734204879999993,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",441965.1,"Numeric",69.045874549999994,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",68.422535211267601,9716,142,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,68.734204879999993,null,69.045874549999994,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator and denominator for both pre/post tests were developed using the HRQOL - 4.  The four questions are coded and syntax developed to interface with SPSS.  Overall score equals all four input values with the exclusion of all surveys that have invalid responses.  (Please note that in the area above that lists the pre and post test scores, the POST test area remains shaded.  With that said, I did input the post test data.)  Additional amplifying information is attached under this project's 022817305.3.8).","The baseline rate for this project should reflect the difference between the pre and post survey.  Although the table computations do not indicate the change, here is the math:  Pre-Test = 62.2; PostTest = 68.4.  Difference = 6.2 = Baseline. ","CDC Health-Related Quality of Life (HRQoL) Measures","Ambulatory",null,"The overall score as defined by selected reporting scenario, multiplied by the number of completed CDC-HRQOL surveys represented in the overall score. ","The total number of CDC-HRQOL surveys aggregated to create the overall score as defined by selected reporting scenario\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.6.2 ","Scenario 1: Pre/Posttest Baseline","CDC Health-Related Quality of Life (HRQoL) Measures",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 10_022817305.2.4","RHP 10_022817305.3.8","RHP 10_022817305.2.4_022817305.3.8",{"$f":"COUNTIFS($FI$4:$FI134,FI134)","v":1},"RHP 10_022817305.2.4_1",null,2,1,1,"RHP 10_022817305",{"$f":"COUNTIFS($FR$4:$FR134,FR134)","v":8},"RHP 10_022817305_8"]
["RHP 10","022817305","Tarrant County Public Health","022817305.2.5","022817305.3.17","IT-15.17","Latent Tuberculosis Infection (LTBI) treatment rate ","Baseline Approved","Eligible to Report in April DY4","The traditional treatment of LTBI patients is a self-administered drug program and lasts 9 months. Consequently, many patients fail to complete treatment. Rifapentine is administered under observation, and it is only a 12 week program. Moreover, TCPH will be administering the drug in the field rather than requiring participants to present at the clinic. Accordingly, TCPH anticipates an improved completion rate and reduced conversion to active tuberculosis.","Latent Tuberculosis Infection (LTBI) treatment rate ","In DY4 and DY5 provider will increase the percentage of patients that complete the treatment regimen for LTBI out of all patients that initiate treatment at Tarrant County Public Health Department outreach clinic. ","Facility ","All LTBI patients that have started treatment through the Tarrant County Public Health Department outreach clinic.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",94957.014999999999,"Yes/No","RHP 10_022817305.3.17_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",94957.014999999999,"Yes/No","RHP 10_022817305.3.17_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",101652.095,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",101652.1,"Numeric",0.588517442,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",441965.1,"Numeric",0.61017399999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.56686000000000003,195,344,"CY 2013: Jan 1st, 2013 - Dec 31st, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.588517442,null,0.61017399999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Clients who last had a medication refill during the measurement period were included in the baseline as this would either be their completion or failure year (the measure is calculating a rate for those eligible to complete in 2013). This is because there are multiple LTBI treatment regimens with varying durations. The LTBI regimens used during the baseline period include Rifampin for 4 months and Isoniazid for 6 or 9 months. It is preferred that a client take Isoniazid for 9 months, but 6 months is considered adequate therapy and also was in establishing the baseline.","56% of all patients in our population completed therapy.","Latent Tuberculosis Infection (LTBI) treatment rate ","Ambulatory/Inpatient",null," Individuals from the denominator that completed a LTBI treatment regimen","Total number of individuals identified with Latent Tuberculosis Infection (LTBI) that initiated (accepted) a LTBI treatment regimen. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.7.1","","Latent Tuberculosis Infection (LTBI) treatment rate ",null,null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 10_022817305.2.5","RHP 10_022817305.3.17","RHP 10_022817305.2.5_022817305.3.17",{"$f":"COUNTIFS($FI$4:$FI135,FI135)","v":1},"RHP 10_022817305.2.5_1",null,2,1,1,"RHP 10_022817305",{"$f":"COUNTIFS($FR$4:$FR135,FR135)","v":9},"RHP 10_022817305_9"]
["RHP 10","022817305","Tarrant County Public Health","022817305.2.8","022817305.3.16","IT-10.1.h","CDC Health-Related Quality of Life (HRQoL) Measures","Baseline Approved","Eligible to Report in October DY4","Project option 2.7.2 will use the American Lung Association’s evidence-based Freedom From Smoking curriculum to decrease tobacco use in Tarrant County. This program has demonstrated smoking cessation success.  This program is new in Tarrant County.  Tarrant County does not have any organized, ongoing tobacco cessation programming for the citizens who are interested in tobacco cessation.","CDC Health-Related Quality of Life (HRQoL) Measures","In DY4 and DY5 provider will improve reported scores on the  HRQoL out of all surveys completed during the measurement period by patients receiving tobacco cessation services.","Facility ","All tobacco users that are enrolled in our project training classes.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",94957.014999999999,"Yes/No","RHP 10_022817305.3.16_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",94957.014999999999,"Yes/No","RHP 10_022817305.3.16_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",101652.095,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",101652.1,"Numeric",78.176893129999996,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",441965.1,"Numeric",78.652031870000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",77.701754385964918,17716,228,"3/1/2014 - 8/31/2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,78.176893129999996,null,78.652031870000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator and denominator for both pre/post tests were developed using the HRQOL - 4.  The four questions are coded and syntax developed to interface with SPSS.  Overall score equals all four input values with the exclusion of all surveys that have invalid responses.  (Please note that in the area above that lists the pre and post test scores, the POST test area remains shaded.  With that said, I did input the post test data.)  Additional amplifying information is attached under this project's 022817305.3.16).","The baseline rate for this project should reflect the difference between the pre and post survey.  Although the table computations do not indicate the change, here is the math:  Pre-Test = 68.2; PostTest = 77.7.  Difference = 9.5 = Baseline. ","CDC Health-Related Quality of Life (HRQoL) Measures","Ambulatory",null,"The overall score as defined by selected reporting scenario, multiplied by the number of completed CDC-HRQOL surveys represented in the overall score. ","The total number of CDC-HRQOL surveys aggregated to create the overall score as defined by selected reporting scenario\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.7.2 ","Scenario 1: Pre/Posttest Baseline","CDC Health-Related Quality of Life (HRQoL) Measures",null,null,null,null,null,"2014-09-01","2015-08-31","2015-09-01","2016-08-31","2014-03-01","2014-08-31",null,null,"RHP 10_022817305.2.8","RHP 10_022817305.3.16","RHP 10_022817305.2.8_022817305.3.16",{"$f":"COUNTIFS($FI$4:$FI136,FI136)","v":1},"RHP 10_022817305.2.8_1",null,2,1,1,"RHP 10_022817305",{"$f":"COUNTIFS($FR$4:$FR136,FR136)","v":10},"RHP 10_022817305_10"]
["RHP 10","081599501","MHMR of Tarrant County","081599501.1.1","081599501.3.1","IT-11.26.c","Adult Needs and Strength Assessment (ANSA)","Baseline Approved","Eligible to Report in October DY4","Expand the number of community based settings where behavioral health services may be delivered by expand the number of MHMRTC's community-based settings by one and extending hours in existing clinics.","Adult Needs and Strength Assessment (ANSA)","In DY4 and DY5 provider will report the average ANSA assessment score out of all ANSA assessments completed during the measurement period.  In addition, in DY5 provider will complete Stretch Activity #4 (SA4)- Emergency Department Improvements",null,null,"P4R","SA4","PM-8","Submission of Category 3 DY3 Status Report",255358.91,"Yes/No","RHP 10_081599501.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",255358.91,"Yes/No","RHP 10_081599501.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",543080.49,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",585998.80500000005,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",585998.80500000005,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",4.5083609999999998,7317.07,1623,"March 1, 2014 - August 31, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator and denominator values were extracted from CMHC, MHMRTC's central database system.  ","From March 2014 to August 2014, based on the ANSA scores of 1623 individuals, the average ANSA score was 4.51 out of a range of 0 to 15 at baseline.","Adult Needs and Strength Assessment (ANSA)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,"MHMR of Tarrant County is working on plans to partner with RHP9 to work with their regional initiatives that is focused on improving and/or facilitating appropriate utilization of Emergency Department (ED) services. This will allow us to go beyond just collecting and monitoring ED utilization data.  We also have a business agreement with the Dallas Fort Worth Hospital Council that will allow us to obtain ED utilization data on our population.",null,null,"1.12.2","Scenario 2: Pre Test Only Baseline","Adult Needs and Strength Assessment (ANSA)",null,null,null,null,null,"2014-09-01","2015-08-31","2015-09-01","2016-08-31","2014-03-01","2014-08-31",null,null,"RHP 10_081599501.1.1","RHP 10_081599501.3.1","RHP 10_081599501.1.1_081599501.3.1",{"$f":"COUNTIFS($FI$4:$FI137,FI137)","v":1},"RHP 10_081599501.1.1_1",null,2,1,1,"RHP 10_081599501",{"$f":"COUNTIFS($FR$4:$FR137,FR137)","v":1},"RHP 10_081599501_1"]
["RHP 10","081599501","MHMR of Tarrant County","081599501.1.2","081599501.3.13","IT-11.26.b","Aberrant Behavior Checklist (ABC)","Baseline Approved","Eligible to Report in October DY4","Behavioral health crisis stabilization services: This project will implement the Systemic Therapeutic Assessment, Respite, and Treatment (START) model in order to provide behavioral health crisis prevention and intervention services for individuals with intellectual/developmental disability (IDD) and/or autism spectrum disorder (ASD) with co-occurring behavioral and/or medical problems. Services will include a 24 hour/7 days a week crisis response capability; a therapeutic emergency respite facility to provide short term planned and emergency respite services; psychological/behavioral support services, and; intensive service coordination.","Aberrant Behavior Checklist (ABC)","In DY4 and DY5 provider will report the average ABC assessment score out of all ABC assessments completed during the measurement period by Individuals with intellectual/developmental disability (IDD) and/or autism spectrum disorder (ASD)  with co-occurring behavioral and/or medical problems.  In addition, in DY5 provider will complete Stretch Activity #1 (SA1)- Validation of P4R measure\n","Comorbid Condition ","Individuals with intellectual/developmental disability (IDD) and/or autism spectrum disorder (ASD)  with co-occurring behavioral and/or medical problems.","P4R","SA1","PM-8","Submission of Category 3 DY3 Status Report",110800.88499999999,"Yes/No","RHP 10_081599501.3.13_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",110800.88499999999,"Yes/No","RHP 10_081599501.3.13_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",235644.01,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",254266.375,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",254266.375,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",79,5214,66,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"A total of 66 individuals completed the instrument as part of their assessment for the intervention and this number represents the denominator.  A total score was calculated by summing the subscale scores for each of the 58 items.  These overall scores for each individual were summed to obtain the numerator.","On average, between April 1, 2014 and September 30, 2014,  respondents scored 79 out of a total possible score of 174.  ","Aberrant Behavior Checklist (ABC)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,"We are collaborating with Austin Travis County Integral Care for the chosen measure (IT-11.26.b) to validate the ABC’s effectiveness with the IDD population and help determine performance benchmarks.",null,null,"1.13.1","Scenario 2: Pre Test Only Baseline","Aberrant Behavior Checklist (ABC)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 10_081599501.1.2","RHP 10_081599501.3.13","RHP 10_081599501.1.2_081599501.3.13",{"$f":"COUNTIFS($FI$4:$FI138,FI138)","v":1},"RHP 10_081599501.1.2_1",null,2,1,1,"RHP 10_081599501",{"$f":"COUNTIFS($FR$4:$FR138,FR138)","v":2},"RHP 10_081599501_2"]
["RHP 10","081599501","MHMR of Tarrant County","081599501.1.2","081599501.3.6","IT-6.2.a","Client Satisfaction Questionnaire 8 (CSQ-8)","Pending Approval","Eligible to Report in October DY4","Behavioral health crisis stabilization services: This project will implement the Systemic Therapeutic Assessment, Respite, and Treatment (START) model in order to provide behavioral health crisis prevention and intervention services for individuals with intellectual/developmental disability (IDD) and/or autism spectrum disorder (ASD) with co-occurring behavioral and/or medical problems. Services will include a 24 hour/7 days a week crisis response capability; a therapeutic emergency respite facility to provide short term planned and emergency respite services; psychological/behavioral support services, and; intensive service coordination.","Client Satisfaction Questionnaire 8 (CSQ-8)","In DY4 and DY5 provider will improve the average score on the CSQ-8 out of all surveys completed during the measurement period by individuals with intellectual/developmental disability (IDD) and/or autism spectrum disorder (ASD)  with co-occurring behavioral and/or medical problems.","Comorbid Condition ","Individuals with intellectual/developmental disability (IDD) and/or autism spectrum disorder (ASD)  with co-occurring behavioral and/or medical problems.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",110800.88499999999,"Yes/No","RHP 10_081599501.3.6_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",110800.88499999999,"Yes/No","RHP 10_081599501.3.6_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",117822.005,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",117822.005,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",508532.75,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"short, proxy","TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"A satisfaction survey was conducted on individuals who received services between June 1, 213 and May 31, 214.  Between June and October of 213, over 2 individuals who enrolled in IDD services at MHMRTC were surveyed by their case manager on topics such as behavioral health issues.  This survey was then utilized to select 224 individuals who met the referral criteria of the project (IDD and/or ASD with co-occuring behavioral and/or medical problems).  Using the list of potential referrals, a random sample of 96 individuals was surveyed.  As of September 8, 35 of these individuals have also enrolled in CRISIS/START services.  ","A total of 96 individuals completed the satisfaction survey as part of a proxy sample and this number represents the denominator.  An \"overall score\" was calculated by summing the respondent’s rating (item rating) score for each of the 8 scale items.  These overall scores for each individual were summed to obtain the numerator.","On average between April 1, 2014 and May 31, 2014, the proxy sample scored 25.61 on the total scale.  ","Client Satisfaction Questionnaire 8 (CSQ-8)","Ambulatory",null,"The sum of the \"overall score\" for all CSQ-8 surveys completed during the measurement period.  ","The total number of CSQ-8 surveys completed during the measurement period. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.13.1","","Client Satisfaction Questionnaire 8 (CSQ-8)",null,null,null,null,null,"2014-06-01","2015-05-31","2015-06-01","2016-05-31","2014-04-01","2014-05-31",null,null,"RHP 10_081599501.1.2","RHP 10_081599501.3.6","RHP 10_081599501.1.2_081599501.3.6",{"$f":"COUNTIFS($FI$4:$FI139,FI139)","v":2},"RHP 10_081599501.1.2_2",null,2,1,1,"RHP 10_081599501",{"$f":"COUNTIFS($FR$4:$FR139,FR139)","v":3},"RHP 10_081599501_3"]
["RHP 10","081599501","MHMR of Tarrant County","081599501.2.1","081599501.3.12","IT-10.1.b.iii","RAND Short Form 36[1] (SF-36) Health Survey","Pending Approval","Eligible to Report in October DY4","Expand medically supervised Detoxification unit from 12 to 20 beds and implement new strategies for post-discharge activities for all of the patients who enter the detoxification unit. Peer specialists will help patients move into services to continue treatment and to stay sober and will work with patients to encourage them to participate. An APN will provide more and better access to physical health assessments during the patient’s time in the unit.","RAND Short Form 36[1] (SF-36) Health Survey","In DY4 and DY5 provider will improve reported scores on the RAND SF-36 out of all surveys completed during the measurement period by individuals who receive services from the MHMR Detox Center.","Facility ","The total number of surveys completed during the measurement period for individuals who receive services from the MHMR Detox Center.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",165582.04999999999,"Yes/No","RHP 10_081599501.3.12_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",165582.04999999999,"Yes/No","RHP 10_081599501.3.12_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",176074.5,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",176074.5,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",759956.92,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"short","TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator and denominator data was extracted from CMHC, MHMRTC’s central database system. \n\n","From August 1 2014 and September 30 2014, individuals surveyed presented with an average score of 35.40 at baseline.  The norm for each scale is 50; thus the average score is below the norm.  The higher the score, the more favorable the health of the individual and thus the quality of life.  ","RAND Short Form 36[1] (SF-36) Health Survey","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.13.1","Scenario 2: Pre Test Only Baseline","RAND Short Form 36[1] (SF-36) Health Survey",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-08-01","2014-09-30",null,null,"RHP 10_081599501.2.1","RHP 10_081599501.3.12","RHP 10_081599501.2.1_081599501.3.12",{"$f":"COUNTIFS($FI$4:$FI140,FI140)","v":1},"RHP 10_081599501.2.1_1",null,2,1,1,"RHP 10_081599501",{"$f":"COUNTIFS($FR$4:$FR140,FR140)","v":4},"RHP 10_081599501_4"]
["RHP 10","081599501","MHMR of Tarrant County","081599501.2.100","081599501.3.100","IT-10.1.a.v","Pediatric Quality of Life Inventory (PedsQL)","Baseline Approved","Eligible to Report in October DY4","Provide children and their families with individualized, trauma-informed, culturally and linguistically competent services based on the Attachment, Self-Regulation, and Competency (ARC) trauma-focused evidence-based practice model","Pediatric Quality of Life Inventory (PedsQL)","In DY4 and DY5 provider will improve reported scores on the PedsQL out of all instruments completed during the measurement period by children with behavioral health diagnosis and trauma related symptoms. ","Comorbid Condition ","Children with behavioral health diagnosis and trauma related symptoms","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",137796.77499999999,"Yes/No","RHP 10_081599501.3.100_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",137796.77499999999,"Yes/No","RHP 10_081599501.3.100_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",146528.54999999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",146528.54999999999,"Numeric",70.242884619999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",632433.35,"Numeric",75.242884619999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",65.24288,6785.26,104,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"proxy",70.242884619999998,null,75.242884619999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"A proxy sample was necessary because the program has not yet begun referring or serving individuals.  Data was collected on individuals from a population who will be part of those screened and/or referred into the Childhood Trauma program once it begins.  This includes children and adolescents in outpatient mental health services (age 3-17), and adolescents in outpatient and intensive residential substance abuse services (ages 13-17).  Outpatient mental health services include children (ages 3-17) participating in a program designed to provide intensive community-based services to assist children and adolescents with severe emotional disturbances.  These children and adolescents are affected by multiple forms of trauma including abuse and neglect, witnessing domestic violence, sexual assault, and community violence.  Staff estimates that all or nearly all of the children from these programs have experienced trauma and many have also been involved with the juvenile justice system.  This proxy population is very similar to the dominator description and will likely overlap with it once the program begins.","A total of 104 individuals completed the instrument as part of a proxy sample and this number represents the denominator.  Each item was reverse scored and transformed to a 0-100 scale.  An \"overall score\" was calculated by summing the transformed item scores score for each of the 23 items.  These overall scores for each individual were summed to obtain the numerator.","For the proxy sample, between 4/1/2014 and 9/30/2014, the average score on a 100 point converted scale was 65.24. ","Pediatric Quality of Life Inventory (PedsQL)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.13.1","Scenario 2: Pre Test Only Baseline","Pediatric Quality of Life Inventory (PedsQL)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 10_081599501.2.100","RHP 10_081599501.3.100","RHP 10_081599501.2.100_081599501.3.100",{"$f":"COUNTIFS($FI$4:$FI141,FI141)","v":1},"RHP 10_081599501.2.100_1",null,2,1,1,"RHP 10_081599501",{"$f":"COUNTIFS($FR$4:$FR141,FR141)","v":5},"RHP 10_081599501_5"]
["RHP 10","081599501","MHMR of Tarrant County","081599501.2.2","081599501.3.3","IT-1.7","Controlling high blood pressure ","Pending Approval","Eligible to Report in October DY4","Co-locate primary care and behavioral health services at MHMRTC’s homeless/crisis services center","Controlling high blood pressure ","In DY4 and DY5 provider will increase the number of patients whose most recent BP is adequately controlled ( <140/90) out of all adult patients (18-85) who had at least one outpatient encounter with a diagnosis of hypertension during the first six months of the measurement year and are receiving services at the MHMR Homeless Clinic. ","Facility ","Individuals served at the MHMR Homeless Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",232271.93,"Yes/No","RHP 10_081599501.3.3_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",232271.93,"Yes/No","RHP 10_081599501.3.3_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",246990.31,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",246990.31,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1066037.3799999999,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"proxy","TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Individuals who received Mental Health services at the MHMRTC Homeless Clinic between 1/1/213 and 6/3/213 received a blood pressure test as part of their visit to the clinic.  Of these 72 individuals, 658 had blood pressure data.  Of these, 158 (24%) met the clinical staff's guideline for hypertension by having at least two readings of high blood pressure (sitting systolic > 14 or sitting diastolic > 9) from 1/1/213 to 12/31/213.  These 158 individuals do represent a similar and overlapping population to those who will be referred for services as all have severe mental illness, all used for metric have signs of hypertension, and all are receiving services in the homeless district. In many cases, individuals from this population may be served in DY4 and DY5.","Electronic chart records of all individuals who received services at the Mental Health Homeless Clinic (and had a severe mental illness) were reviewed.  Between 1/1/2013 and 6/31/2013, 158 (24%) met clinical staff's guideline for hypertension by having at least two readings of high blood pressure (sitting systolic > 140 or sitting diastolic > 90).  The most recent blood pressure record between 7/1/2013 and 12/31/2013 was used to determine the numerator.","During the calendar year 2013, 44% of patients ages 18 to 85 who met the criteria for hypertension, by having at least two readings of high blood pressure (sitting systolic > 140 or sitting diastolic > 90), no longer had a high blood pressure reading at their most recent measurement.","Controlling high blood pressure ","ambulatory",null,"The number of patients in the denominator whose most recent BP is adequately controlled during the measurement year. For a patient’s BP to be controlled, both the systolic and diastolic BP must be <140/90 (adequate control). To determine if a patient’s BP is adequately controlled, the representative BP must be identified.\n","Patients 18 to 85 years of age by the end of the measurement year who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.15.1","","Controlling high blood pressure ",null,null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 10_081599501.2.2","RHP 10_081599501.3.3","RHP 10_081599501.2.2_081599501.3.3",{"$f":"COUNTIFS($FI$4:$FI142,FI142)","v":1},"RHP 10_081599501.2.2_1",null,2,1,1,"RHP 10_081599501",{"$f":"COUNTIFS($FR$4:$FR142,FR142)","v":6},"RHP 10_081599501_6"]
["RHP 10","081599501","MHMR of Tarrant County","081599501.2.3","081599501.3.4","IT-10.1.b.iii","RAND Short Form 36[1] (SF-36) Health Survey","Pending Approval","Eligible to Report in October DY4","A team care coordination model with RNs and behaviorists to provide a variety of disease management guidelines and techniques to engage the patient and family. Provide behavioral supports to caregivers of the IDD patients to help reduce their levels of stress.","RAND Short Form 36[1] (SF-36) Health Survey","In DY4 and DY5 provider will improve reported scores on the RAND SF-36 out of all surveys completed during the measurement period by IDD patients with chronic disease","Comorbid Condition ","IDD patients with chronic disease","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",299168.94,"Yes/No","RHP 10_081599501.3.4_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",299168.94,"Yes/No","RHP 10_081599501.3.4_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",318126.38,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",318126.38,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1373068.5,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator was abstracted from the QualityMetric website www.amihealthy.com (the team who manage the SF-36).   Completed assessments were entered into this website by the RN Care Management team for scientifically valid scoring, interpretation, and reporting in real time. \n\nThe denominator was extracted from CMHC, MHMRTC’s central database system.  \n\nFor reporting purposes, data was downloaded from both www.amihealthy.com and CMHC via csv files and placed into an access database.  The data was linked using a common ID, in this case CMHC ID, and cross checked to identify who had and had not completed an SF36.  Then data was analyzed using SPSS. \n","From March 2014 to August 2014, individuals surveyed presented with an average score of 45.70 (at baseline).   The norm for each scale is 50; thus the average score is below the norm.  The higher the score, the more favorable the health of the individual and thus the quality of life.  ","RAND Short Form 36[1] (SF-36) Health Survey","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.19.1","Scenario 2: Pre Test Only Baseline","RAND Short Form 36[1] (SF-36) Health Survey",null,null,null,null,null,"2014-09-01","2015-08-31","2015-09-01","2016-08-31","2014-03-01","2014-08-31",null,null,"RHP 10_081599501.2.3","RHP 10_081599501.3.4","RHP 10_081599501.2.3_081599501.3.4",{"$f":"COUNTIFS($FI$4:$FI143,FI143)","v":1},"RHP 10_081599501.2.3_1",null,2,1,1,"RHP 10_081599501",{"$f":"COUNTIFS($FR$4:$FR143,FR143)","v":7},"RHP 10_081599501_7"]
["RHP 10","081599501","MHMR of Tarrant County","081599501.2.4","081599501.3.11","IT-11.26.c","Adult Needs and Strength Assessment (ANSA)","Baseline Approved","Eligible to Report in October DY4","Integrate substance abuse services and mental health services through a 6 – 12 month program that includes SUD screening, assessment, individual and group counseling, and peer support services within our existing adult mental health outpatient clinics.","Adult Needs and Strength Assessment (ANSA)","In DY4 and DY5 provider will report the average ANSA assessment score out of all ANSA assessments completed during the measurement period by MHMR consumers at existing Mental Health Clinics with co-occurring behavioral health conditions (mental health and substance abuse disorders).  In addition, in DY5 provider will complete Stretch Activity #4 (SA4)- Emergency Department Improvements","Facility, Comorbid Condition ","MHMR consumers at existing Mental Health Clinics with co-occurring behavioral health conditions (mental health and substance abuse disorders).","P4R","SA4","PM-8","Submission of Category 3 DY3 Status Report",236699.15,"Yes/No","RHP 10_081599501.3.11_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",236699.15,"Yes/No","RHP 10_081599501.3.11_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",503396.14,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",543178.29,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",543178.29,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",4.4642200000000001,973.2,218,"March 1, 2014 - August 31, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator and denominator values were extracted from CMHC, MHMRTC’s central database system. \n\n","From March 2014 to August 2014, based on the ANSA score of 218 individuals, the average ANSA score was 4.46 out of a range of 0 to 15 at baseline.","Adult Needs and Strength Assessment (ANSA)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,"MHMR of Tarrant County is working on plans to partner with RHP9 to work with their regional initiatives that is focused on improving and/or facilitating appropriate utilization of Emergency Department (ED) services. This will allow us to go beyond just collecting and monitoring ED utilization data.  We also have a business agreement with the Dallas Fort Worth Hospital Council that will allow us to obtain ED utilization data on our population.",null,null,"2.13.2","Scenario 2: Pre Test Only Baseline","Adult Needs and Strength Assessment (ANSA)",null,null,null,null,null,"2014-09-01","2015-08-31","2015-09-01","2016-08-31","2014-03-01","2014-08-31",null,null,"RHP 10_081599501.2.4","RHP 10_081599501.3.11","RHP 10_081599501.2.4_081599501.3.11",{"$f":"COUNTIFS($FI$4:$FI144,FI144)","v":1},"RHP 10_081599501.2.4_1",null,2,1,1,"RHP 10_081599501",{"$f":"COUNTIFS($FR$4:$FR144,FR144)","v":8},"RHP 10_081599501_8"]
["RHP 10","094105602","North Hills Hospital","094105602.2.1","094105602.3.1","IT-4.10","Sepsis bundle  (NQF 0500)","Baseline Approved","Eligible to Report in October DY4","This project will implement process improvement methodologies in a sepsis evidenced based care program to reduce sepsis complications. Sepsis Resuscitation and Management Bundle program was kicked off in 2012 as a hospital specific program. Process improvement would be an expansion/enhancement.","Sepsis bundle  (NQF 0500)","In DY 4 and DY 5 provider will increase the percentage of patients that receive care compliant with the sepsis identification and management bundles for patients with severe sepsis and/or septic shock excluding patients who fall in to denominator exclusions A) thru E) where as PICC Line placement are also alternatives for Central lines for patient access for treatment . ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",37091,"Yes/No","RHP 10_094105602.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",37091,"Yes/No","RHP 10_094105602.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",39679,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",39679,"Numeric",0.222727273,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",189769,"Numeric",0.26363599999999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.18181800000000001,14,77,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.222727273,null,0.26363599999999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator was the number of patients  that meet the 3 hour metric for treatment or 6 hour bundle metric if they should have received these additional sepsis treatments. If a patient was eligible to receive the 3 and 6 hours treatment bundles based on their diagnosis and response to initial treatment but did not meet 3 hour time metric or documentation was not clear that treament met the time metric, the patient claim was not in the numerator. The denominator was a sample of claims with as diagnosis fo severe sepsis or septic shock selected with a sampling process. ","The baseline rate represents 18.18 % of patients received the bundle treatment in time measurements of 3 hours and 6 hours.  Often the patients receive the bundle treatment but they are not timely. Processes need to be improved to impact the timeliness of treament,","Sepsis bundle  (NQF 0500)","inpatient",null,"Patients from the denominator who received all the following: A, B, C, and D within 3 hours of time of presentation†, \nAND, \nIF septic shock is present (as either defined as hypotension* or lactate >=4 mmol/L) who also received E, ,F and G within 6 hours of time of presentation\n\nTo be completed within 3 hours:\nA. measure lactate level\nB. obtain blood cultures prior to antibiotics\nC. administer broad spectrum antibiotics\nD. administer 30 ml/kg crystalloid (bolus) for hypotension or lactate >=4 mmol/L\n\nTo be completed within 6 hours (or if septic shock is present):\nE. apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure >= 65)\nF. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate >=4 mmol/L (36 mg/dl) the resuscitation is objectively monitored using a method such as lactate clearance, ScvO2 monitoring or CVP monitoring\nG. re-measure lactate if initial lactate is elevated\n","Number of patients presenting with severe sepsis or septic shock.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.8.11","","Sepsis bundle  (NQF 0500)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 10_094105602.2.1","RHP 10_094105602.3.1","RHP 10_094105602.2.1_094105602.3.1",{"$f":"COUNTIFS($FI$4:$FI145,FI145)","v":1},"RHP 10_094105602.2.1_1",null,2,1,1,"RHP 10_094105602",{"$f":"COUNTIFS($FR$4:$FR145,FR145)","v":1},"RHP 10_094105602_1"]
["RHP 10","094193202","Plaza Medical Center Fort Worth","094193202.2.1","094193202.3.1","IT-6.1.a.ix","HCAHPS Overall Hospital Rating","Baseline Approved","Eligible to Report in April DY4","The goal of the project is to implement process improvement plans that target specific patient experiences. The purpose is to change the organizational culture and impact patient safety and quality with improved patient experience. This is would be a new intervention.","HCAHPS Overall Hospital Rating","In DY4 and DY5 provider will increase the percentage of top box scores on the HCAHPS survey- Overall Hospital Rating domain. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",91290.25,"Yes/No","RHP 10_094193202.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",91290.25,"Yes/No","RHP 10_094193202.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",36555.375,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",36555.379999999997,"Numeric",0.71,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",174830,"Numeric",0.72,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.7,806.4,1152,"DY2: Oct 1st, 2012 - Sept 30th, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.71,null,0.72,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The Numerator is the total number of surveys administered in the period provided by our survery administrator Gallup patient mix and mode adjusted by CMS multiplies times top box score for Overall Hospital Rating. The Denomintor is the number of suverys adminstered by Gallup for the period obtained from you Gallup website","The baseline rate above is 70% top box score for Overall Hospital Rating for the period 2012 Q4 to 2013 Q3. Top Box score is % of survey responses that rated the hospital a 9 or 10 on a scale 0-10 (0 being worst to 10 being best).","HCAHPS Overall Hospital Rating","Inpatient",null,"Patient-mix and survey mode adjusted percent \"top box\" score for a given subdomain as provided by your survey administrator, multiplied by the number of completed surveys represented in the \"top box\" score.","The number of HCAHPS surveys completed during the measurement period as reported by your survey administrator. The denominator should be the same as the multiplier used in the numerator. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.4.1 ","","HCAHPS Overall Hospital Rating",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 10_094193202.2.1","RHP 10_094193202.3.1","RHP 10_094193202.2.1_094193202.3.1",{"$f":"COUNTIFS($FI$4:$FI146,FI146)","v":1},"RHP 10_094193202.2.1_1",null,2,1,1,"RHP 10_094193202",{"$f":"COUNTIFS($FR$4:$FR146,FR146)","v":1},"RHP 10_094193202_1"]
["RHP 10","094193202","Plaza Medical Center Fort Worth","094193202.2.1","094193202.3.200","IT-9.10.a","Median Time from ED Arrival to ED Departure for Discharged ED Patients","Baseline Approved","Eligible to Report in October DY4","The goal of the project is to implement process improvement plans that target specific patient experiences. The purpose is to change the organizational culture and impact patient safety and quality with improved patient experience. This is would be a new intervention.","Median Time from ED Arrival to ED Departure for Discharged ED Patients","In DY4 and DY5 provider will reduce the median time from ED arrival to ED departure for discharged patients. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",91290.25,"Yes/No","RHP 10_094193202.3.200_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",91290.25,"Yes/No","RHP 10_094193202.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",36555.375,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",36555.379999999997,"Numeric",126.35,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",174830,"Numeric",119.7,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"time (minutes)",133,133,1,"September 1, 2013 -August 31, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,126.35,null,119.7,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The ED median time is  133 minutes.  These were  12,516 ED cases in the measurement period. Total minutes were 1,937,170. Median time was 133 minutes and average  time from arrival to departure from ED was 154.77. ","The  time from arrival at the ED to the time patients is departed (physically left the ED to home/transfer) mid point of all times recorded is 133 minutes so basically 50% of times are below 133  minutes and 50% of times are greater than 133 minutes. However the average time is 154.7 which takes into account lower and higher times","Median Time from ED Arrival to ED Departure for Discharged ED Patients","ED",null,"Median Time from ED Arrival to ED Departure for Discharged ED Patients: Continuous Variable Statement: Time (in minutes) from ED arrival to ED departure for patients discharged from the emergency department. ",1,null,null,null,null,null,null,null,null,null,null,null,null,null,"2.4.1 ","","Median Time from ED Arrival to ED Departure for Discharged ED Patients",null,null,null,null,null,"2014-09-01","2015-08-31","2015-09-01","2016-08-31","2013-09-01","2014-08-31",null,null,"RHP 10_094193202.2.1","RHP 10_094193202.3.200","RHP 10_094193202.2.1_094193202.3.200",{"$f":"COUNTIFS($FI$4:$FI147,FI147)","v":2},"RHP 10_094193202.2.1_2",null,2,1,1,"RHP 10_094193202",{"$f":"COUNTIFS($FR$4:$FR147,FR147)","v":2},"RHP 10_094193202_2"]
["RHP 10","094193202","Plaza Medical Center Fort Worth","094193202.2.2","094193202.3.2","IT-4.10","Sepsis bundle  (NQF 0500)","Baseline Approved","Eligible to Report in October DY4","This project will implement process improvement methodologies in a sepsis evidenced based care program to reduce sepsis complications. Sepsis Resuscitation and Management Bundle program was kicked off in 2012 as a hospital specific program. Process improvement would be an expansion/enhancement.","Sepsis bundle  (NQF 0500)","In DY 4 and DY 5 provider will increase the percentage of patients that receive care compliant with the sepsis identification and management bundle for patients with severe sepsis and/or septic shock excluding patients who fall in to denominator exclusions A) thru E) where as PICC Line placement are also alternatives for Central lines for patient access for treatment",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",182580.5,"Yes/No","RHP 10_094193202.3.2_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",182580.5,"Yes/No","RHP 10_094193202.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",73110.75,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",73110.75,"Numeric",0.21249999999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",349660,"Numeric",0.25394699999999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.17105300000000001,13,76,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.21249999999999999,null,0.25394699999999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator was the number of patients  that meet the 3 hour metric for treatment or 6 hour bundle metric if they should have received these additional sepsis treatments. If a patient was eligible to receive the 3 and 6 hours treatment bundles based on their diagnosis and response to initial treatment but did not meet 3 hour time metric or documentation was not clear that treament met the time metric, the patient claim was not in the numerator. The denominator was a sample of claims with as diagnosis fo severe sepsis or septic shock selected with a sampling process. ","The baseline rate represents 17.1% of patients received the bundle treatment in time measurement s 3 hours and 6 hours.  Often the patients receive the bundle treatment but they are not timely. Processes need to be improved to impact the timeliness of treament,","Sepsis bundle  (NQF 0500)","inpatient",null,"Patients from the denominator who received all the following: A, B, C, and D within 3 hours of time of presentation†, \nAND, \nIF septic shock is present (as either defined as hypotension* or lactate >=4 mmol/L) who also received E, ,F and G within 6 hours of time of presentation\n\nTo be completed within 3 hours:\nA. measure lactate level\nB. obtain blood cultures prior to antibiotics\nC. administer broad spectrum antibiotics\nD. administer 30 ml/kg crystalloid (bolus) for hypotension or lactate >=4 mmol/L\n\nTo be completed within 6 hours (or if septic shock is present):\nE. apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure >= 65)\nF. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate >=4 mmol/L (36 mg/dl) the resuscitation is objectively monitored using a method such as lactate clearance, ScvO2 monitoring or CVP monitoring\nG. re-measure lactate if initial lactate is elevated\n","Number of patients presenting with severe sepsis or septic shock.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.8.11","","Sepsis bundle  (NQF 0500)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 10_094193202.2.2","RHP 10_094193202.3.2","RHP 10_094193202.2.2_094193202.3.2",{"$f":"COUNTIFS($FI$4:$FI148,FI148)","v":1},"RHP 10_094193202.2.2_1",null,2,1,1,"RHP 10_094193202",{"$f":"COUNTIFS($FR$4:$FR148,FR148)","v":3},"RHP 10_094193202_3"]
["RHP 10","109574702","Huguley Memorial Medical Center","109574702.1.100","109574702.3.100","IT-1.18","Follow-Up After Hospitalization for Mental Illness ","Baseline Approved","Eligible to Report in October DY4","The project would include a behavioral health intake center and a mobile assessment/response team to assist in the evaluation and navigation of patients presenting to the emergency department with behavioral health needs. ","Follow-Up After Hospitalization for Mental Illness ","In DY4 and DY5, the provider will improve the percentage of individuals with an outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 7- and 30-days after discharge over all Medicaid patients 6 years and older as of the date of discharge with a principal diagnosis of mental illness during the first 11 months of the measurement year","Payer ","Subset Medicaid Only","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",7676.5249999999996,"Yes/No","RHP 10_109574702.3.100_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",7676.5249999999996,"Yes/No","RHP 10_109574702.3.100_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",10429.905000000001,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- 7 day follow-up",5214.9525000000003,"Numeric",0.32200000000000001,"AM-1.2","Achievement of DY4 performance goal- 30 day follow-up",5214.9525000000003,"Numeric",0.57289999999999996,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- 7 day follow-up",21800.61,"Numeric",0.35937000000000002,"AM-2.2","Achievement of DY5 performance goal- 30 day follow-up",21800.61,"Numeric",0.59989000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"%",9.8859000000000002E-2,78,789,"DY3: Oct 1st, 2013- Sept 30th, 2014",0.108999,86,789,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0.32200000000000001,null,0.35937000000000002,null,0.57289999999999996,null,0.59989000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator was abstracted based on inpatients seen in OP treatment.  Denominator was abstracted based on all Behavioral Health patients discharged.  Both were pulled based on measure specifications in the compendium document.","9.9% of all behavioral health discharges were followed up in OP treatment withn 7 days, while 10.9% were followed up within 30 days.","Follow-Up After Hospitalization for Mental Illness ","ambulatory",null,"Rate #1: 7-Day Follow-Up: An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 7 days after discharge. ","Patients 6 years and older as of the date of discharge who were discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal diagnosis of mental illness during the first 11 months of the measurement year. ","Rate #2: 30-Day Follow-Up: An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 30 days after discharge. ","Patients 6 years and older as of the date of discharge who were discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal diagnosis of mental illness during the first 11 months of the measurement year. ",null,null,null,null,null,null,null,null,null,null,null,"1.12.1","","7 day follow-up","30 day follow-up",null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 10_109574702.1.100","RHP 10_109574702.3.100","RHP 10_109574702.1.100_109574702.3.100",{"$f":"COUNTIFS($FI$4:$FI149,FI149)","v":1},"RHP 10_109574702.1.100_1",null,3,2,1,"RHP 10_109574702",{"$f":"COUNTIFS($FR$4:$FR149,FR149)","v":1},"RHP 10_109574702_1"]
["RHP 10","109574702","Huguley Memorial Medical Center","109574702.1.100","109574702.3.101","IT-11.16","Assessment for Substance Abuse Problems of Psychiatric Patients ","Pending Approval","Eligible to Report in October DY4","The project would include a behavioral health intake center and a mobile assessment/response team to assist in the evaluation and navigation of patients presenting to the emergency department with behavioral health needs. ","Assessment for Substance Abuse Problems of Psychiatric Patients ","In DY4 and DY5 Provider will increase the number of psychiatric patients with a record of current or past substance abuse disorders assessed for substance abuse problems out of all patients who received psychiatric evaluations. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",7676.5249999999996,"Yes/No","RHP 10_109574702.3.101_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",7676.5249999999996,"Yes/No","RHP 10_109574702.3.101_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",10429.905000000001,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",10429.905000000001,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",43601.22,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator was pulled based on documented chemical dependency screening.  Denominator includes all patients assessed by mobile team. ","95.6% of all patients assessed had a documented chemical dependency screening during their assessment.","Assessment for Substance Abuse Problems of Psychiatric Patients ","Ambulatory/Inpatient",null,"Number of patients in the denominator whose medical record indicates explicit evidence of assessment of current and/or past substance use disorders.","Total number of patients who received psychiatric evaluations within the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.12.1","","Assessment for Substance Abuse Problems of Psychiatric Patients ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 10_109574702.1.100","RHP 10_109574702.3.101","RHP 10_109574702.1.100_109574702.3.101",{"$f":"COUNTIFS($FI$4:$FI150,FI150)","v":2},"RHP 10_109574702.1.100_2",null,2,1,1,"RHP 10_109574702",{"$f":"COUNTIFS($FR$4:$FR150,FR150)","v":2},"RHP 10_109574702_2"]
["RHP 10","109574702","Huguley Memorial Medical Center","109574702.1.100","109574702.3.102","IT-11.17","Assessment of Risk to Self/Others ","Baseline Approved","Eligible to Report in October DY4","The project would include a behavioral health intake center and a mobile assessment/response team to assist in the evaluation and navigation of patients presenting to the emergency department with behavioral health needs. ","Assessment of Risk to Self/Others ","In DY4 and DY5 provider will increase the number of patients (whose medical record demonstrates patient's potential harm to self or others ) that are assessed of risk to self/others out of all patients diagnosed with a depressive disorder during a formal evaluation.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",7676.5249999999996,"Yes/No","RHP 10_109574702.3.102_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",7676.5249999999996,"Yes/No","RHP 10_109574702.3.102_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",10429.905000000001,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",10429.91,"Numeric",0.13173996199999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",43601.22,"Numeric",0.177437859,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",8.6041999999999993E-2,90,1046,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.13173996199999999,null,0.177437859,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator was abstracted for all patients with a documented screening.  Denominator includes all patients identified with a depressive disorder documented following an assessment.","8.6% of all patients diagnosed with a depressive disorder were screened  for risk to self and others.","Assessment of Risk to Self/Others ","Ambulatory/Inpatient",null,"Number of patients from the denominator whose medical record of the formal evaluation contains specific documentation of the patient's potential to harm self or others.","The number of patients diagnosed with a depressive disorder during a formal evaluation. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.12.1","","Assessment of Risk to Self/Others ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 10_109574702.1.100","RHP 10_109574702.3.102","RHP 10_109574702.1.100_109574702.3.102",{"$f":"COUNTIFS($FI$4:$FI151,FI151)","v":3},"RHP 10_109574702.1.100_3",null,2,1,1,"RHP 10_109574702",{"$f":"COUNTIFS($FR$4:$FR151,FR151)","v":3},"RHP 10_109574702_3"]
["RHP 10","109574702","Huguley Memorial Medical Center","109574702.2.1","109574702.3.1","IT-3.3","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","Baseline Approved","Eligible to Report in April DY4","This CHF Project incorporates performance improvement methodologies and evidence-based interventions to decrease 30-day readmissions through medication management, weight monitoring and dietary education/management and appropriate primary care placement and follow-up.","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","In DY4 and DY5, provider will improve the ratio of observed to expected readmissions that occur within 30 days following discharge from an index admission for CHF for patients 18 years of age and older. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",49897.404999999999,"Yes/No","RHP 10_109574702.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",49897.404999999999,"Yes/No","RHP 10_109574702.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",67794.395000000004,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",67794.395000000004,"Numeric",0.80384615400000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",283407.92,"Numeric",0.76153800000000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",0.84615399999999996,0.16793893129770993,0.19847328244274809,"CY 2013: Jan 1st, 2013 - Dec 31st, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.80384615400000003,null,0.76153800000000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Premier's report was produced using measure specifications in the compendium documentation.","Texas Health Huguley experiences a lower than expected number of risk-adjusted CHF 30-day readmissions.","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission for CHF during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk CHF admissions during the measurement period.\n","Expected (risk-adjusted) rate of readmissions for CHF during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc. \n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.8.4 ","","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate",null,null,null,null,"Produced using Premier's report for 3M methodology","2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 10_109574702.2.1","RHP 10_109574702.3.1","RHP 10_109574702.2.1_109574702.3.1",{"$f":"COUNTIFS($FI$4:$FI152,FI152)","v":1},"RHP 10_109574702.2.1_1",null,2,1,1,"RHP 10_109574702",{"$f":"COUNTIFS($FR$4:$FR152,FR152)","v":4},"RHP 10_109574702_4"]
["RHP 10","109574702","Huguley Memorial Medical Center","109574702.2.100","109574702.3.103","IT-12.6","Influenza Immunization -- Ambulatory","Baseline Approved","Eligible to Report in April DY4","The proposal is to create an expansion of the current Mobile Health Unit (MHU) to facilitate access to high-quality early cancer detection screening services to targeted medically underserved counties in Region 10 (RHP 10). The cancer screenings that will be performed are breast examinations (to include referral and voucher for mammogram) and self-exam education, cervical cancer screening and colon cancer screening (fecal occult blood test). The proposal requires the creation of a robust system for facilitating care transition into specialty and primary care through the use of an ARNP as indicated based on initial patient assessment, prevention and cancer screening activities. ","Influenza Immunization -- Ambulatory","In DY4 and DY5 Provider will improve the percentage of patients ages 6 months and older who have received an influenza vaccination between October and March out of all patients ages 6 months and older seen between October and March. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",16632.47,"Yes/No","RHP 10_109574702.3.103_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",16632.47,"Yes/No","RHP 10_109574702.3.103_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",22598.13,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",22598.13,"Numeric",0.79642857199999995,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",94469.31,"Numeric",0.80714300000000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.78571400000000002,1650,2100,"DY3 (1): Oct 1st, 2013 - March 31st, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.79642857199999995,null,0.80714300000000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator includes all patients visiting the MHU age 6 months and up.  The numerator includes all patients 6 months and up with a documented flu shot or were given a flu shot.","75% of all patients visiting the MHU age 6 months and older received an influenza vaccination or had a documented shot during flu season.","Influenza Immunization -- Ambulatory","ambulatory",null,"Patients who received an influenza immunization OR who reported previous receipt* of influenza immunization","All patients aged 6 months and older seen for a visit between October 1 and March 31.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.7.1","","Influenza Immunization -- Ambulatory",null,null,null,null,null,"2014-04-01","2015-03-31","2015-04-01","2016-03-31","2013-10-01","2014-03-31",null,null,"RHP 10_109574702.2.100","RHP 10_109574702.3.103","RHP 10_109574702.2.100_109574702.3.103",{"$f":"COUNTIFS($FI$4:$FI153,FI153)","v":1},"RHP 10_109574702.2.100_1",null,2,1,1,"RHP 10_109574702",{"$f":"COUNTIFS($FR$4:$FR153,FR153)","v":5},"RHP 10_109574702_5"]
["RHP 10","109574702","Huguley Memorial Medical Center","109574702.2.100","109574702.3.104","IT-12.2","Cervical Cancer Screening ","Pending Approval","Eligible to Report in October DY4","The proposal is to create an expansion of the current Mobile Health Unit (MHU) to facilitate access to high-quality early cancer detection screening services to targeted medically underserved counties in Region 10 (RHP 10). The cancer screenings that will be performed are breast examinations (to include referral and voucher for mammogram) and self-exam education, cervical cancer screening and colon cancer screening (fecal occult blood test). The proposal requires the creation of a robust system for facilitating care transition into specialty and primary care through the use of an ARNP as indicated based on initial patient assessment, prevention and cancer screening activities. ","Cervical Cancer Screening ","In DY4 and DY5 provider will improve (increase) the percentage of women 21–64 years of age who were screened for cervical cancer using either of the following criteria: - Women age 21–64 who had cervical cytology performed every 3 years. - Women age 30–64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years","facility","mobile clinic program","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",16632.47,"Yes/No","RHP 10_109574702.3.104_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",16632.47,"Yes/No","RHP 10_109574702.3.104_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",22598.13,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",22598.13,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",94469.31,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator abstracted from MHU paper records and denominator pulled using Claritas demographics.  Both were created using the measure specifications outlined in the denominator.","0.06% of all women age 24-64 received cervical cancer screening from the MHU.","Cervical Cancer Screening ","ambulatory",null,"The number of women who were screened for cervical cancer during the measurement year or the two years prior to the measurement year.","Women 24-64 years of age as of the end of the measurement year ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.7.1","","Cervical Cancer Screening ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 10_109574702.2.100","RHP 10_109574702.3.104","RHP 10_109574702.2.100_109574702.3.104",{"$f":"COUNTIFS($FI$4:$FI154,FI154)","v":2},"RHP 10_109574702.2.100_2",null,2,1,1,"RHP 10_109574702",{"$f":"COUNTIFS($FR$4:$FR154,FR154)","v":6},"RHP 10_109574702_6"]
["RHP 10","109574702","Huguley Memorial Medical Center","109574702.2.100","109574702.3.105","IT-12.3","Colorectal Cancer Screening ","Pending Approval","Eligible to Report in October DY4","The proposal is to create an expansion of the current Mobile Health Unit (MHU) to facilitate access to high-quality early cancer detection screening services to targeted medically underserved counties in Region 10 (RHP 10). The cancer screenings that will be performed are breast examinations (to include referral and voucher for mammogram) and self-exam education, cervical cancer screening and colon cancer screening (fecal occult blood test). The proposal requires the creation of a robust system for facilitating care transition into specialty and primary care through the use of an ARNP as indicated based on initial patient assessment, prevention and cancer screening activities. ","Colorectal Cancer Screening ","In DY4 and DY5 Provider will increase the percentage of all patients ages 50-75 who had one or more screening for colorectal cancer out of all patients ages 50-75.","facility","mobile clinic program","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",16632.47,"Yes/No","RHP 10_109574702.3.105_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",16632.47,"Yes/No","RHP 10_109574702.3.105_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",22598.13,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",22598.13,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",94469.31,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator abstracted from MHU paper records and denominator pulled using Claritas demographics.  Both were created using the measure specifications outlined in the denominator.","0.06% of the total Johnson county population age 51 - 75 received a colorectal screening from the MHU.","Colorectal Cancer Screening ","ambulatory",null,"One or more screenings for colorectal cancer. Any of the following meet the criteria: \n\n• Fecal occult blood test (FOBT) during the measurement year. For administrative data, assume the required number of samples were returned regardless of FOBT type.\n• Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year.\n• Colonoscopy during the measurement year or the nine years prior to the measurement year.\n","Patients 51–75 years of age as of the end of the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.7.1","","Colorectal Cancer Screening ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 10_109574702.2.100","RHP 10_109574702.3.105","RHP 10_109574702.2.100_109574702.3.105",{"$f":"COUNTIFS($FI$4:$FI155,FI155)","v":3},"RHP 10_109574702.2.100_3",null,2,1,1,"RHP 10_109574702",{"$f":"COUNTIFS($FR$4:$FR155,FR155)","v":7},"RHP 10_109574702_7"]
["RHP 10","109574702","Huguley Memorial Medical Center","109574702.2.2","109574702.3.2","IT-4.10","Sepsis bundle  (NQF 0500)","Baseline Approved","Eligible to Report in October DY4","This project incorporates the development and implementation of an evidence-based early detection and treatment plan for patients with sepsis (sepsis resuscitation bundle). Specific symptoms will be identified as target symptoms and when those are exhibited it triggers the use of the sepsis resuscitation bundle (bundle) for the patient.","Sepsis bundle  (NQF 0500)","In DY4 and DY5 Provider will increase the number of patients ages 18 and older presenting with symptoms of severe sepsis or sepsis shock that receive the sepsis bundle out of all patients presenting with severe septic or sepsis shock.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",30706.095000000001,"Yes/No","RHP 10_109574702.3.2_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",30706.095000000001,"Yes/No","RHP 10_109574702.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",41719.629999999997,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",41719.629999999997,"Numeric",0.59485294099999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",174404.88,"Numeric",0.61617599999999995,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.57352899999999996,39,68,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.59485294099999997,null,0.61617599999999995,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator includes all patients receiving both the 3 hour and  6 hour bundles appropriately.  Denominator includes patients with Severe Sepsis or Septic Shock.  Both were extracted  as compendium document measure specifications.","57.4% of all Severe Sepsis or Septic Shock patients had both 3 and 6 hour bundle inteventions appropriately.","Sepsis bundle  (NQF 0500)","inpatient",null,"Patients from the denominator who received all the following: A, B, C, and D within 3 hours of time of presentation†, \nAND, \nIF septic shock is present (as either defined as hypotension* or lactate >=4 mmol/L) who also received E, ,F and G within 6 hours of time of presentation\n\nTo be completed within 3 hours:\nA. measure lactate level\nB. obtain blood cultures prior to antibiotics\nC. administer broad spectrum antibiotics\nD. administer 30 ml/kg crystalloid (bolus) for hypotension or lactate >=4 mmol/L\n\nTo be completed within 6 hours (or if septic shock is present):\nE. apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure >= 65)\nF. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate >=4 mmol/L (36 mg/dl) the resuscitation is objectively monitored using a method such as lactate clearance, ScvO2 monitoring or CVP monitoring\nG. re-measure lactate if initial lactate is elevated\n","Number of patients presenting with severe sepsis or septic shock.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.8.11","","Sepsis bundle  (NQF 0500)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 10_109574702.2.2","RHP 10_109574702.3.2","RHP 10_109574702.2.2_109574702.3.2",{"$f":"COUNTIFS($FI$4:$FI156,FI156)","v":1},"RHP 10_109574702.2.2_1",null,2,1,1,"RHP 10_109574702",{"$f":"COUNTIFS($FR$4:$FR156,FR156)","v":8},"RHP 10_109574702_8"]
["RHP 10","112677302","Texas Health Harris Methodist Hospital Ft Worth","112677302.1.100","112677302.3.102","IT-4.11","Risk-Adjusted Average Length of Inpatient Hospital Stay\n","Pending Approval","Eligible to Report in October DY4","Increase access and availability to equipment and physical therapy staff for patients with cystic fibrosis (CF)","Risk-Adjusted Average Length of Inpatient Hospital Stay\n","In DY4 and DY5 provider will improve (decrease) the percentage of inpatients with excessive in-hospital days for patients with Cystic Fibrosis admitted to the hospital.","Facility, Comorbid Condition ","Cystic Fibrosis Inpatients","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",13857.35,"Yes/No","RHP 10_112677302.3.102_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",13857.35,"Yes/No","RHP 10_112677302.3.102_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",15812.785,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",15812.785,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",74316.149999999994,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"time (days)",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Both numerator and denominator were abstracted from the electronic health record using measure specifications outlined in the compendium document for CF patients,","30% of all CF patients admitted to the palliative care unit had longer lengths of stay than the average.","Risk-Adjusted Average Length of Inpatient Hospital Stay\n","inpatient",null,"Number of excess in-hospital days in a given inpatient population","Patients admitted to a hospital",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2","","Risk-Adjusted Average Length of Inpatient Hospital Stay\n",null,null,null,null,null,"2014-08-01","2015-07-31","2015-08-01","2016-07-31","2014-02-01","2014-07-31",null,null,"RHP 10_112677302.1.100","RHP 10_112677302.3.102","RHP 10_112677302.1.100_112677302.3.102",{"$f":"COUNTIFS($FI$4:$FI157,FI157)","v":1},"RHP 10_112677302.1.100_1",null,2,1,1,"RHP 10_112677302",{"$f":"COUNTIFS($FR$4:$FR157,FR157)","v":1},"RHP 10_112677302_1"]
["RHP 10","112677302","Texas Health Harris Methodist Hospital Ft Worth","112677302.1.100","112677302.3.103","IT-5.2","Per Episode Cost of Care","Baseline Approved","Eligible to Report in October DY4","Increase access and availability to equipment and physical therapy staff for patients with cystic fibrosis (CF)","Per Episode Cost of Care","In DY4 and DY5 provider will improve (decrease) the per episode cost of care for the services involved in the diagnosis, management and treatment for Cystic Fibrosis patients that are treated in the inpatient setting. ","Facility, Comorbid Condition ","Cystic Fibrosis Inpatients","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",13857.35,"Yes/No","RHP 10_112677302.3.103_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",13857.35,"Yes/No","RHP 10_112677302.3.103_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",15812.785,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",15812.785,"Numeric",26529.054,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",74316.149999999994,"Numeric",25132.788,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"$",27925.32,1675519.49,60,"02/01/14 - 07/31/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,26529.054,null,25132.788,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Both numerator and denomminator were abstracted using measure specifications outlined in the compendium for CF patients.","The average cost per case for CF patients was $27,925.32.","Per Episode Cost of Care","Multiple",null,"Total cost for episode of care","Total number of episodes during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2","","Per Episode Cost of Care",null,null,null,null,null,"2014-08-01","2015-07-31","2015-08-01","2016-07-31","2014-02-01","2014-07-31",null,null,"RHP 10_112677302.1.100","RHP 10_112677302.3.103","RHP 10_112677302.1.100_112677302.3.103",{"$f":"COUNTIFS($FI$4:$FI158,FI158)","v":2},"RHP 10_112677302.1.100_2",null,2,1,1,"RHP 10_112677302",{"$f":"COUNTIFS($FR$4:$FR158,FR158)","v":2},"RHP 10_112677302_2"]
["RHP 10","112677302","Texas Health Harris Methodist Hospital Ft Worth","112677302.1.100","112677302.3.201","IT-12.7","Influenza Immunization- Inpatient","Pending Approval","Eligible to Report in October DY4","Increase access and availability to equipment and physical therapy staff for patients with cystic fibrosis (CF)","Influenza Immunization- Inpatient","In DY4 and DY5 provider will improve (increase) the percentage of inpatients with a CF diagnosis age 6 months and older discharged during October, November, December, January, February or March who are screened for influenza vaccine status and vaccinated prior to discharge if indicated.","Facility, Comorbid Condition ","Cystic Fibrosis Inpatients","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",13857.35,"Yes/No","RHP 10_112677302.3.201_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",13857.35,"Yes/No","RHP 10_112677302.3.201_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",15812.785,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",15812.785,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",74316.149999999994,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator and denominator were abstracted from the electronic health record using measure specifications outlined in the compendium document for CF patients.","97% of all CF inpatients either had an influenza shot documented in their health record or received the vaccination before discharge.","Influenza Immunization- Inpatient","inpatient",null,"Inpatient discharges who were screened for influenza vaccine status and were vaccinated prior to discharge if indicated.","Inpatients age 6 months and older discharged during the months of October, November, December, January, February or March. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2","","Influenza Immunization- Inpatient",null,null,null,null,null,"2014-08-01","2015-07-31","2015-08-01","2016-07-31","2014-02-01","2014-07-31",null,null,"RHP 10_112677302.1.100","RHP 10_112677302.3.201","RHP 10_112677302.1.100_112677302.3.201",{"$f":"COUNTIFS($FI$4:$FI159,FI159)","v":3},"RHP 10_112677302.1.100_3",null,2,1,1,"RHP 10_112677302",{"$f":"COUNTIFS($FR$4:$FR159,FR159)","v":3},"RHP 10_112677302_3"]
["RHP 10","112677302","Texas Health Harris Methodist Hospital Ft Worth","112677302.2.1","112677302.3.5","IT-3.5","Risk Adjusted Diabetes 30-day Readmission Rate ","Baseline Approved","Eligible to Report in April DY4","Link diabetes patients that present to the ED or as inpatients to a primary care physician ","Risk Adjusted Diabetes 30-day Readmission Rate ","In DY4 and DY5, provider will improve the ratio of observed to expected readmissions that occur within 30 days following discharge from an index admission for Diabetes for patients ages 18 and older. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",41572.050000000003,"Yes/No","RHP 10_112677302.3.5_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",41572.050000000003,"Yes/No","RHP 10_112677302.3.5_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",47438.355000000003,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",47438.355000000003,"Numeric",1.3602272727272728,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",222948.44,"Numeric",1.2886363636363636,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",1.4318181818181819,0.2413793103448276,0.16858237547892721,"CY2012: January 1, 2012 - December 31, 2012",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,1.3602272727272728,null,1.2886363636363636,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator and denominator were extracted from Premier using the specifications outlined in the measure compendium document.","A risk-adjusted readmission rate of 1.43 reflects a significantly higher than expected rate.  More diabetic inpatients at risk for readmission are actually being readmitted than were expected to be.","Risk Adjusted Diabetes 30-day Readmission Rate ","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission for Diabetes during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk Diabetes admissions during the measurement period.\n","Expected (risk-adjusted) rate of readmissions for Diabetes during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.1 ","","Risk Adjusted Diabetes 30-day Readmission Rate ",null,null,null,null,"Rate was produced by Premier using their 3M methodology report.","2013-01-01","2013-12-31","2014-01-01","2014-12-31","2012-01-01","2012-12-31",null,null,"RHP 10_112677302.2.1","RHP 10_112677302.3.5","RHP 10_112677302.2.1_112677302.3.5",{"$f":"COUNTIFS($FI$4:$FI160,FI160)","v":1},"RHP 10_112677302.2.1_1",null,2,1,1,"RHP 10_112677302",{"$f":"COUNTIFS($FR$4:$FR160,FR160)","v":4},"RHP 10_112677302_4"]
["RHP 10","112677302","Texas Health Harris Methodist Hospital Ft Worth","112677302.2.100","112677302.3.100","IT-13.5","Hospice and Palliative Care – documentation of spiritual/religions concerns ","Pending Approval","Eligible to Report in October DY4","Addition of a Child Life Specialist to the weeCARE Palliative care team  ","Hospice and Palliative Care – Percentage of patients receiving hospice or palliative care services with documentation in the clinical record of a discussion of spiritual/religions concerns or documentation that the patient/caregiver did not want to discuss ","In DY4 and DY5 provider will improve (increase) the percentage of hospice patients aged birth to two years with documentation of a discussion of spiritual/religious concerns or documentation that the patient/caregiver/family did not want to discuss.","Age","age birth to two years","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",13857.35,"Yes/No","RHP 10_112677302.3.100_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",13857.35,"Yes/No","RHP 10_112677302.3.100_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",15812.785,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",15812.785,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",74316.149999999994,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator and denominator were abstracted using measure specifications outlined in the Compendium.","97.41% ot all weeCARE patients/families received a pastoral visit.","Hospice and Palliative Care – documentation of spiritual/religions concerns ","Ambulatory/Inpatient",null,"Number of patient with clinical record documentation of spiritual/religious concerns or documentation that the patient/family did not want to discuss","Total number of patient’s discharged from hospice care and/or palliative care during the designated reporting period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.10.1","","Hospice and Palliative Care – documentation of spiritual/religions concerns ",null,null,null,null,null,"2014-08-01","2015-07-31","2015-08-01","2016-07-31","2014-02-01","2014-07-31",null,null,"RHP 10_112677302.2.100","RHP 10_112677302.3.100","RHP 10_112677302.2.100_112677302.3.100",{"$f":"COUNTIFS($FI$4:$FI161,FI161)","v":1},"RHP 10_112677302.2.100_1",null,2,1,1,"RHP 10_112677302",{"$f":"COUNTIFS($FR$4:$FR161,FR161)","v":5},"RHP 10_112677302_5"]
["RHP 10","112677302","Texas Health Harris Methodist Hospital Ft Worth","112677302.2.100","112677302.3.101","IT-5.2","Per Episode Cost of Care","Baseline Approved","Eligible to Report in October DY4","Addition of a Child Life Specialist to the weeCARE Palliative care team  ","Per Episode Cost of Care","In DY4 and DY5 provider will improve (decrease) the per episode cost of care for the services involved in the diagnosis, management and treatment of palliative care patients","Facility ","Palliative care patients","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",13857.35,"Yes/No","RHP 10_112677302.3.101_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",13857.35,"Yes/No","RHP 10_112677302.3.101_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",15812.785,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",15812.785,"Numeric",135031.95499999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",74316.149999999994,"Numeric",127925.01,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"$",142138.9,4974861.6399999997,35,"02/01/14 - 07/31/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,135031.95499999999,null,127925.01,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator and Denominator were abstracted from the internal electronic health record  using measure specifications outlined in the compendium.","The average cost per case for all weeCARE patients was $142,138.90.","Per Episode Cost of Care","Multiple",null,"Total cost for episode of care","Total number of episodes during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.10.1","","Per Episode Cost of Care",null,null,null,null,null,"2014-08-01","2015-07-31","2015-08-01","2016-07-31","2014-02-01","2014-07-31",null,null,"RHP 10_112677302.2.100","RHP 10_112677302.3.101","RHP 10_112677302.2.100_112677302.3.101",{"$f":"COUNTIFS($FI$4:$FI162,FI162)","v":2},"RHP 10_112677302.2.100_2",null,2,1,1,"RHP 10_112677302",{"$f":"COUNTIFS($FR$4:$FR162,FR162)","v":6},"RHP 10_112677302_6"]
["RHP 10","112677302","Texas Health Harris Methodist Hospital Ft Worth","112677302.2.100","112677302.3.200","IT-13.2","Hospice and Palliative Care – Treatment Preferences ","Pending Approval","Eligible to Report in October DY4","Addition of a Child Life Specialist to the weeCARE Palliative care team  ","Hospice and Palliative Care – Treatment Preferences ","In DY4 and DY5 provider will improve (increase) the percentage of patients with chart documentation of preferences for life sustaining treatments.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",13857.35,"Yes/No","RHP 10_112677302.3.200_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",13857.35,"Yes/No","RHP 10_112677302.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",15812.785,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",15812.785,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",74316.149999999994,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"both numerator and denominator were abstracted from internal electronic medical record ","84.21% of all weeCARE patients requiring advanced care planning had it documented in the medical record.","Hospice and Palliative Care – Treatment Preferences ","Ambulatory/Inpatient",null,"Patients whose medical record includes documentation of life sustaining preferences","Seriously ill patients enrolled in hospice OR receiving palliative care in an acute hospital setting",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.10.1","","Hospice and Palliative Care – Treatment Preferences ",null,null,null,null,null,"2014-08-01","2015-07-31","2015-08-01","2016-07-31","2014-02-01","2014-07-31",null,null,"RHP 10_112677302.2.100","RHP 10_112677302.3.200","RHP 10_112677302.2.100_112677302.3.200",{"$f":"COUNTIFS($FI$4:$FI163,FI163)","v":3},"RHP 10_112677302.2.100_3",null,2,1,1,"RHP 10_112677302",{"$f":"COUNTIFS($FR$4:$FR163,FR163)","v":7},"RHP 10_112677302_7"]
["RHP 10","112677302","Texas Health Harris Methodist Hospital Ft Worth","112677302.2.101","112677302.3.104","IT-2.21","Ambulatory Care Sensitive Conditions Admissions Rate","Pending Approval","Eligible to Report in October DY4","Implement a medication reconciliation program","Ambulatory Care Sensitive Conditions Admissions Rate","In DY4 and DY5, the provider will improve the rate of acute care hospitalizations for ambulatory care sensitive conditions younger than age 75 years",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",69286.744999999995,"Yes/No","RHP 10_112677302.3.104_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",69286.744999999995,"Yes/No","RHP 10_112677302.3.104_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",79063.925000000003,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",79063.925000000003,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",371580.74,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator was abstracted from THFW internal electronic health record and demographics were pulled using THFW's service area zip codes using measure specifications outlined in the compendium document.","60.02% of all Inpatients at THFW are admitted for an ambulatory sensitive condition.","Ambulatory Care Sensitive Conditions Admissions Rate","inpatient",null,"Total number of acute care hospitalizations for ambulatory care sensitive conditions younger than age 75 years ","Total mid-measurement period population younger than age 75",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.11.1","","Ambulatory Care Sensitive Conditions Admissions Rate",null,null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 10_112677302.2.101","RHP 10_112677302.3.104","RHP 10_112677302.2.101_112677302.3.104",{"$f":"COUNTIFS($FI$4:$FI164,FI164)","v":1},"RHP 10_112677302.2.101_1",null,2,1,1,"RHP 10_112677302",{"$f":"COUNTIFS($FR$4:$FR164,FR164)","v":8},"RHP 10_112677302_8"]
["RHP 10","112677302","Texas Health Harris Methodist Hospital Ft Worth","112677302.2.2","112677302.3.7","IT-3.3","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","Baseline Approved","Eligible to Report in April DY4","Increase the number of patients served at the newly existing clinic","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","In DY4 and DY5, provider will improve the ratio of observed to expected readmissions that occur within 30 days following discharge from an index admission for CHF for patients 18 years of age and older. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",41572.050000000003,"Yes/No","RHP 10_112677302.3.7_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",41572.050000000003,"Yes/No","RHP 10_112677302.3.7_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",47438.36,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",47438.36,"Numeric",0.78375000000000006,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",222948.44,"Numeric",0.74250000000000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",0.82500000000000007,0.16117216117216118,0.19536019536019536,"CY 2013: Jan 1st, 2013 - Dec 31st, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.78375000000000006,null,0.74250000000000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator and denominator were abstracted from Premier's 3M report using measure specifications.","A rate of 0.83 demonstrates that THFW experiences fewer CHF readmissions than are expected.","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission for CHF during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk CHF admissions during the measurement period.\n","Expected (risk-adjusted) rate of readmissions for CHF during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc. \n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.1 ","","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate",null,null,null,null,"Rate was produced using Premier's 3M methodology report.","2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 10_112677302.2.2","RHP 10_112677302.3.7","RHP 10_112677302.2.2_112677302.3.7",{"$f":"COUNTIFS($FI$4:$FI165,FI165)","v":1},"RHP 10_112677302.2.2_1",null,2,1,1,"RHP 10_112677302",{"$f":"COUNTIFS($FR$4:$FR165,FR165)","v":9},"RHP 10_112677302_9"]
["RHP 10","112677302","Texas Health Harris Methodist Hospital Ft Worth","112677302.2.3","112677302.3.8","IT-9.2","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","Baseline Approved","Eligible to Report in April DY4","Increase navigation of services for patients to appropriate health care resources","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","In DY4 and DY5, the provider will improve the rate of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period over all ED visits for individuals 18 years or older during the measurement period for those patients referred for patient navigation services.  ","Facility ","Patients referred to ED navigation services","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",200931.565,"Yes/No","RHP 10_112677302.3.8_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",200931.565,"Yes/No","RHP 10_112677302.3.8_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",229285.39,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",229285.39,"Numeric",0.321262518,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1077584.1399999999,"Numeric",0.30435400000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.338171,33530,99151,"CY 2013: Jan 1st, 2013 - Dec 31st, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.321262518,null,0.30435400000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator and denominator were extracted from electornic health record using specifications in measure compendium","33.82% of all THFW ED patients present with an ambulatory care sensitive condition.","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","ED",null,"Total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1 ","","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ",null,null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 10_112677302.2.3","RHP 10_112677302.3.8","RHP 10_112677302.2.3_112677302.3.8",{"$f":"COUNTIFS($FI$4:$FI166,FI166)","v":1},"RHP 10_112677302.2.3_1",null,2,1,1,"RHP 10_112677302",{"$f":"COUNTIFS($FR$4:$FR166,FR166)","v":10},"RHP 10_112677302_10"]
["RHP 10","112677302","Texas Health Harris Methodist Hospital Ft Worth","112677302.2.4","112677302.3.10","IT-4.10","Sepsis bundle  (NQF 0500)","Baseline Approved","Eligible to Report in October DY4","Early intervention and treatment of Sepsis patient entering through the ED.","Sepsis bundle  (NQF 0500)","In DY4 and DY5 provider will improve (increase) the percentage of patients aged 18 years and older who present with symptoms of severe sepsis or septic shock and receive the 3 hour (severe sepsis) and/or 6 hour (septic shock) early management bundle.\n",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",86608.434999999998,"Yes/No","RHP 10_112677302.3.10_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",86608.434999999998,"Yes/No","RHP 10_112677302.3.10_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",98829.91,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",98829.91,"Numeric",0.116169154,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",464475.92,"Numeric",0.162687,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",6.9652000000000006E-2,28,402,"02/01/14 - 07/31/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.116169154,null,0.162687,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Both numerator and denominator were pulled from the internal electronic health record using measure specifications outlined in the compendium.","6.97% of  severe sepsis and septic shock patients received both the 3 and 6 hour bundles appropriately as defined by HHSC.  It should be noted that while all 402 patients presenting required the 3 hour bundle, not all required the 6 hour bundle intervention.","Sepsis bundle  (NQF 0500)","inpatient",null,"Patients from the denominator who received all the following: A, B, C, and D within 3 hours of time of presentation†, \nAND, \nIF septic shock is present (as either defined as hypotension* or lactate >=4 mmol/L) who also received E, ,F and G within 6 hours of time of presentation\n\nTo be completed within 3 hours:\nA. measure lactate level\nB. obtain blood cultures prior to antibiotics\nC. administer broad spectrum antibiotics\nD. administer 30 ml/kg crystalloid (bolus) for hypotension or lactate >=4 mmol/L\n\nTo be completed within 6 hours (or if septic shock is present):\nE. apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure >= 65)\nF. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate >=4 mmol/L (36 mg/dl) the resuscitation is objectively monitored using a method such as lactate clearance, ScvO2 monitoring or CVP monitoring\nG. re-measure lactate if initial lactate is elevated\n","Number of patients presenting with severe sepsis or septic shock.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.8.11","","Sepsis bundle  (NQF 0500)",null,null,null,null,null,"2014-08-01","2015-07-31","2015-08-01","2016-07-31","2014-02-01","2014-07-31",null,null,"RHP 10_112677302.2.4","RHP 10_112677302.3.10","RHP 10_112677302.2.4_112677302.3.10",{"$f":"COUNTIFS($FI$4:$FI167,FI167)","v":1},"RHP 10_112677302.2.4_1",null,2,1,1,"RHP 10_112677302",{"$f":"COUNTIFS($FR$4:$FR167,FR167)","v":11},"RHP 10_112677302_11"]
["RHP 10","112677302","Texas Health Harris Methodist Hospital Ft Worth","112677302.2.4","112677302.3.9","IT-4.11","Risk-Adjusted Average Length of Inpatient Hospital Stay\n","Pending Approval","Eligible to Report in October DY4","Early intervention and treatment of Sepsis patient entering through the ED.","Risk-Adjusted Average Length of Inpatient Hospital Stay\n","In DY4 and DY5 provider will improve (decrease) the percentage of inpatients with excessive in-hospital days for patients with Sepsis admitted to the hospital through the ED.","Facility, Comorbid Condition ","Sepsis patients admitted through ED","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",86608.434999999998,"Yes/No","RHP 10_112677302.3.9_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",86608.434999999998,"Yes/No","RHP 10_112677302.3.9_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",98829.91,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",98829.91,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",464475.92,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"time (days)",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator was  all severe sepsis and Septic shock that were admitted through the ED.  Numerator reflects those patients with excessive days over the average.","36.07% of severe sepsis and septic shock patients admitted through the ED had lengths of stay above the average.","Risk-Adjusted Average Length of Inpatient Hospital Stay\n","inpatient",null,"Number of excess in-hospital days in a given inpatient population","Patients admitted to a hospital",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.8.11","","Risk-Adjusted Average Length of Inpatient Hospital Stay\n",null,null,null,null,null,"2014-08-01","2015-07-31","2015-08-01","2016-07-31","2014-02-01","2014-07-31",null,null,"RHP 10_112677302.2.4","RHP 10_112677302.3.9","RHP 10_112677302.2.4_112677302.3.9",{"$f":"COUNTIFS($FI$4:$FI168,FI168)","v":2},"RHP 10_112677302.2.4_2",null,2,1,1,"RHP 10_112677302",{"$f":"COUNTIFS($FR$4:$FR168,FR168)","v":12},"RHP 10_112677302_12"]
["RHP 10","112677302","Texas Health Harris Methodist Hospital Ft Worth","112677302.2.5","112677302.3.11","IT-12.13","Mammography follow-up rate ","Baseline Approved","Eligible to Report in April DY4","Expand the current Wellness for Life Mobile Cancer Screening Service ","Mammography follow-up rate ","In DY4 and DY5 provider will improve (increase) the percentage of patients with mammography screening studies done in the Mobile Health Unit that are followed within 45 days by a diagnostic mammography or ultrasound of the breast study in an outpatient or office setting.","Facility ","Limit to Mobile Health Unit Patients receiving a mammogram","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",27714.7,"Yes/No","RHP 10_112677302.3.11_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",27714.7,"Yes/No","RHP 10_112677302.3.11_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",31625.57,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",31625.57,"Numeric",0.388811189,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",148632.29,"Numeric",0.42097899999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.35664299999999999,51,143,"DY3 (1): Oct 1st, 2013 - March 31st, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.388811189,null,0.42097899999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Both numerator and denominator were abstracted using the measure specifications outlined in the new Compendium documentation.","35.7% of all patients with an abnormal result during their mammogram received diagnostic  follow-up within 45 days of the screening mammogram.","Mammography follow-up rate ","ambulatory",null,"Number of patients who had a diagnostic mammography study, ultrasound or magnetic resonance imaging (MRI) of the breast study following a screening mammography study with abnormal results within 45 days","The number of patients who had abnormal findings on a screening mammography study.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.7.1 ","","Mammography follow-up rate ",null,null,null,null,null,"2014-04-01","2015-03-31","2015-04-01","2016-03-31","2013-10-01","2014-03-31",null,null,"RHP 10_112677302.2.5","RHP 10_112677302.3.11","RHP 10_112677302.2.5_112677302.3.11",{"$f":"COUNTIFS($FI$4:$FI169,FI169)","v":1},"RHP 10_112677302.2.5_1",null,2,1,1,"RHP 10_112677302",{"$f":"COUNTIFS($FR$4:$FR169,FR169)","v":13},"RHP 10_112677302_13"]
["RHP 10","112677302","Texas Health Harris Methodist Hospital Ft Worth","112677302.2.5","112677302.3.12","IT-12.2","Cervical Cancer Screening ","Baseline Approved","Eligible to Report in April DY4","Expand the current Wellness for Life Mobile Cancer Screening Service ","Cervical Cancer Screening ","In DY4 and DY5 provider will improve (increase) the percentage of women 21–64 years of age who were screened for cervical cancer in the Mobile Health Unit using either of the following criteria: - Women age 21–64 who had cervical cytology performed every 3 years. - Women age 30–64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years","Facility ","Limit to Mobile Health Unit Patients","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",27714.7,"Yes/No","RHP 10_112677302.3.12_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",27714.7,"Yes/No","RHP 10_112677302.3.12_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",31625.57,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",31625.57,"Numeric",0.68369999999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",148632.29,"Numeric",0.69384000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.32261200000000001,331,1026,"DY3 (1): Oct 1st, 2013 - March 31st, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.68369999999999997,null,0.69384000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator was abstracted outlining all patients receiving a cervical cancer screening.  Denominator  includes all women, 24 - 64 seen on the mobile health unit in DY 3.","32.26% of all eligible women presenting to the mobile health unit received a cervical cancer screening.","Cervical Cancer Screening ","ambulatory",null,"The number of women who were screened for cervical cancer during the measurement year or the two years prior to the measurement year.","Women 24-64 years of age as of the end of the measurement year ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.7.1 ","","Cervical Cancer Screening ",null,null,null,null,null,"2014-04-01","2015-03-31","2015-04-01","2016-03-31","2013-10-01","2014-03-31",null,null,"RHP 10_112677302.2.5","RHP 10_112677302.3.12","RHP 10_112677302.2.5_112677302.3.12",{"$f":"COUNTIFS($FI$4:$FI170,FI170)","v":2},"RHP 10_112677302.2.5_2",null,2,1,1,"RHP 10_112677302",{"$f":"COUNTIFS($FR$4:$FR170,FR170)","v":14},"RHP 10_112677302_14"]
["RHP 10","112677302","Texas Health Harris Methodist Hospital Ft Worth","112677302.2.5","112677302.3.13","IT-12.3","Colorectal Cancer Screening ","Baseline Approved","Eligible to Report in April DY4","Expand the current Wellness for Life Mobile Cancer Screening Service ","Colorectal Cancer Screening ","In DY4 and DY5 provider will improve (increase) the percentage of patients 50–75 years of age who had appropriate screening for colorectal cancer in the Mobile Health Unit.","Facility ","Limit to Mobile Health Unit Patients","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",27714.7,"Yes/No","RHP 10_112677302.3.13_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",27714.7,"Yes/No","RHP 10_112677302.3.13_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",31625.57,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",31625.57,"Numeric",0.51,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",148632.29,"Numeric",0.53300000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.15376300000000001,143,930,"DY3 (1): Oct 1st, 2013 - March 31st, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.51,null,0.53300000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator includes all patients visiting the mobile health unit returning a colorectal screening kit.  Denominator includes all patients 51-75 presenting to the mobile health unit during DY 3.","15.38% of all patients age 51 - 75 presenting to the mobile health unit in DY 3 returned and had evaluated a colorectal screening kit.","Colorectal Cancer Screening ","ambulatory",null,"One or more screenings for colorectal cancer. Any of the following meet the criteria: \n\n• Fecal occult blood test (FOBT) during the measurement year. For administrative data, assume the required number of samples were returned regardless of FOBT type.\n• Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year.\n• Colonoscopy during the measurement year or the nine years prior to the measurement year.\n","Patients 51–75 years of age as of the end of the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.7.1 ","","Colorectal Cancer Screening ",null,null,null,null,null,"2014-04-01","2015-03-31","2015-04-01","2016-03-31","2013-10-01","2014-03-31",null,null,"RHP 10_112677302.2.5","RHP 10_112677302.3.13","RHP 10_112677302.2.5_112677302.3.13",{"$f":"COUNTIFS($FI$4:$FI171,FI171)","v":3},"RHP 10_112677302.2.5_3",null,2,1,1,"RHP 10_112677302",{"$f":"COUNTIFS($FR$4:$FR171,FR171)","v":15},"RHP 10_112677302_15"]
["RHP 10","120726804","Texas Health Harris Methodist Hospital SW Ft Worth","120726804.2.1","120726804.3.1","IT-1.10","Diabetes care: HbA1c poor control (>9.0%) ","Pending Approval","Eligible to Report in October DY4","This project will increase patient engagement through outpatient education and self-management for the diabetic population ","Diabetes care: HbA1c poor control (>9.0%) ","In DY4 and DY5 provider will improve (decrease) the percentage of diabetic education program patients, attending at least one class, 18-75 years of age with diabetes (type 1 and type 2) whose most recent HbA1c level during the measurement year was greater than 9.0% (poor control) or was missing a result, or if an HbA1c test was not done during the measurement year.","Facility ","Population attending at least one education class","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",11878.24,"Yes/No","RHP 10_120726804.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",11878.24,"Yes/No","RHP 10_120726804.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",14223.73,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",14223.73,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",63730.93,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator includes diabetic patients at THSW with A1c values >9.0 or missing.  Denoninator includes all diabetic patients at THSW.","64.31% of all diabetic patients at THSW had A1c values registering out of control or did not have a value documented.","Diabetes care: HbA1c poor control (>9.0%) ","ambulatory",null,"Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.1 ","","Diabetes care: HbA1c poor control (>9.0%) ",null,null,null,null,null,"2013-01-01","2013-12-31","2014-01-01","2014-12-31","2012-01-01","2012-12-31",null,null,"RHP 10_120726804.2.1","RHP 10_120726804.3.1","RHP 10_120726804.2.1_120726804.3.1",{"$f":"COUNTIFS($FI$4:$FI172,FI172)","v":1},"RHP 10_120726804.2.1_1",null,2,1,1,"RHP 10_120726804",{"$f":"COUNTIFS($FR$4:$FR172,FR172)","v":1},"RHP 10_120726804_1"]
["RHP 10","120726804","Texas Health Harris Methodist Hospital SW Ft Worth","120726804.2.1","120726804.3.2","IT-3.5","Risk Adjusted Diabetes 30-day Readmission Rate ","Baseline Approved","Eligible to Report in April DY4","This project will increase patient engagement through outpatient education and self-management for the diabetic population ","Risk Adjusted Diabetes 30-day Readmission Rate ","In DY4 and DY5, provider will improve the ratio of observed to expected readmissions that occur within 30 days following discharge from an index admission for Diabetes for patients ages 18 and older. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",11878.24,"Yes/No","RHP 10_120726804.3.2_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",11878.24,"Yes/No","RHP 10_120726804.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",14223.73,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",14223.73,"Numeric",0.91935483870967738,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",63730.93,"Numeric",0.87096774193548376,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",0.96774193548387089,0.15151515151515152,0.15656565656565657,"CY2012: January 1, 2012 - December 31, 2012",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.91935483870967738,null,0.87096774193548376,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Data was abstracted using Premier's 3M methodology using the measure specifications outlined in the compendium.","With a rate of 0.97, THSW experiences slightly fewer than expected readmissions.","Risk Adjusted Diabetes 30-day Readmission Rate ","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission for Diabetes during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk Diabetes admissions during the measurement period.\n","Expected (risk-adjusted) rate of readmissions for Diabetes during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.1 ","","Risk Adjusted Diabetes 30-day Readmission Rate ",null,null,null,null,"Premier","2013-01-01","2013-12-31","2014-01-01","2014-12-31","2012-01-01","2012-12-31",null,null,"RHP 10_120726804.2.1","RHP 10_120726804.3.2","RHP 10_120726804.2.1_120726804.3.2",{"$f":"COUNTIFS($FI$4:$FI173,FI173)","v":2},"RHP 10_120726804.2.1_2",null,2,1,1,"RHP 10_120726804",{"$f":"COUNTIFS($FR$4:$FR173,FR173)","v":2},"RHP 10_120726804_2"]
["RHP 10","120726804","Texas Health Harris Methodist Hospital SW Ft Worth","120726804.2.100","120726804.3.100","IT-13.3","Hospice and Palliative Care – Emergency room visit in the last days of life","Baseline Approved","Eligible to Report in October DY4","Implement a comprehensive palliative care program focused on providing patients with chronic pain/symptom management, assistance with complex medical decisions and end-of-life care planning","Hospice and Palliative Care – Proportion with more than one emergency room visit in the last days of life","In DY4 and DY5 provider will improve (decrease) the percentage of patients who died from cancer with more than one emergency room visit in the last days of life for palliative care patients of the hospital or clinic.","Facility ","Limited to Palliative care population of hospital and those followed by OP Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",47512.95,"Yes/No","RHP 10_120726804.3.100_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",47512.95,"Yes/No","RHP 10_120726804.3.100_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",56894.92,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",56894.92,"Numeric",0.123148149,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",254923.72,"Numeric",0.11666700000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.12963,7,54,"07/01/13 - 06/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.123148149,null,0.11666700000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"A Business Requirements Document was developed by the Business Intelligence team based upon the specific requirements of the measure. Code was developed and exceuted to pull the proportion of  patients, that dies from cancer,  that had more than 1 ED visit in the last 30 days of life. ","12.96% of the patient population that died from cancer had more than 1 ED visit in the last 30 days of life. ","Hospice and Palliative Care – Emergency room visit in the last days of life","Ambulatory/Inpatient",null,"Patients who died from cancer and had > 1 ER visit in the last 30 days of life","Patients who died from cancer",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.10.1","","Hospice and Palliative Care – Emergency room visit in the last days of life",null,null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2013-07-01","2014-06-30",null,null,"RHP 10_120726804.2.100","RHP 10_120726804.3.100","RHP 10_120726804.2.100_120726804.3.100",{"$f":"COUNTIFS($FI$4:$FI174,FI174)","v":1},"RHP 10_120726804.2.100_1",null,2,1,1,"RHP 10_120726804",{"$f":"COUNTIFS($FR$4:$FR174,FR174)","v":3},"RHP 10_120726804_3"]
["RHP 10","120726804","Texas Health Harris Methodist Hospital SW Ft Worth","120726804.2.100","120726804.3.101","IT-13.6","Palliative Care:  documentation of interdisciplinary family meeting","Baseline Approved","Eligible to Report in October DY4","Implement a comprehensive palliative care program focused on providing patients with chronic pain/symptom management, assistance with complex medical decisions and end-of-life care planning","Palliative Care:  Percent of patients who have documentation in the medical record that an interdisciplinary family meeting was conducted on or before day five of ICU admission ","In DY4 and DY5 provider will improve (increase) the percentage of patients with documentation that an interdisciplinary family meeting was conducted on or before Day Five of intensive care unit (ICU) admission over all patients with an intensive care unit (ICU) length of stay greater than or equal to 5 days",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",47512.95,"Yes/No","RHP 10_120726804.3.101_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",47512.95,"Yes/No","RHP 10_120726804.3.101_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",56894.92,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",56894.92,"Numeric",0.150757576,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",254923.72,"Numeric",0.19545499999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.106061,14,132,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.150757576,null,0.19545499999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator was abstracted from programmatic database tracking consults counting those with meeting within first 5 days of ICU stay.  Denominator was abstracted using internal EMR and ICU LOS of 5 days or greater.  Both were pulled using measure specifications outlined in the compendium document.","10.61% of all 5 day or greater ICU stays had a multidisciplinary meeting within the first 5 days.","Palliative Care:  documentation of interdisciplinary family meeting","Ambulatory/Inpatient",null,"Number of patients who have documentation in the medical record that an interdisciplinary family meeting was conducted on or before Day Five of intensive care unit (ICU) admission","Total number of patients with an intensive care unit (ICU) length of stay greater than or equal to 5 days",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.10.1","","Palliative Care:  documentation of interdisciplinary family meeting",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 10_120726804.2.100","RHP 10_120726804.3.101","RHP 10_120726804.2.100_120726804.3.101",{"$f":"COUNTIFS($FI$4:$FI175,FI175)","v":2},"RHP 10_120726804.2.100_2",null,2,1,1,"RHP 10_120726804",{"$f":"COUNTIFS($FR$4:$FR175,FR175)","v":4},"RHP 10_120726804_4"]
["RHP 10","120726804","Texas Health Harris Methodist Hospital SW Ft Worth","120726804.2.2","120726804.3.3","IT-4.10","Sepsis bundle  (NQF 0500)","Baseline Approved","Eligible to Report in October DY4","Early intervention and treatment of Sepsis patient entering through the ED","Sepsis bundle  (NQF 0500)","In DY4 and DY5 provider will improve (increase) the percentage of patients aged 18 years and older who present with symptoms of severe sepsis or septic shock and receive the 3 hour (severe sepsis) and/or 6 hour (septic shock) early management bundle.\n",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",14253.885,"Yes/No","RHP 10_120726804.3.3_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",14253.885,"Yes/No","RHP 10_120726804.3.3_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",17068.474999999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",17068.48,"Numeric",0.31544117700000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",76477.119999999995,"Numeric",0.35147099999999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.27941199999999999,57,204,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.31544117700000002,null,0.35147099999999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator includes all Severe Sepsis or Septic Shock patients receiving all elements of the 3 and 6 hour bundles appropriately.  Denominator includes all patients presenting to THSW ED with Severe Sepsis and Septic Shock.  Both were pull following measure specification outlined in the compendium.","27.9% of  severe sepsis and septic shock patients received both the 3 and 6 hour bundles appropriately as defined by HHSC.  It should be noted that while all 204 patients presenting required the 3 hour bundle, not all required the 6 hour bundle intervention.","Sepsis bundle  (NQF 0500)","inpatient",null,"Patients from the denominator who received all the following: A, B, C, and D within 3 hours of time of presentation†, \nAND, \nIF septic shock is present (as either defined as hypotension* or lactate >=4 mmol/L) who also received E, ,F and G within 6 hours of time of presentation\n\nTo be completed within 3 hours:\nA. measure lactate level\nB. obtain blood cultures prior to antibiotics\nC. administer broad spectrum antibiotics\nD. administer 30 ml/kg crystalloid (bolus) for hypotension or lactate >=4 mmol/L\n\nTo be completed within 6 hours (or if septic shock is present):\nE. apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure >= 65)\nF. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate >=4 mmol/L (36 mg/dl) the resuscitation is objectively monitored using a method such as lactate clearance, ScvO2 monitoring or CVP monitoring\nG. re-measure lactate if initial lactate is elevated\n","Number of patients presenting with severe sepsis or septic shock.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.8.11","","Sepsis bundle  (NQF 0500)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 10_120726804.2.2","RHP 10_120726804.3.3","RHP 10_120726804.2.2_120726804.3.3",{"$f":"COUNTIFS($FI$4:$FI176,FI176)","v":1},"RHP 10_120726804.2.2_1",null,2,1,1,"RHP 10_120726804",{"$f":"COUNTIFS($FR$4:$FR176,FR176)","v":5},"RHP 10_120726804_5"]
["RHP 10","120726804","Texas Health Harris Methodist Hospital SW Ft Worth","120726804.2.2","120726804.3.4","IT-9.10.b","Median time from admit decision time to time of departure from the ED for ED patients admitted to inpatient status","Baseline Approved","Eligible to Report in October DY4","Early intervention and treatment of Sepsis patient entering through the ED","Median time from admit decision time to time of departure from the ED for ED patients admitted to inpatient status","In DY4 and DY5 provider will improve (decrease) the median time from admit decision time to time of departure from the emergency department for Sepsis patients admitted to inpatient status","Comorbid Condition ","Sepsis patients admitted  through ED","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",14253.885,"Yes/No","RHP 10_120726804.3.4_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",14253.885,"Yes/No","RHP 10_120726804.3.4_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",17068.474999999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",17068.48,"Numeric",52.25,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",76477.119999999995,"Numeric",49.5,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"time (minutes)",55,55,1,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,52.25,null,49.5,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"median time from decision to admit to time leaving the ED was abstracted from the internal EMR using measure specifications outlined in the compendium document.","The median time from decision to admit and leaving the ED was 55 minutes.","Median time from admit decision time to time of departure from the ED for ED patients admitted to inpatient status","ED",null,"Median time from admit decision time to time of departure from the ED for ED patients admitted to inpatient status: Continuous variable statement: Time (in minutes) from admit decision time to time of departure from the emergency department (ED) for ED patients admitted to inpatient status",1,null,null,null,null,null,null,null,null,null,null,null,null,null,"2.8.11","","Median time from admit decision time to time of departure from the ED for ED patients admitted to inpatient status",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 10_120726804.2.2","RHP 10_120726804.3.4","RHP 10_120726804.2.2_120726804.3.4",{"$f":"COUNTIFS($FI$4:$FI177,FI177)","v":2},"RHP 10_120726804.2.2_2",null,2,1,1,"RHP 10_120726804",{"$f":"COUNTIFS($FR$4:$FR177,FR177)","v":6},"RHP 10_120726804_6"]
["RHP 10","120726804","Texas Health Harris Methodist Hospital SW Ft Worth","120726804.2.3","120726804.3.5","IT-9.2","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","Baseline Approved","Eligible to Report in April DY4","This project proposes to implement an Emergency Department Case Management Program (EDCM) using skilled case managers (Navigators) to identify high risk population patients (those who are unfunded, underfunded, or have Medicaid) requiring intervention and guidance in the use of care settings in primary care, non-emergent clinics, and community-based resources.","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","In DY4 and DY5, the provider will improve the rate of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period over all ED visits for individuals 18 years or older during the measurement period for those patients referred for patient navigation services.  ","Facility ","Patients referred to ED navigation services","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",33259.065000000002,"Yes/No","RHP 10_120726804.3.5_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",33259.065000000002,"Yes/No","RHP 10_120726804.3.5_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",39826.445,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",39826.449999999997,"Numeric",0.287797197,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",178446.6,"Numeric",0.27265,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.30294399999999999,13468,44457,"CY 2013: Jan 1st, 2013 - Dec 31st, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.287797197,null,0.27265,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"numerator and denominator were abstracted from the internal system using measure specifications outlined in the compendium.","30.29% of all THSW ED visits present with an ASCS related condition.","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","ED",null,"Total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1 ","","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ",null,null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 10_120726804.2.3","RHP 10_120726804.3.5","RHP 10_120726804.2.3_120726804.3.5",{"$f":"COUNTIFS($FI$4:$FI178,FI178)","v":1},"RHP 10_120726804.2.3_1",null,2,1,1,"RHP 10_120726804",{"$f":"COUNTIFS($FR$4:$FR178,FR178)","v":7},"RHP 10_120726804_7"]
["RHP 10","120726804","Texas Health Harris Methodist Hospital SW Ft Worth","120726804.2.4","120726804.3.6","IT-1.10","Diabetes care: HbA1c poor control (>9.0%) ","Baseline Approved","Eligible to Report in October DY4","Deliver an innovative coordinated care approach to at-risk populations with chronic conditions through the Extensivist Clinic, an outpatient primary care clinic in the Project Area.","Diabetes care: HbA1c poor control (>9.0%) ","In DY4 and DY5 provider will improve (decrease) the percentage of diabetic Extensivist Clinic patients 18-75 years of age with diabetes (type 1 and type 2) whose most recent HbA1c level during the measurement year was greater than 9.0% (poor control) or was missing a result, or if an HbA1c test was not done during the measurement year.","Facility ","Extensivist Clinics diabetic patient population","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",19005.18,"Yes/No","RHP 10_120726804.3.6_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",19005.18,"Yes/No","RHP 10_120726804.3.6_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",22757.97,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",22757.97,"Numeric",0.31741153900000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",101969.49,"Numeric",0.31430999999999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.32051299999999999,25,78,"07/01/13 - 06/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.31741153900000002,null,0.31430999999999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator includes all extensivist clinics patients with diabetes and an A1c >9 or missing.  Denominator includes all extensivist clinics patients.  Measures extracted per specifications outlined in the compendium document.","32.05% of both clinics diabetic population had a most recent A1c value of > 9.0 or was missing.","Diabetes care: HbA1c poor control (>9.0%) ","ambulatory",null,"Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.1 ","","Diabetes care: HbA1c poor control (>9.0%) ",null,null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2013-07-01","2014-06-30",null,null,"RHP 10_120726804.2.4","RHP 10_120726804.3.6","RHP 10_120726804.2.4_120726804.3.6",{"$f":"COUNTIFS($FI$4:$FI179,FI179)","v":1},"RHP 10_120726804.2.4_1",null,2,1,1,"RHP 10_120726804",{"$f":"COUNTIFS($FR$4:$FR179,FR179)","v":8},"RHP 10_120726804_8"]
["RHP 10","120726804","Texas Health Harris Methodist Hospital SW Ft Worth","120726804.2.4","120726804.3.7","IT-10.2.b","Lawton Instrumental Activities of Daily Living (IADLs) Scale ","Baseline Approved","Eligible to Report in October DY4","Deliver an innovative coordinated care approach to at-risk populations with chronic conditions through the Extensivist Clinic, an outpatient primary care clinic in the Project Area.","Lawton Instrumental Activities of Daily Living (IADLs) Scale ","In DY4 and DY5 provider will improve reported scores on the LIADLs out of all instruments completed during the measurement period by patients of the Extensivist Clinic. ","Facility ","Extensivist clinics patient population","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",19005.18,"Yes/No","RHP 10_120726804.3.7_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",19005.18,"Yes/No","RHP 10_120726804.3.7_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",22757.97,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",22757.97,"Numeric",5.3346938780000004,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",101969.49,"Numeric",4.934693878,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",5.7346940000000002,281,49,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,5.3346938780000004,null,4.934693878,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator and denominator were calculated by exact specifications of data collected,  according to surveys administered by the care team. Numerator: The sum of the \"total score\" for all LIADLs questionnaires completed during the measurement period. Denominator: The total number of LIADLs questionnaires completed during the measurement period. ","A score of 5.73 indicates our members have a fairly high level of function and independence, with a maximum score of 8. This could also indicate members reported a higher score than their current functionality. ","Lawton Instrumental Activities of Daily Living (IADLs) Scale ","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.1 ","Scenario 3: Average Score","Lawton Instrumental Activities of Daily Living (IADLs) Scale ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 10_120726804.2.4","RHP 10_120726804.3.7","RHP 10_120726804.2.4_120726804.3.7",{"$f":"COUNTIFS($FI$4:$FI180,FI180)","v":2},"RHP 10_120726804.2.4_2",null,2,1,1,"RHP 10_120726804",{"$f":"COUNTIFS($FR$4:$FR180,FR180)","v":9},"RHP 10_120726804_9"]
["RHP 10","120726804","Texas Health Harris Methodist Hospital SW Ft Worth","120726804.2.4","120726804.3.8","IT-10.3.e","Problem Areas in Diabetes (PAID) Scale","Pending Approval","Eligible to Report in October DY4","Deliver an innovative coordinated care approach to at-risk populations with chronic conditions through the Extensivist Clinic, an outpatient primary care clinic in the Project Area.","Problem Areas in Diabetes (PAID) Scale","In DY4 and DY5 provider will improve reported scores on the PAID out of all instruments completed during the measurement period by diabetic patients of the Extensivist Clinic","Facility, Comorbid Condition ","Extensivist Clinics diabetic patient population","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",19005.18,"Yes/No","RHP 10_120726804.3.8_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",19005.18,"Yes/No","RHP 10_120726804.3.8_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",22757.97,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",22757.97,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",101969.49,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator and denominator were calculated by exact specifications of data collected,  according to surveys administered by the care team. Numerator: The sum \"total score\" of all PAID surveys completed during the measurement period. Denominator: Total number of PAID surveys completed during the measurement period. ","Our core of 22.53 represents an average to good overall score for our member population. This could also indicate members reported a higher score than their current functionality. ","Problem Areas in Diabetes (PAID) Scale","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.1 ","Scenario 3: Average Score","Problem Areas in Diabetes (PAID) Scale",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 10_120726804.2.4","RHP 10_120726804.3.8","RHP 10_120726804.2.4_120726804.3.8",{"$f":"COUNTIFS($FI$4:$FI181,FI181)","v":3},"RHP 10_120726804.2.4_3",null,2,1,1,"RHP 10_120726804",{"$f":"COUNTIFS($FR$4:$FR181,FR181)","v":10},"RHP 10_120726804_10"]
["RHP 10","121794503","Texas Health Harris Methodist Hospital Stephenville","121794503.2.1","121794503.3.1","IT-1.10","Diabetes care: HbA1c poor control (>9.0%) ","Pending Approval","Eligible to Report in October DY4","Refer diabetic patients to a comprehensive outpatient diabetes education classes offered by Texas Health Stephenville","Diabetes care: HbA1c poor control (>9.0%) ","In DY4 and DY5 provider will improve (decrease) the percentage of patients receiving diabetic education services, 18-75 years of age with diabetes (type 1 and type 2) whose most recent HbA1c level during the measurement year was greater than 9.0% (poor control) or was missing a result, or if an HbA1c test was not done during the measurement year.","Facility ","the number of diabetic education program patients, attending at least one class, 18-75 years of age with diabetes (type 1 and type 2).  The diabetic education center is located across town from the hospital.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",1117.99,"Yes/No","RHP 10_121794503.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",1117.99,"Yes/No","RHP 10_121794503.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",1195.99,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",1195.99,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",5719.95,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Both numerator and denminator were abstracted from the database using the measure criteria outlined in the Compendium.","68% of all diabetic education participants at THS' outpatient education center had an HbA1C score of greater than 9.0 or was missing/not measured during DY 3.","Diabetes care: HbA1c poor control (>9.0%) ","ambulatory",null,"Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.1 ","","Diabetes care: HbA1c poor control (>9.0%) ",null,null,null,null,null,"2014-04-01","2015-03-31","2015-04-01","2016-03-31","2013-10-01","2014-03-31",null,null,"RHP 10_121794503.2.1","RHP 10_121794503.3.1","RHP 10_121794503.2.1_121794503.3.1",{"$f":"COUNTIFS($FI$4:$FI182,FI182)","v":1},"RHP 10_121794503.2.1_1",null,2,1,1,"RHP 10_121794503",{"$f":"COUNTIFS($FR$4:$FR182,FR182)","v":1},"RHP 10_121794503_1"]
["RHP 10","121794503","Texas Health Harris Methodist Hospital Stephenville","121794503.2.1","121794503.3.2","IT-3.5","Risk Adjusted Diabetes 30-day Readmission Rate ","Baseline Approved","Eligible to Report in April DY4","Refer diabetic patients to a comprehensive outpatient diabetes education classes offered by Texas Health Stephenville","Risk Adjusted Diabetes 30-day Readmission Rate ","In DY4 and DY5, provider will improve the ratio of observed to expected readmissions that occur within 30 days following discharge from an index admission for Diabetes for patients ages 18 and older. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",1117.99,"Yes/No","RHP 10_121794503.3.2_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",1117.99,"Yes/No","RHP 10_121794503.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",1195.99,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",1195.99,"Numeric",0.83125000000000004,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",5719.95,"Numeric",0.78749999999999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",0.875,0.12280701754385964,0.14035087719298245,"CY 2013: Jan 1st, 2013 - Dec 31st, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.83125000000000004,null,0.78749999999999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator and denominator were abstracted using Premier's 3M methodology report using measure specifications outlined in the compendium.","With a diabetes 30-day risk-adjusted readmission rate of 0.88, THS experiences fewer than expected readmissions.","Risk Adjusted Diabetes 30-day Readmission Rate ","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission for Diabetes during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk Diabetes admissions during the measurement period.\n","Expected (risk-adjusted) rate of readmissions for Diabetes during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.1 ","","Risk Adjusted Diabetes 30-day Readmission Rate ",null,null,null,null,"Premier","2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 10_121794503.2.1","RHP 10_121794503.3.2","RHP 10_121794503.2.1_121794503.3.2",{"$f":"COUNTIFS($FI$4:$FI183,FI183)","v":2},"RHP 10_121794503.2.1_2",null,2,1,1,"RHP 10_121794503",{"$f":"COUNTIFS($FR$4:$FR183,FR183)","v":2},"RHP 10_121794503_2"]
["RHP 10","121822403","Ennis Regional Medical Center","121822403.1.1","121822403.3.1","IT-9.2","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","Pending Approval","Eligible to Report in October DY4","The goal of this project is to increase the general population’s access to primary care across all payer sources. The expansion approach will include three facets: (1) expanding existing primary care base and expanding clinic hours and off-hours through assisting growing practices in recruitment efforts; (2) further expanding relationships (and clinic sites) with existing Federally Qualified Health Clinics, and (3) partner with established clinics and physician offices to educate and encourage the public on right care, right service. ","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","In DY4 and DY5, the provider will improve the rate of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period over all ED visits for individuals 18 years or older during the measurement period",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",22613,"Yes/No","RHP 10_121822403.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",22613,"Yes/No","RHP 10_121822403.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",24190.5,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",24190.5,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",115693,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"No Sampling was used. The numerator number was derived  from the census report of all ED patient who were discharged status  \"home\". This census was used to run a report  by Primary and Secondary Diagnosis to discover the described individual ACSC category specifications.","Less than expected. Some of the subsets were zero population. The total  population is still an area of needed focus. Many of these patients have multiple visits for the same reason and are either not funded or are lacking in primary care and did not meet medical necessity for ED visit. Focusing on this total ACSC population helped us understand which group to focus on to maximize the potential of our efforts.","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","ED",null,"Total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1 ","","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 10_121822403.1.1","RHP 10_121822403.3.1","RHP 10_121822403.1.1_121822403.3.1",{"$f":"COUNTIFS($FI$4:$FI184,FI184)","v":1},"RHP 10_121822403.1.1_1",null,2,1,1,"RHP 10_121822403",{"$f":"COUNTIFS($FR$4:$FR184,FR184)","v":1},"RHP 10_121822403_1"]
["RHP 10","121988304","Lakes Regional MHMR Center","121988304.1.1","121988304.3.1","IT-6.2.a","Client Satisfaction Questionnaire 8 (CSQ-8)","Baseline Approved","Eligible to Report in October DY4","Behavioral health crisis stabilization service for dually diagnosed individuals as an alternative to hospitalization which will include a crisis respite facility, and wraparound services. Based on assessed levels of need and risk, the team would provide in-home consultation, specialty psychiatric services/telemedicine, skills training, family education, treatment planning, monitoring and\nreferrals to needed services to ensure that high-risk individuals remain in the least restrictive environment in the community. In addition, a crisis respite/short-term treatment site would be\nestablished to stabilize referred individuals in crisis or in danger of out-of-home placement and/or psychiatric hospitalization.","Client Satisfaction Questionnaire 8 (CSQ-8)","In DY4 and DY5, the provider will improve the average score on the CSQ-8 over all completed surveys",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",44479.11,"Yes/No","RHP 10_121988304.3.1_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",44479.11,"Yes/No","RHP 10_121988304.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",47601.894999999997,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",47601.9,"Numeric",25.948499999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",206965.1,"Numeric",26.266999999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",25.63,2563,100,"06/10/14 - 09/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"short",25.948499999999999,null,26.266999999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator was determined by identifying the estimated population of the region served and a percentage was determined which would best represent that population. The numerator was determined by running an electronic report based on the CSQ-8 survey reponses.","The baseline is based on individuals who have had experiences with similar services in the past or have a limited knowledge of the array of services offered by a crisis program. The findings of the baseline surveys will assist the program in improving areas of potential gaps which will in turn serve the individuals more effectively. The baseline derived is an average of 25 total score out of a possible maximum score of 32 for the CSQ-8. The difference is the room for improvement. ","Client Satisfaction Questionnaire 8 (CSQ-8)","Ambulatory",null,"The sum of the \"overall score\" for all CSQ-8 surveys completed during the measurement period.  ","The total number of CSQ-8 surveys completed during the measurement period. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.13.1","","Client Satisfaction Questionnaire 8 (CSQ-8)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-06-10","2014-09-30",null,null,"RHP 10_121988304.1.1","RHP 10_121988304.3.1","RHP 10_121988304.1.1_121988304.3.1",{"$f":"COUNTIFS($FI$4:$FI185,FI185)","v":1},"RHP 10_121988304.1.1_1",null,2,1,1,"RHP 10_121988304",{"$f":"COUNTIFS($FR$4:$FR185,FR185)","v":1},"RHP 10_121988304_1"]
["RHP 10","121988304","Lakes Regional MHMR Center","121988304.1.1","121988304.3.200","IT-10.2.a","Supports Intensity Scale (SIS) ","Baseline not yet reported","Eligible to Report in October DY4","Behavioral health crisis stabilization service for dually diagnosed individuals as an alternative to hospitalization which will include a crisis respite facility, and wraparound services. Based on assessed levels of need and risk, the team would provide in-home consultation, specialty psychiatric services/telemedicine, skills training, family education, treatment planning, monitoring and\nreferrals to needed services to ensure that high-risk individuals remain in the least restrictive environment in the community. In addition, a crisis respite/short-term treatment site would be\nestablished to stabilize referred individuals in crisis or in danger of out-of-home placement and/or psychiatric hospitalization.","Supports Intensity Scale (SIS) ","In DY4 and DY5 provider will report the average score of all SIS scales completed during the measurement period. In addition, in DY5 provider will complete Stretch Activity #3 (SA3)- Outcome Evaluation.",null,null,"P4R","SA3","PM-8","Submission of Category 3 DY3 Status Report",44479.11,"Yes/No","RHP 10_121988304.3.200_PM-8","Metric Carried Forward in October DY3","PM-9","Validation and submission of baseline performance",44479.11,"Yes/No","RHP 10_121988304.3.200_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",95203.79,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",103482.55,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",103482.55,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"dy4 ","P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Supports Intensity Scale (SIS) ","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,"Stretch Activity status not reported in DY3",null,null,"1.13.1","","Supports Intensity Scale (SIS) ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 10_121988304.1.1","RHP 10_121988304.3.200","RHP 10_121988304.1.1_121988304.3.200",{"$f":"COUNTIFS($FI$4:$FI186,FI186)","v":2},"RHP 10_121988304.1.1_2",null,2,1,1,"RHP 10_121988304",{"$f":"COUNTIFS($FR$4:$FR186,FR186)","v":2},"RHP 10_121988304_2"]
["RHP 10","121988304","Lakes Regional MHMR Center","121988304.1.2","121988304.3.2","IT-6.2.a","Client Satisfaction Questionnaire 8 (CSQ-8)","Baseline Approved","Eligible to Report in October DY4","Telemedicine and telehealth for behavioral health and other specialty provider services","Client Satisfaction Questionnaire 8 (CSQ-8)","In DY4 and DY5, the provider will improve the average score on the CSQ-8 over all completed surveys",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",25632.03,"Yes/No","RHP 10_121988304.3.2_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",25632.03,"Yes/No","RHP 10_121988304.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",27431.599999999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",27431.599999999999,"Numeric",25.939,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",119268.02,"Numeric",26.257999999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",25.62,2562,100,"07/01/14 - 09/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"short",25.939,null,26.257999999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator is the 100 sampled surveys and the denominator is the summed total score of those surveys. ","The numerator is the 100 sampled surveys and the denominator is the summed total score of those surveys. The calculated baseline is an average total score of those sampled casses. This yeilds a satisfaction score of 25.6 out of a maximun score of 32 possible on the survey. ","Client Satisfaction Questionnaire 8 (CSQ-8)","Ambulatory",null,"The sum of the \"overall score\" for all CSQ-8 surveys completed during the measurement period.  ","The total number of CSQ-8 surveys completed during the measurement period. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.7.1 ","","Client Satisfaction Questionnaire 8 (CSQ-8)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-07-01","2014-09-30",null,null,"RHP 10_121988304.1.2","RHP 10_121988304.3.2","RHP 10_121988304.1.2_121988304.3.2",{"$f":"COUNTIFS($FI$4:$FI187,FI187)","v":1},"RHP 10_121988304.1.2_1",null,2,1,1,"RHP 10_121988304",{"$f":"COUNTIFS($FR$4:$FR187,FR187)","v":3},"RHP 10_121988304_3"]
["RHP 10","121988304","Lakes Regional MHMR Center","121988304.1.3","121988304.3.3","IT-10.1.b.iii","RAND Short Form 36[1] (SF-36) Health Survey","Baseline Approved","Eligible to Report in October DY4","Behavioral health clinic for individuals who suffer from depression or trauma related disorders that do not meet the state mandated diagnostic criteria for state funded behavioral health services","RAND Short Form 36[1] (SF-36) Health Survey","In DY4 and DY5 provider will improve reported scores on the RAND SF-36 out of all surveys completed during the measurement period",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",36186.394999999997,"Yes/No","RHP 10_121988304.3.3_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",36186.394999999997,"Yes/No","RHP 10_121988304.3.3_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",38726.964999999997,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",38726.97,"Numeric",42.207547169999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",168378.38,"Numeric",47.207547169999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",37.207549999999998,5916,159,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,42.207547169999998,null,47.207547169999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator was the number of individuals who presented to participate in the intervention prior to starting.  ","The baseline is an adequate representation of the expected population as they enter services with predominately depression symptoms at four times that of the general population.","RAND Short Form 36[1] (SF-36) Health Survey","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.12.2","Scenario 2: Pre Test Only Baseline","RAND Short Form 36[1] (SF-36) Health Survey",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 10_121988304.1.3","RHP 10_121988304.3.3","RHP 10_121988304.1.3_121988304.3.3",{"$f":"COUNTIFS($FI$4:$FI188,FI188)","v":1},"RHP 10_121988304.1.3_1",null,2,1,1,"RHP 10_121988304",{"$f":"COUNTIFS($FR$4:$FR188,FR188)","v":4},"RHP 10_121988304_4"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.1.1","126675104.3.1","IT-1.18","Follow-Up After Hospitalization for Mental Illness ","Baseline Approved","Eligible to Report in October DY4","Develop the full continuum of behavioral health capacity to improve accessibility to appropriate levels of behavioral health services for population health needs. The project’s ultimate benefits and goals are to expand hours and services, provide a more patient-centered focus, manage more patients in an outpatient setting and avoid preventable inpatient admissions and readmissions and emergency department (ED) utilization","Follow-Up After Hospitalization for Mental Illness ","In DY4 and DY5, the provider will improve the percentage of individuals with an outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 7- and 30-days after discharge over all patients 6 years and older as of the date of discharge who were discharged alive from  Trinity Springs Pavilion to a JPS Behavioral Health Outpatient Clinic  with a principal diagnosis of mental illness during the first 11 months of the measurement year","Facility ","Only patients discharging from Trinity Springs Pavilion to a JPS Behavioral Health Outpatient Clinic for 7 or 30 day follow up","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",161523.60105800003,"Yes/No","RHP 10_126675104.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",161523.60105800003,"Yes/No","RHP 10_126675104.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",179182.928904,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- 7 day follow-up",89591.464452,"Numeric",0.18542819999999999,"AM-1.2","Achievement of DY4 performance goal- 30 day follow-up",89591.464452,"Numeric",0.3125173,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- 7 day follow-up",419529.53370060003,"Numeric",0.22830039999999999,"AM-2.2","Achievement of DY5 performance goal- 30 day follow-up",419529.53370060003,"Numeric",0.34870060000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"%",0.14255599999999999,406,2848,"07/01/13 - 06/30/14",0.27633400000000002,787,2848,"07/01/13 - 06/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0.18542819999999999,null,0.22830039999999999,null,0.3125173,null,0.34870060000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator: Patients 6 years and older as of the date of discharge who were discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal diagnosis of mental illness during the first 11 months of the measurement year.\nNumerator: \n30-Day Follow-Up:  An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner with 30 days after discharge.\n7-Day Follow-Up:  An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 7 days after discharge.\n","The percentage rate will be calculated by adding all the cases in the numerator and dividing it by all the cases in the denominator and multiplying the result by 100 to a percentage.","Follow-Up After Hospitalization for Mental Illness ","ambulatory",null,"Rate #1: 7-Day Follow-Up: An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 7 days after discharge. ","Patients 6 years and older as of the date of discharge who were discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal diagnosis of mental illness during the first 11 months of the measurement year. ","Rate #2: 30-Day Follow-Up: An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 30 days after discharge. ","Patients 6 years and older as of the date of discharge who were discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal diagnosis of mental illness during the first 11 months of the measurement year. ",null,null,null,null,null,null,null,null,null,null,null,"1.12.1","","7 day follow-up","30 day follow-up",null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2013-07-01","2014-06-30",null,null,"RHP 10_126675104.1.1","RHP 10_126675104.3.1","RHP 10_126675104.1.1_126675104.3.1",{"$f":"COUNTIFS($FI$4:$FI189,FI189)","v":1},"RHP 10_126675104.1.1_1",null,3,2,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR189,FR189)","v":1},"RHP 10_126675104_1"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.1.100","126675104.3.100","IT-11.17","Assessment of Risk to Self/Others ","Baseline Approved","Eligible to Report in October DY4","Create an anti-stigma campaign, a central information center staffed by behavioral health navigators, and supporting psychological first aid training throughout Tarrant County. It will improve access to behavioral health services by creating a central information center staffed by behavioral health navigators. Additionally, it will create a centralized behavioral health assessment and referral center to create a front door the JPS Behavioral Health system. Finally, it will reduce the psychological impact from exposure to trauma with particular emphasis on gun-related and violent events through counseling with particular emphasis on Trauma Informed Cognitive Behavioral Health evidence based approach","Assessment of Risk to Self/Others ","In DY4 and DY5, the provider will improve the percentage of patients from the denominator whose medical record of the formal evaluation contains specific documentation of the patient's potential to harm self or others over all patients diagnosed with a depressive disorder during a formal evaluation at the Central Assessment Facility","Facility ","Only patients in Central Assessment Facility","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",57470.944196666671,"Yes/No","RHP 10_126675104.3.100_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",57470.944196666671,"Yes/No","RHP 10_126675104.3.100_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",63754.224999999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",63754.23,"Numeric",6.5461120999999997E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",298541.62,"Numeric",0.11464737799999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",1.6275000000000001E-2,27,1659,"March 1, 2014 - August 31, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"proxy",6.5461120999999997E-2,null,0.11464737799999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The Cental Assessment Facility was not operational until 8/4/14 which would not have allowed enough time to collect six months worth of baseline data. With that in mind we requested and received approval to include our traditional outpatient individuals served in our behavioral health clinics in addition to these new facilities for this measure from 3/1/14 – 8/31/14 to get a better representation of data for these measures. After the baseline setting, the provider would then report their DY4 and DY5 achievement with their proposed facility subsets which were approved during the Category 3 feedback setting processes.  Without this proxy population, the provider would not have a full 6 months’ worth of data for their current subset denominator population. ","Denominator: The number of patients diagnosed with a depressive disorder during a formal evaluation.\nNumerator: Number of patients from the denominator whose medical record of the formal evaluation contains specific documentation of the patient's potential to harm self or others.  \n","Sum of Numerator / sum of denominator * 100","Assessment of Risk to Self/Others ","Ambulatory/Inpatient",null,"Number of patients from the denominator whose medical record of the formal evaluation contains specific documentation of the patient's potential to harm self or others.","The number of patients diagnosed with a depressive disorder during a formal evaluation. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.12.2","","Assessment of Risk to Self/Others ",null,null,null,null,null,"2014-09-01","2015-08-31","2015-09-01","2016-08-31","2014-03-01","2014-08-31",null,null,"RHP 10_126675104.1.100","RHP 10_126675104.3.100","RHP 10_126675104.1.100_126675104.3.100",{"$f":"COUNTIFS($FI$4:$FI190,FI190)","v":1},"RHP 10_126675104.1.100_1",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR190,FR190)","v":2},"RHP 10_126675104_2"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.1.100","126675104.3.101","IT-11.19","Assessment for Psychosocial Issues of Psychiatric Patients ","Baseline Approved","Eligible to Report in October DY4","Create an anti-stigma campaign, a central information center staffed by behavioral health navigators, and supporting psychological first aid training throughout Tarrant County. It will improve access to behavioral health services by creating a central information center staffed by behavioral health navigators. Additionally, it will create a centralized behavioral health assessment and referral center to create a front door the JPS Behavioral Health system. Finally, it will reduce the psychological impact from exposure to trauma with particular emphasis on gun-related and violent events through counseling with particular emphasis on Trauma Informed Cognitive Behavioral Health evidence based approach","Assessment for Psychosocial Issues of Psychiatric Patients ","In DY4 and DY5, the provider will improve the percentage of individuals in the denominator whose medical record documents a psychosocial/developmental history over all individuals age 18 and older who undergo a psychiatric evaluation at the Central Assessment Facility","Facility ","Only patients in Central Assessment Facility","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",57470.944196666671,"Yes/No","RHP 10_126675104.3.101_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",57470.944196666671,"Yes/No","RHP 10_126675104.3.101_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",63754.224999999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",63754.23,"Numeric",6.8109720999999998E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",298541.62,"Numeric",0.117156578,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",1.9063E-2,131,6872,"March 1, 2014 - August 31, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"proxy",6.8109720999999998E-2,null,0.117156578,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The Cental Assessment Facility was not operational until 8/4/14 which would not have allowed enough time to collect six months worth of baseline data. With that in mind we requested and received approval to include our traditional outpatient individuals served in our behavioral health clinics in addition to these new facilities for this measure from 3/1/14 – 8/31/14 to get a better representation of data for these measures. After the baseline setting, the provider would then report their DY4 and DY5 achievement with their proposed facility subsets which were approved during the Category 3 feedback setting processes.  Without this proxy population, the provider would not have a full 6 months’ worth of data for their current subset denominator population.","Denominator: All individuals age 18 and older who undergo a psychiatric evaluation during the measurement period.\nNumerator: Number of individuals in the denominator whose medical record documents a psychosocial/developmental history.","Sum of Numerator / sum of denominator * 100","Assessment for Psychosocial Issues of Psychiatric Patients ","Ambulatory/Inpatient",null,"Number of individuals in the denominator whose medical record documents a psychosocial/developmental history.","All individuals age 18 and older who undergo a psychiatric evaluation during the measurement period.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.12.2","","Assessment for Psychosocial Issues of Psychiatric Patients ",null,null,null,null,null,"2014-09-01","2015-08-31","2015-09-01","2016-08-31","2014-03-01","2014-08-31",null,null,"RHP 10_126675104.1.100","RHP 10_126675104.3.101","RHP 10_126675104.1.100_126675104.3.101",{"$f":"COUNTIFS($FI$4:$FI191,FI191)","v":2},"RHP 10_126675104.1.100_2",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR191,FR191)","v":3},"RHP 10_126675104_3"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.1.100","126675104.3.102","IT-11.20","Bipolar Disorder and Major Depression: Assessment for Manic or hypomanic behaviors","Baseline Approved","Eligible to Report in October DY4","Create an anti-stigma campaign, a central information center staffed by behavioral health navigators, and supporting psychological first aid training throughout Tarrant County. It will improve access to behavioral health services by creating a central information center staffed by behavioral health navigators. Additionally, it will create a centralized behavioral health assessment and referral center to create a front door the JPS Behavioral Health system. Finally, it will reduce the psychological impact from exposure to trauma with particular emphasis on gun-related and violent events through counseling with particular emphasis on Trauma Informed Cognitive Behavioral Health evidence based approach","Bipolar Disorder and Major Depression: Assessment for Manic or hypomanic behaviors","In DY4 and DY5, the provider will report the percentage of patients treated for depression who were assessed, prior to treatment, for the presence of current and/or prior manic or hypomanic behaviors over all patients at the Central Assessment Facility 18 years of age or older with an initial diagnosis or new presentation/episode of depression AND Documentation of a diagnosis of depression. In DY5, the provider will improve the rate of Depression management: Screening and Treatment Plan for Clinical Depression (CMHC.6). ","Facility ","Only patients in Central Assessment Facility","P4R","CMHC.6","PM-8","Submission of Category 3 DY3 Status Report",57470.944196666671,"Yes/No","RHP 10_126675104.3.102_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",57470.944196666671,"Yes/No","RHP 10_126675104.3.102_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",127508.45127999999,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",149270.807871,"Yes/No","NA","AM-3.1","Achievement of DY5 performance goal for PFP measure",149270.807871,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"%",4.5619E-2,63,1381,"March 1, 2014 - August 31, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"proxy","P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The Cental Assessment Facility was not operational until 8/4/14 which would not have allowed enough time to collect six months worth of baseline data. With that in mind we requested and received approval to include our traditional outpatient individuals served in our behavioral health clinics in addition to these new facilities for this measure from 3/1/14 – 8/31/14 to get a better representation of data for these measures. After the baseline setting, the provider would then report their DY4 and DY5 achievement with their proposed facility subsets which were approved during the Category 3 feedback setting processes.  Without this proxy population, the provider would not have a full 6 months’ worth of data for their current subset denominator population.","Denominator: Number of patients 18 years of age or older with an initial diagnosis or new presentation/episode of depression.\nNumerator: Number of patients with documentation of an assessment that considers the presence or absence of current and/or prior symptoms or behaviors of mania or hypomania.\n","Sum of Numerator / sum of denominator * 100","Bipolar Disorder and Major Depression: Assessment for Manic or hypomanic behaviors","Ambulatory/Inpatient",null,"Number of patients with documentation of an assessment that considers the presence or absence of current and/or prior symptoms or behaviors of mania or hypomania.","Number of patients 18 years of age or older with an initial diagnosis or new presentation/episode of depression",null,null,null,null,null,null,null,null,null,null,null,"PFP baseline not yet reported",null,"1.12.2","","Bipolar Disorder and Major Depression: Assessment for Manic or hypomanic behaviors",null,null,null,null,null,"2014-09-01","2015-08-31","2015-09-01","2016-08-31","2014-03-01","2014-08-31",null,null,"RHP 10_126675104.1.100","RHP 10_126675104.3.102","RHP 10_126675104.1.100_126675104.3.102",{"$f":"COUNTIFS($FI$4:$FI192,FI192)","v":3},"RHP 10_126675104.1.100_3",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR192,FR192)","v":4},"RHP 10_126675104_4"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.1.2","126675104.3.3","IT-2.21","Ambulatory Care Sensitive Conditions Admissions Rate","Pending Approval","Eligible to Report in October DY4","Establish a 24/7 call center with nurse advice to direct patients to the right care at the right place and reduce ED admissions. ","Ambulatory Care Sensitive Conditions Admissions Rate","In DY4 and DY5, the provider will improve the rate of acute care hospitalizations for ambulatory care sensitive conditions out of all patients receiving care through the JPS System (ambulatory and inpatients) ages 18-75 years old. ","Facility","JPS System (inpatient and ambulatory)","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",307620.79077900003,"Yes/No","RHP 10_126675104.3.3_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",307620.79077900003,"Yes/No","RHP 10_126675104.3.3_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",341252.881452,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",341252.881452,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1597983.2800505999,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator was determined by the total number of acute care hospitalizations for ambulatory care sensitive conditions in patients younger than age 75 years. Demoninator was determined by the total mid-measurement period population younger than age 75.","During the period of 7/1/2013 through 6/30/2014, 8.19 percent of patients age 75 or younger who had an acute care hospitaliztion at JPS had a primary or secondary diagnosis of an ambulatory care sensitive condition.","Ambulatory Care Sensitive Conditions Admissions Rate","inpatient",null,"Total number of acute care hospitalizations for ambulatory care sensitive conditions younger than age 75 years ","Total mid-measurement period population younger than age 75",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.6.2 ","","Ambulatory Care Sensitive Conditions Admissions Rate",null,null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2013-07-01","2014-06-30",null,null,"RHP 10_126675104.1.2","RHP 10_126675104.3.3","RHP 10_126675104.1.2_126675104.3.3",{"$f":"COUNTIFS($FI$4:$FI193,FI193)","v":1},"RHP 10_126675104.1.2_1",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR193,FR193)","v":5},"RHP 10_126675104_5"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.1.2","126675104.3.4","IT-9.2","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","Baseline Approved","Eligible to Report in October DY4","Establish a 24/7 call center with nurse advice to direct patients to the right care at the right place and reduce ED admissions. ","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","In DY4 and DY5, the provider will improve the rate of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period over all ED visits for individuals 18 years or older during the measurement period",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",307620.79077900003,"Yes/No","RHP 10_126675104.3.4_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",307620.79077900003,"Yes/No","RHP 10_126675104.3.4_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",341252.88,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",341252.88,"Numeric",0.13754523499999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1597983.28,"Numeric",0.13030600000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.144784,14123,97545,"07/01/13 - 06/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.13754523499999999,null,0.13030600000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator includes any ED visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period. Denominator includes the total number of ED visits for individuals 18 years or older during the measurement period.","During the period of 7/1/2013 through 6/30/2014 14.48 percent of patients who presented at the JPS emergency department had a primary or secondary diagnosis of an ambulatory care sensitive condition.","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","ED",null,"Total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.6.2 ","","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ",null,null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2013-07-01","2014-06-30",null,null,"RHP 10_126675104.1.2","RHP 10_126675104.3.4","RHP 10_126675104.1.2_126675104.3.4",{"$f":"COUNTIFS($FI$4:$FI194,FI194)","v":2},"RHP 10_126675104.1.2_2",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR194,FR194)","v":6},"RHP 10_126675104_6"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.1.3","126675104.3.5","IT-1.12","Diabetes care: Retinal eye exam ","Baseline Approved","Eligible to Report in October DY4","To improve access to specialty care for a vulnerable population, JPS Health Network will recruit optometrists to be housed in our primary care clinics for more general eye exams and diagnoses such as hypertensive and diabetic eye exams, glaucoma care, red eye, dry eye and minor traumatic eye injuries. In addition, JPS Health Network will launch a Wound Care Center – an outpatient specialty currently not provided. JPS Health Network will recruit a medical director, a mid-level, and RN coordinator. The project also includes the development and implementation of a specialty care access plan for the 17 largest specialty clinics. As that plan is developed, six specialty clinics will be targeted for operational redesign to include referral standardization, enhancing operational efficiency and expanding hours of access to reduce 3rd next available appointment times.","Diabetes care: Retinal eye exam ","In DY4 and DY5, the provider will improve the percentage of patients who received an eye screening for diabetic retinal disease over all patients  assigned to a JPS primary care medical home (PCMH) 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year","Facility ","Patients assigned to a JPS primary care medical home (PCMH) 18 to 75 years old","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",94675.818597666686,"Yes/No","RHP 10_126675104.3.5_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",94675.818597666686,"Yes/No","RHP 10_126675104.3.5_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",105026.7,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",105026.7,"Numeric",0.45029999999999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",491808.03,"Numeric",0.47499000000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.44143199999999999,7409,16784,"07/01/13 - 06/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.45029999999999998,null,0.47499000000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator Description: Patients who received an eye screening for diabetes retinal disease. This includes diabetics who had the following:A retinal or dilated eye exam by an eye care professional (optometrist or opthalmologist) in the measurement year OR A negative retinal eye exam or dilated eye exam (negative for retinopathy) by an eye care professional in the year prior to the measurement year.\nNumerator Inclusions: Blindness is not an exclusion as it is difficult to distinguish between individuals who are legally blind but require retinal eye exam and those who are completely blind and therefore do not require an exam.\nNumerator Exclusions: Measure Steward does not identify any numerator exclusions.\nDenominator Description: Patients 18-75 years of age by the end of the measurement year who had a diagnosis of Diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.\nDenominator Inclusion: Patients 18 to 75 years of age as of month 12 of the measurement year with diabetes (type 1 and type 2). This data is obtained from the pharmacy and administrative data. The patient must have had at least one (1) outpatient encounterin the prior 12-month period.\nDenominator Exclusion: Patients with Polycystic ovaries, gestational diabetes, and/or steroid induced diabetes without a diagnosis of type 1 or type 2 diabetes and a face to face encounter in any setting during the measurement period. ","The percentage of patients 18-75 years of age with diabetes (type 1 and type 2)  who had retinal eye exams in the baseline period is 44.14%. ","Diabetes care: Retinal eye exam ","ambulatory",null,"Patients who received an eye screening for diabetic retinal disease. This includes diabetics who had the following:\n- A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year\n\nOR\n\n- A negative retinal exam or dilated eye exam (negative for retinopathy) by an eye care professional in the year prior to the measurement year.\n\nFor exams performed in the year prior to the measurement year, a result must be available.\n\n","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2 ","","Diabetes care: Retinal eye exam ",null,null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2013-07-01","2014-06-30",null,null,"RHP 10_126675104.1.3","RHP 10_126675104.3.5",{"$f":"A195&\"_\"&D195&\"_\"&E195","v":"RHP 10_126675104.1.3_126675104.3.5"},{"$f":"COUNTIFS($FI$4:$FI195,FI195)","v":1},{"$f":"FI195&\"_\"&FL195","v":"RHP 10_126675104.1.3_1"},null,2,1,1,{"$f":"A195&\"_\"&RIGHT(\"000000000\"&B195,9)","v":"RHP 10_126675104"},{"$f":"COUNTIFS($FR$4:$FR195,FR195)","v":7},"RHP 10_126675104_7"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.1.3","126675104.3.51","IT-6.2.b","Visit-Specific Satisfaction Instrument (VSQ-9)","Baseline Approved","Eligible to Report in October DY4","To improve access to specialty care for a vulnerable population, JPS Health Network will recruit optometrists to be housed in our primary care clinics for more general eye exams and diagnoses such as hypertensive and diabetic eye exams, glaucoma care, red eye, dry eye and minor traumatic eye injuries. In addition, JPS Health Network will launch a Wound Care Center – an outpatient specialty currently not provided. JPS Health Network will recruit a medical director, a mid-level, and RN coordinator. The project also includes the development and implementation of a specialty care access plan for the 17 largest specialty clinics. As that plan is developed, six specialty clinics will be targeted for operational redesign to include referral standardization, enhancing operational efficiency and expanding hours of access to reduce 3rd next available appointment times.","Visit-Specific Satisfaction Instrument (VSQ-9)","In DY4 and DY5, the provider will improve the average score on the Visit-Specific Satisfaction Instrument (VSQ-9) survey out of all surveys completed by patients receiving services through Optometry and wound care clinics","Facility ","Optometry and wound care clinics","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",94675.818597666686,"Yes/No","RHP 10_126675104.3.51_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",94675.818597666686,"Yes/No","RHP 10_126675104.3.51_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",105026.7,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",105026.7,"Numeric",84.067085950000006,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",491808.03,"Numeric",84.90566038,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",83.22851,397000,4770,"04/01/14 - 09/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,84.067085950000006,null,84.90566038,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator Description: Sum of all the \"overall score\" of all VSQ-9 surveys completed during the measurement period.\nNumerator Inclusions and Exclusions: The survey developer does not identify specific numerator inclusions/exclusions beyond what is described in the numerator description.\nDenominator Description: The total number VSQ-9 surveys completed during the measurement period. \nDenominator Inclusions and Exclusions: The survey developer does not identify specific denominator inclusions/exclusionsbeyond what is described in the denominator description.","Out of a possible 100% - VSQ completed survey results indicate patient satisfaction of 83.23% of the measured clinics.","Visit-Specific Satisfaction Instrument (VSQ-9)","Ambulatory",null,"Sum of all the \"overall score\" of all VSQ-9 surveys completed during the measurement period. ","The total number VSQ-9 surveys completed during the measurement period. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2 ","","Visit-Specific Satisfaction Instrument (VSQ-9)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,{"$f":"A196&\"_\"&D196","v":"RHP 10_126675104.1.3"},{"$f":"A196&\"_\"&E196","v":"RHP 10_126675104.3.51"},"RHP 10_126675104.1.3_126675104.3.51",{"$f":"COUNTIFS($FI$4:$FI196,FI196)","v":2},"RHP 10_126675104.1.3_2",null,2,{"$f":"IF(DC196=\"\",0,1)+IF(DG196=\"\",0,1)+IF(DK196=\"\",0,1)+IF(DO196=\"\",0,1)+IF(DS196=\"\",0,1)","v":1},1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR196,FR196)","v":8},{"$f":"FR196&\"_\"&FS196","v":"RHP 10_126675104_8"}]
["RHP 10","126675104","John Peter Smith Hospital","126675104.1.3","126675104.3.6","IT-5.2","Per Episode Cost of Care","Baseline Approved","Eligible to Report in October DY4","To improve access to specialty care for a vulnerable population, JPS Health Network will recruit optometrists to be housed in our primary care clinics for more general eye exams and diagnoses such as hypertensive and diabetic eye exams, glaucoma care, red eye, dry eye and minor traumatic eye injuries. In addition, JPS Health Network will launch a Wound Care Center – an outpatient specialty currently not provided. JPS Health Network will recruit a medical director, a mid-level, and RN coordinator. The project also includes the development and implementation of a specialty care access plan for the 17 largest specialty clinics. As that plan is developed, six specialty clinics will be targeted for operational redesign to include referral standardization, enhancing operational efficiency and expanding hours of access to reduce 3rd next available appointment times.","Per Episode Cost of Care","In DY4 and DY5, the provider will improve the Per episode cost of care measurement (including services involved in the diagnosis, management and treatment of specific clinical conditions) of wound care clinic patients","Comorbid Condition ","Targeted condition for wound care treatment","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",94675.818597666686,"Yes/No","RHP 10_126675104.3.6_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",94675.818597666686,"Yes/No","RHP 10_126675104.3.6_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",105026.7,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",105026.7,"Numeric",14192.468000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",491808.03,"Numeric",13445.496000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"$",14939.44,16418441,1099,"08/01/13 - 07/31/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,14192.468000000001,null,13445.496000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator Description: Total cost for episode of care. \nNumerator Inclusions and Exclusions: None\nDenominator Description: Total number of episodes during the measurement period. \nDenominator Inclusions and Exclusions: None","The average cost of care per visit with final diagnosis of wound care (ICD-9 707.xx) is $14,939. ","Per Episode Cost of Care","Multiple",null,"Total cost for episode of care","Total number of episodes during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2 ","","Per Episode Cost of Care",null,null,null,null,null,"2014-08-01","2015-07-31","2015-08-01","2016-07-31","2013-08-01","2014-07-31",null,null,"RHP 10_126675104.1.3","RHP 10_126675104.3.6","RHP 10_126675104.1.3_126675104.3.6",{"$f":"COUNTIFS($FI$4:$FI197,FI197)","v":3},"RHP 10_126675104.1.3_3",null,{"$f":"MAX(IF(AC197=\"\",0,1)+IF(AH197=\"\",0,1)+IF(AM197=\"\",0,1)+IF(AR197=\"\",0,1)+IF(AW197=\"\",0,1)+IF(BB197=\"\",0,1),IF(BG197=\"\",0,1)+IF(BL197=\"\",0,1)+IF(BQ197=\"\",0,1)+IF(BV197=\"\",0,1)+IF(CA197=\"\",0,1))","v":2},1,{"$f":"FO197-FP197","v":1},"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR197,FR197)","v":9},"RHP 10_126675104_9"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.1.4","126675104.3.7","IT-1.18","Follow-Up After Hospitalization for Mental Illness ","Baseline Approved","Eligible to Report in October DY4","This project ensures adequate access to needed services by expanding the number of community-based settings where behavioral health services are delivered. This project will establish a full continuum of care by creating Partial Hospitalization Programs (PHP) and Intensive Outpatient Programs (IOP) to expand treatment availability in our Region in a way that matches level of care with a patient’s needs and acuity","Follow-Up After Hospitalization for Mental Illness ","In DY4 and DY5, the provider will improve the percentage of individuals with an outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 7- and 30-days after discharge over all patients 6 years and older as of the date of discharge who were discharged alive from  Trinity Springs Pavilion to a JPS Behavioral Health Outpatient Clinic  with a principal diagnosis of mental illness during the first 11 months of the measurement year","Facility ","Only patients discharging from Trinity Springs Pavilion to a JPS Behavioral Health Outpatient Clinic for 7 or 30 day follow up","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",312157.97058400005,"Yes/No","RHP 10_126675104.3.7_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",312157.97058400005,"Yes/No","RHP 10_126675104.3.7_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",346286.10979199997,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- 7 day follow-up",173143.05489599999,"Numeric",0.18542819999999999,"AM-1.2","Achievement of DY4 performance goal- 30 day follow-up",173143.05489599999,"Numeric",0.31251755617977528,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- 7 day follow-up",810776.17748880002,"Numeric",0.22830039999999999,"AM-2.2","Achievement of DY5 performance goal- 30 day follow-up",810776.17748880002,"Numeric",0.34870084269662921,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"%",0.14255599999999999,406,2848,"07/01/13 - 06/30/14",0.27633426966292135,787,2848,"07/01/13 - 06/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0.18542819999999999,null,0.22830039999999999,null,0.31251755617977528,null,0.34870084269662921,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator: Patients 6 years and older as of the date of discharge who were discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal diagnosis of mental illness during the first 11 months of the measurement year.\nNumerator: \n30-Day Follow-Up:  An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner with 30 days after discharge.\n7-Day Follow-Up:  An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 7 days after discharge.\n","The percentage rate will be calculated by adding all the cases in the numerator and dividing it by all the cases in the denominator and multiplying the result by 100 to a percentage.","Follow-Up After Hospitalization for Mental Illness ","ambulatory",null,"Rate #1: 7-Day Follow-Up: An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 7 days after discharge. ","Patients 6 years and older as of the date of discharge who were discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal diagnosis of mental illness during the first 11 months of the measurement year. ","Rate #2: 30-Day Follow-Up: An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 30 days after discharge. ","Patients 6 years and older as of the date of discharge who were discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal diagnosis of mental illness during the first 11 months of the measurement year. ",null,null,null,null,null,null,null,null,null,null,null,"1.12.2","","7 day follow-up","30 day follow-up",null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2013-07-01","2014-06-30",null,null,"RHP 10_126675104.1.4","RHP 10_126675104.3.7","RHP 10_126675104.1.4_126675104.3.7",{"$f":"COUNTIFS($FI$4:$FI198,FI198)","v":1},"RHP 10_126675104.1.4_1",null,3,2,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR198,FR198)","v":10},"RHP 10_126675104_10"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.1.5","126675104.3.36","IT-4.2","Central line-associated bloodstream infections (CLABSI) rates ","Baseline Approved","Eligible to Report in April DY4","Erect and staff a continuous quality improvement infrastructure for JPS Health Network.  The infrastructure will include:  a) Governance and oversight structure for performance improvement initiatives; b) Centralized experts trained in Lean, Six Sigma, Rapid Cycle Improvement and Project Management; c) Resources to educate and expand internal capabilities in PI skills; d) Decision Support resources.","Central line-associated bloodstream infections (CLABSI) rates ","In DY4 and DY5, the provider will improve the percentage of cases of CLABSI as designated by IQR criteria over all patient events",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",136417.87280366669,"Yes/No","RHP 10_126675104.3.36_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",136417.87280366669,"Yes/No","RHP 10_126675104.3.36_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",151332.4,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",151332.4,"Numeric",0.62091503199999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",708643.52,"Numeric",0.58823499999999995,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",0.65359500000000004,21,32.130000000000003,"CY2013 (1): January 1, 2013- June 30, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.62091503199999998,null,0.58823499999999995,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator was determined by the total number of observed healh care associated CLABSI Events occuring in the qualifying areas during the selected baseline period.\nThe denominator was determined by the total number of expected CLABSI events, which is calculated by multiplying the number of central line device days for each location under surveillance for CLABSI during the selected baseline period by the CLABSI rate for the same types of loations obtained from the standard population. ","The SIR is calculated by summing the actual events and dividing by the NHSN calculated expected events. A ratio of 1 would mean that the number of events equaled the number of expected events. A ratio less than 1 represents performance better than expected, and a ratio greater than 1 represents performance worse than expected. The baseline ratio of 0.65 indicates a better than expected CLABSI rate.","Central line-associated bloodstream infections (CLABSI) rates ","inpatient",null,"Total number of observed healthcare-associated CLABSI among patients in ICUs, NICUs, SCAs and other acute care hospital locations where patients reside overnight.","Total number of expected CLABSIs ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.10.2","","Central line-associated bloodstream infections (CLABSI) rates ",null,null,null,null,null,"2013-07-01","2014-06-30","2014-07-01","2015-06-30","2013-01-01","2013-06-30",null,null,"RHP 10_126675104.1.5","RHP 10_126675104.3.36","RHP 10_126675104.1.5_126675104.3.36",{"$f":"COUNTIFS($FI$4:$FI199,FI199)","v":1},"RHP 10_126675104.1.5_1",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR199,FR199)","v":11},"RHP 10_126675104_11"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.1.5","126675104.3.37","IT-4.3","Catheter-associated Urinary Tract Infections (CAUTI) rates ","Baseline Approved","Eligible to Report in October DY4","Erect and staff a continuous quality improvement infrastructure for JPS Health Network.  The infrastructure will include:  a) Governance and oversight structure for performance improvement initiatives; b) Centralized experts trained in Lean, Six Sigma, Rapid Cycle Improvement and Project Management; c) Resources to educate and expand internal capabilities in PI skills; d) Decision Support resources.","Catheter-associated Urinary Tract Infections (CAUTI) rates ","In DY4 and DY5, the provider will improve the percentage of cases of CAUTI as designated by IQR criteria over all patient events",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",136417.87280366669,"Yes/No","RHP 10_126675104.3.37_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",136417.87280366669,"Yes/No","RHP 10_126675104.3.37_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",151332.4,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",151332.4,"Numeric",1.8485617599999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",708643.52,"Numeric",1.751269,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",1.945854,46,23.64,"CY 2014 (1): January 1, 2014 - June 30, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,1.8485617599999999,null,1.751269,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator was determined by the total number of observed healh care associated CAUTI Events occuring in the qualifying areas during the selected baseline period.\nThe denominator was determined by the total number of expected CAUTI events, which is calculated by multiplying the number of urinary catheter days for each location under surveillance for CAUTI during the selected baseline period by the CAUTI rate for the same types of loations obtained from the standard population.","The SIR is calculated by summing the actual events and dividing by the NHSN calculated expected events. A ratio of 1 would mean that the number of events equaled the number of expected events. A ratio less than 1 represents performance better than expected, and a ratio greater than 1 represents performance worse than expected. The baseline ratio of 1.95 indicates a higher than expected CAUTI rate.","Catheter-associated Urinary Tract Infections (CAUTI) rates ","inpatient",null,"Total number of observed healthcare-associated CAUTI among inpatients in ICUs, SCAs, and other inpatient locations.","Total number of expected CAUTIs ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.10.2","","Catheter-associated Urinary Tract Infections (CAUTI) rates ",null,null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2014-01-01","2014-06-30",null,null,"RHP 10_126675104.1.5","RHP 10_126675104.3.37","RHP 10_126675104.1.5_126675104.3.37",{"$f":"COUNTIFS($FI$4:$FI200,FI200)","v":2},"RHP 10_126675104.1.5_2",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR200,FR200)","v":12},"RHP 10_126675104_12"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.1.5","126675104.3.39","IT-4.5","Patient Fall Rate","Baseline Approved","Eligible to Report in April DY4","Erect and staff a continuous quality improvement infrastructure for JPS Health Network.  The infrastructure will include:  a) Governance and oversight structure for performance improvement initiatives; b) Centralized experts trained in Lean, Six Sigma, Rapid Cycle Improvement and Project Management; c) Resources to educate and expand internal capabilities in PI skills; d) Decision Support resources.","Patient Fall Rate","In DY4 and DY5, the provider will improve the percentage of patient falls (with or without injury to the patient and whether or not assisted by a staff member) by hospital unit during the calendar month over all patient days by hospital unit during the calendar month (Note: Rate is multiplied by 1000)",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",136417.87280366669,"Yes/No","RHP 10_126675104.3.39_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",136417.87280366669,"Yes/No","RHP 10_126675104.3.39_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",151332.39875600001,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- Total Falls",75666.199378000005,"Numeric",3.8108178050000001,"AM-1.2","Achievement of DY4 performance goal- Unassisted Falls",75666.199378000005,"Numeric",3.3600759999999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- Total Falls",354321.75973590004,"Numeric",3.6102479999999999,"AM-2.2","Achievement of DY5 performance goal- Unassisted Falls",354321.75973590004,"Numeric",3.18323,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"number per 1K",4.0113871635610767,186,46368,"CY2013 (1): January 1, 2013- June 30, 2013",3.5369220151828844,164,46368,"01/01/13 - 06/30/13",null,0,0,null,null,0,0,null,null,0,0,null,null,3.8108178050000001,null,3.6102479999999999,null,3.3600759999999998,null,3.18323,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator was determined by the total number of Fall Events occuring in the qualifying areas during the selected baseline period.\nThe denominator was determined by the total number of inpatient days for the eligible reporting units.","The results display the total fall and total unassisted fall rates per 1,000 inpatient stays. There are approximately 4 total falls for every 1,000 inpatient days, with 3.5 of the 4 total falls being unassisted.","Patient Fall Rate","inpatient",null,"Rate #1 (Total Falls): Total number of patient falls (with or without injury to the patient and whether or not assisted by a staff member) by hospital unit during the measurement period","Patient days by hospital unit ","Rate #2 (Total Unassisted Falls): Total number of patient falls (with or without injury to the patient) that were not not assisted by a staff member by hospital unit during the measurement period","Patient days by hospital unit ",null,null,null,null,null,null,null,null,null,null,null,"1.10.2","","Total Falls","Unassisted Falls",null,null,null,null,"2013-07-01","2014-06-30","2014-07-01","2015-06-30","2013-01-01","2013-06-30",null,null,"RHP 10_126675104.1.5","RHP 10_126675104.3.39","RHP 10_126675104.1.5_126675104.3.39",{"$f":"COUNTIFS($FI$4:$FI201,FI201)","v":3},"RHP 10_126675104.1.5_3",null,3,2,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR201,FR201)","v":13},"RHP 10_126675104_13"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.1","126675104.3.10","IT-1.10","Diabetes care: HbA1c poor control (>9.0%) ","Baseline Approved","Eligible to Report in October DY4","Improve diabetes clinical outcomes and self-management skills in a patient-centered medical home. This is a new intervention based on Wagner’s chronic care model interwoven into a new medical home setting. ","Diabetes care: HbA1c poor control (>9.0%) ","In DY4 and DY5, the provider will improve the percentage of patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year over all patients at all patients served in Patient Centered Medical Home (PCMH) clinics within the JPS network 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.","Facility ","all patients served in Patient Centered Medical Home (PCMH) clinics within the JPS network","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",356168.61469250004,"Yes/No","RHP 10_126675104.3.10_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",356168.61469250004,"Yes/No","RHP 10_126675104.3.10_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",395108.42499999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",395108.42,"Numeric",0.35121866000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1850172.38,"Numeric",0.34436099999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.35807600000000001,6083,16988,"07/01/13 - 06/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.35121866000000002,null,0.34436099999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The percentage of patients 18–75 years of age with diabetes (type 1 and type 2) who had\nwho had A1C greater than 9%.  DENOMINATOR:  1.1.1 Denominator Inclusion Criteria\nMonthly 7/1/2013 - 6/30/2014\no Have at least 1 completed office visit {encounter type 101 - office visit , 201 - nurse only, 2 -\nwalk in , or 2502 -follow-up & appt status 2 - completed or 2 - arrived} based on anchor date\nand\nDepartment_ID\n101005001 -- ARLINGTON (Sanford) CHC\n101006001 -- ARLINGTON FAMILY MEDICINE CHC\n101011001 -- CENTRAL ARLINGTON CHC\n101015001 -- DIAMOND HILL Northside) CHC\n101020001 -- FAMILY HEALTH CHC\n101023001 -- GRAND PRAIRIE CHC\n101030001 -- LIFE SPAN CLINIC\n101035001 -- ARLINGTON CHC\n101036001 -- NORTHWEST CHC\n101039001 -- POLYTECHNIC CHC\n101041001 -- CYPRESS CHC\n101042001 -- SOUTH CAMPUS CHC\n101043002 -- STOP SIX CHC\n101047002 -- VIOLA PITTS CLINIC\n101048001 -- WATAUGA G TARPLEY CHC.  o Patient Status is not deceased {patient status 2 - deceased} (and)\no Patient 18 and 75 years as of the anchor date and\no Have been identified as having diabetes during last 24 months from anchor date by any\nencounter data with a diagnosis of diabetes or\no Have been identified as having active diabetes in the problem list.  DENOMINATOR EXCLUSIONS:  1.1.2 Denominator Exclusion Criteria\no Patient with diagnosis of polycystic ovaries at any time in the member’s history, but must have\noccurred by anchor date. The member must not have a face-to-face encounter in any setting,\nwith a diagnosis of diabetes, during the measurement year or year prior to the measurement\nyear. or\no Patient with diagnosis of gestational or steroid-induced diabetes during the last 24 months\nfrom the anchor date. The member must not have a face-to-face encounter in any setting, with\na diagnosis of diabetes, during the measurement year or year prior to the measurement year.\nNote: The exclusion is applicable when we qualified patient through pharmacy data.","35.81% of the JPS DSRIP DIABETIC POPULATION have their most recent A1C value greater than 9.","Diabetes care: HbA1c poor control (>9.0%) ","ambulatory",null,"Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.2 ","","Diabetes care: HbA1c poor control (>9.0%) ",null,null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2013-07-01","2014-06-30",null,null,"RHP 10_126675104.2.1","RHP 10_126675104.3.10","RHP 10_126675104.2.1_126675104.3.10",{"$f":"COUNTIFS($FI$4:$FI202,FI202)","v":1},"RHP 10_126675104.2.1_1",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR202,FR202)","v":14},"RHP 10_126675104_14"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.1","126675104.3.11","IT-1.11","Diabetes care:  BP control (<140/90mm Hg) ","Baseline Approved","Eligible to Report in October DY4","Improve diabetes clinical outcomes and self-management skills in a patient-centered medical home. This is a new intervention based on Wagner’s chronic care model interwoven into a new medical home setting. ","Diabetes care:  BP control (<140/90mm Hg) ","In DY4 and DY5, the provider will improve the percentage of patients whose most recent BP reading is <140/90 mm Hg during the measurement year over all patients at all patients served in Patient Centered Medical Home (PCMH) clinics within the JPS network 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.","Facility ","all patients served in Patient Centered Medical Home (PCMH) clinics within the JPS network","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",356168.61469250004,"Yes/No","RHP 10_126675104.3.11_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",356168.61469250004,"Yes/No","RHP 10_126675104.3.11_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",395108.42499999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",395108.42,"Numeric",0.68506444099999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1850172.38,"Numeric",0.69276800000000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.67735999999999996,11507,16988,"07/01/13 - 06/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.68506444099999997,null,0.69276800000000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The percentage of patients 18–75 years of age with diabetes (type 1 and type 2) who had\nwho had BP < 140/90.  DENOMINATOR:  1.1.1 Denominator Inclusion Criteria\nMonthly 7/1/2013 - 6/30/2014\no Have at least 1 completed office visit {encounter type 101 - office visit , 201 - nurse only, 2 -\nwalk in , or 2502 -follow-up & appt status 2 - completed or 2 - arrived} based on anchor date\nand\nDepartment_ID\n101005001 -- ARLINGTON (Sanford) CHC\n101006001 -- ARLINGTON FAMILY MEDICINE CHC\n101011001 -- CENTRAL ARLINGTON CHC\n101015001 -- DIAMOND HILL Northside) CHC\n101020001 -- FAMILY HEALTH CHC\n101023001 -- GRAND PRAIRIE CHC\n101030001 -- LIFE SPAN CLINIC\n101035001 -- ARLINGTON CHC\n101036001 -- NORTHWEST CHC\n101039001 -- POLYTECHNIC CHC\n101041001 -- CYPRESS CHC\n101042001 -- SOUTH CAMPUS CHC\n101043002 -- STOP SIX CHC\n101047002 -- VIOLA PITTS CLINIC\n101048001 -- WATAUGA G TARPLEY CHC.  o Patient Status is not deceased {patient status 2 - deceased} (and)\no Patient 18 and 75 years as of the anchor date and\no Have been identified as having diabetes during last 24 months from anchor date by any\nencounter data with a diagnosis of diabetes or\no Have been identified as having active diabetes in the problem list.  DENOMINATOR EXCLUSIONS:  1.1.2 Denominator Exclusion Criteria\no Patient with diagnosis of polycystic ovaries at any time in the member’s history, but must have\noccurred by anchor date. The member must not have a face-to-face encounter in any setting,\nwith a diagnosis of diabetes, during the measurement year or year prior to the measurement\nyear. or\no Patient with diagnosis of gestational or steroid-induced diabetes during the last 24 months\nfrom the anchor date. The member must not have a face-to-face encounter in any setting, with\na diagnosis of diabetes, during the measurement year or year prior to the measurement year.\nNote: The exclusion is applicable when we qualified patient through pharmacy data.","67.74% of the JPS DIABETES DSRIP population have their most recent  blood pressure value less than 140/90.","Diabetes care:  BP control (<140/90mm Hg) ","ambulatory",null,"Patients whose most recent BP reading is <140/90 mm Hg during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.2 ","","Diabetes care:  BP control (<140/90mm Hg) ",null,null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2013-07-01","2014-06-30",null,null,"RHP 10_126675104.2.1","RHP 10_126675104.3.11","RHP 10_126675104.2.1_126675104.3.11",{"$f":"COUNTIFS($FI$4:$FI203,FI203)","v":2},"RHP 10_126675104.2.1_2",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR203,FR203)","v":15},"RHP 10_126675104_15"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.10","126675104.3.32","IT-1.10","Diabetes care: HbA1c poor control (>9.0%) ","Baseline Approved","Eligible to Report in October DY4","Increase access to primary and specialty care services, and improve quality outcomes for the residually uninsured Tarrant County residents through care coordinators, expanded primary care and specialty services, and improved information sharing with JPS Health Network collaborative partners.  The project will also improve care transitions to identify and navigate patients at risk for reducing potentially preventable emergency department (ED) visits and hospital re-admissions to more appropriate and effective settings.","Diabetes care: HbA1c poor control (>9.0%) ","In DY4 and DY5, the provider will improve the percentage of patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year over all patients seen at Mission Arlington, North Texas Area Community Health Centers and Cornerstone community clinics, 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.","Facility ","Mission Arlington, North Texas Area Community Health Centers and Cornerstone community clinics","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",50362.69583550001,"Yes/No","RHP 10_126675104.3.32_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",50362.69583550001,"Yes/No","RHP 10_126675104.3.32_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",55868.834999999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",55868.83,"Numeric",0.50700000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",261616.73,"Numeric",0.48525000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.63279799999999997,1339,2116,"07/01/13 - 06/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.50700000000000001,null,0.48525000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The reported cases were determined using  the established Hedis measures for HbA1c values to identify patients seen at the above approved facilities.  ","JPS used the total number of identified diabetic patients at the clinics compared to the number of diabetic patients with HbA1c measures >=9 or did not have a documented HbA1c value during the measurement period. ","Diabetes care: HbA1c poor control (>9.0%) ","ambulatory",null,"Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.12.1","","Diabetes care: HbA1c poor control (>9.0%) ",null,null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2013-07-01","2014-06-30",null,null,"RHP 10_126675104.2.10","RHP 10_126675104.3.32","RHP 10_126675104.2.10_126675104.3.32",{"$f":"COUNTIFS($FI$4:$FI204,FI204)","v":1},"RHP 10_126675104.2.10_1",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR204,FR204)","v":16},"RHP 10_126675104_16"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.10","126675104.3.33","IT-3.22","Risk Adjusted All-Cause Readmission","Pending Approval","Eligible to Report in October DY4","Increase access to primary and specialty care services, and improve quality outcomes for the residually uninsured Tarrant County residents through care coordinators, expanded primary care and specialty services, and improved information sharing with JPS Health Network collaborative partners.  The project will also improve care transitions to identify and navigate patients at risk for reducing potentially preventable emergency department (ED) visits and hospital re-admissions to more appropriate and effective settings.","Risk Adjusted All-Cause Readmission","In DY4 and DY5, provider will improve the ratio of observed to expected readmissions that occur within 30 days following discharge from an index admission for any reason for those patients whose payer status is 'Self-Pay' and 18 years and older.","Payer ","Self Pay Population","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",50362.69583550001,"Yes/No","RHP 10_126675104.3.33_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",50362.69583550001,"Yes/No","RHP 10_126675104.3.33_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",55868.834574,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",55868.834574,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",261616.73168970001,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"JPS Hospital is using an Indirect Standardization model using vendor provided normative data.  Data reported by the Dallas/ Fort Worth Hospital Council (DFWHC) is reported by APR DRG, SOI, and age >= 85. All inpatient discharges from 70 hospitals in North Texas have been included in the normative data set.\n\nStep 1.  All eligible Index Admission cases are identified \n\nStep 2.  Individual index cases are categorized by APR DRG, SOI, and age > = 85\n\nStep 3.  All Index Admissions that resulted in a readmission within 30 days of discharge are flagged as an Observed Readmission.\n\nStep 4.  The Observed Readmission Rate is calculated by dividing the number of actual readmissions from step 3 by the number of Index Admissions from step 1.\n\nStep 5.  Using DFWHC data, the expected rate of readmission for each index admission is determined.  A value is assigned to each eligible Index admission of the likelihood to be readmitted based on matching APR DRG, SOI, and age >= 85 in the normative data set.\n\nStep 6.  Calculate the Expected number of readmission by summing the values of step 5 for all Index Admissions.\n\nStep 7.  Calculate the Expected Readmission Rate by dividing the number of Expected Readmissions in Step 6 by the number of Index Admissions from step 1.\n\nStep 8. Calculate the Risk Adjusted Readmission Rate by dividing the Observed Readmission Rate from step 4 by the Expected Readmission Rate from step 7 to determine the Observed to Expected Ratio.\nJPS Hospital is using an Indirect Standardization model using vendor provided normative data.  Data reported by the Dallas/ Fort Worth Hospital Council (DFWHC) is reported by APR DRG, SOI, and age >= 85. All inpatient discharges from 70 hospitals in North Texas have been included in the normative data set.\n\nStep 1.  All eligible Index Admission cases are identified \n\nStep 2.  Individual index cases are categorized by APR DRG, SOI, and age > = 85\n\nStep 3.  All Index Admissions that resulted in a readmission within 30 days of discharge are flagged as an Observed Readmission.\n\nStep 4.  The Observed Readmission Rate is calculated by dividing the number of actual readmissions from step 3 by the number of Index Admissions from step 1.\n\nStep 5.  Using DFWHC data, the expected rate of readmission for each index admission is determined.  A value is assigned to each eligible Index admission of the likelihood to be readmitted based on matching APR DRG, SOI, and age >= 85 in the normative data set.\n\nStep 6.  Calculate the Expected number of readmission by summing the values of step 5 for all Index Admissions.\n\nStep 7.  Calculate the Expected Readmission Rate by dividing the number of Expected Readmissions in Step 6 by the number of Index Admissions from step 1.\n\nStep 8. Calculate the Risk Adjusted Readmission Rate by dividing the Observed Readmission Rate from step 4 by the Expected Readmission Rate from step 7 to determine the Observed to Expected Ratio.\nJPS Hospital is using an Indirect Standardization model using vendor provided normative data.  Data reported by the Dallas/ Fort Worth Hospital Council (DFWHC) is reported by APR DRG, SOI, and age >= 85. All inpatient discharges from 70 hospitals in North Texas have been included in the normative data set.\n\nStep 1.  All eligible Index Admission cases are identified \n\nStep 2.  Individual index cases are categorized by APR DRG, SOI, and age > = 85\n\nStep 3.  All Index Admissions that resulted in a readmission within 30 days of discharge are flagged as an Observed Readmission.\n\nStep 4.  The Observed Readmission Rate is calculated by dividing the number of actual readmissions from step 3 by the number of Index Admissions from step 1.\n\nStep 5.  Using DFWHC data, the expected rate of readmission for each index admission is determined.  A value is assigned to each eligible Index admission of the likelihood to be readmitted based on matching APR DRG, SOI, and age >= 85 in the normative data set.\n\nStep 6.  Calculate the Expected number of readmission by summing the values of step 5 for all Index Admissions.\n\nStep 7.  Calculate the Expected Readmission Rate by dividing the number of Expected Readmissions in Step 6 by the number of Index Admissions from step 1.\n\nStep 8. Calculate the Risk Adjusted Readmission Rate by dividing the Observed Readmission Rate from step 4 by the Expected Readmission Rate from step 7 to determine the Observed to Expected Ratio.\n","The baseline O/E ratio is 0.87.  The observed rate from JPS to JPS only readmissions is 13% less than the expected rated across all hospitals in the DFW Hospital Council region for similar patients.","Risk Adjusted All-Cause Readmission","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk admissions during the measurement period.","Expected (risk-adjusted) rate of readmissions for all-causes during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.12.1","","Risk Adjusted All-Cause Readmission",null,null,null,null,"Dallas/Fort Worth Hospital Council","2014-07-01","2015-06-30","2015-07-01","2016-06-30","2013-07-01","2014-06-30",null,null,"RHP 10_126675104.2.10","RHP 10_126675104.3.33","RHP 10_126675104.2.10_126675104.3.33",{"$f":"COUNTIFS($FI$4:$FI205,FI205)","v":2},"RHP 10_126675104.2.10_2",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR205,FR205)","v":17},"RHP 10_126675104_17"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.100","126675104.3.103","IT-8.16","Any Breastfeeding at 6 Months","Baseline Approved","Eligible to Report in October DY4","Provide resources and education for expectant, and recently delivered, mothers regarding the health and financial benefits of breastfeeding. The intervention will use both human resources and technological resources to accomplish project goals. Home visits and outpatient lactation visits will be provided which is a new intervention for JPS Health Network","Any Breastfeeding at 6 Months","In DY4 and DY5, the provider will report the rate of caregivers of children born in a cohort year at JPS who indicate their child was breastfed any amount at 6 months of age over all children born in the same cohort year at JPS. In DY5, the provider will demonstrate improvement on Timeliness of Prenatal and Postnatal Care (PP.9). ","Facility ","Number of children born at JPS in the same cohort year.","P4R","PP.9","PM-8","Submission of Category 3 DY3 Status Report",81971.715143666675,"Yes/No","RHP 10_126675104.3.103_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",81971.715143666675,"Yes/No","RHP 10_126675104.3.103_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",181867.31735200001,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",212907.31017390001,"Yes/No","NA","AM-3.1","Achievement of DY5 performance goal for PFP measure",212907.31017390001,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"%",0.47115400000000002,49,104,"CY 2014 (1): January 1, 2014 - June 30, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Our denominator was determined by narrowing our scope from the total number of babies born between 1/1/14-6/30/14 to 9 clinics where babies and newborns are seen to babies that had at least 3 visits in 6 months following their birth. Our numerator was determined by reporting the number of babies that were being fed any breastmilk at their 6 month wellness visit. ","During the measurement period 1/1/14-6/30/14, we found that 47.1% of babies born at JPS had received breast milk at least once during their 6 month wellness visit. ","Any Breastfeeding at 6 Months","ambulatory",null,"Number of caregivers of children born in a cohort year who indicate their child was breastfed any amount at 6 months of age\n\n","Number of children born in the same cohort year.\n",null,null,null,null,null,null,null,null,null,null,null,"PFP baseline not yet reported",null,"2.6.1","","Any Breastfeeding at 6 Months",null,null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2014-01-01","2014-06-30",null,null,"RHP 10_126675104.2.100","RHP 10_126675104.3.103","RHP 10_126675104.2.100_126675104.3.103",{"$f":"COUNTIFS($FI$4:$FI206,FI206)","v":1},"RHP 10_126675104.2.100_1",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR206,FR206)","v":18},"RHP 10_126675104_18"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.100","126675104.3.104","IT-8.18","Rate of Exclusive Breastfeeding","Baseline Approved","Eligible to Report in October DY4","Provide resources and education for expectant, and recently delivered, mothers regarding the health and financial benefits of breastfeeding. The intervention will use both human resources and technological resources to accomplish project goals. Home visits and outpatient lactation visits will be provided which is a new intervention for JPS Health Network","Rate of Exclusive Breastfeeding","In DY4 and DY5, the provider will improve the percentage of newborns exclusively fed breast milk feeding during the newborn´s entire hospitalization and a second rate, a subset of the first, which includes only those newborns whose mothers chose to exclusively feed breast milk over all single term newborns discharged alive from the hospital (second rate: Single term newborns discharged alive from the hospital excluding those whose mothers chose not to breast feed)",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",81971.715143666675,"Yes/No","RHP 10_126675104.3.104_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",81971.715143666675,"Yes/No","RHP 10_126675104.3.104_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",90933.66,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- % exclusive breastfeeding for all newborns",45466.83,"Numeric",0.44426048600000001,"AM-1.2","Achievement of DY4 performance goal- % exclusive breastfeeding for all newborns whose mothers chose to exclusively feed breast milk ",45466.83,"Numeric",0.76155399999999995,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- % exclusive breastfeeding for all newborns",212907.31,"Numeric",0.47350999999999999,"AM-2.2","Achievement of DY5 performance goal- % exclusive breastfeeding for all newborns whose mothers chose to exclusively feed breast milk ",212907.31,"Numeric",0.77410400000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"%",0.41501100000000002,188,453,"07/01/13 - 06/30/14",0.749004,188,251,"07/01/13 - 06/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0.44426048600000001,null,0.47350999999999999,null,0.76155399999999995,null,0.77410400000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator was determined by identifying the number of patients that were exclusively breastfeeding during their entire hospitalization and the denominator was determined by taking a sampling of total births at JPS from Midas.  ","During the measurement period, July 1, 2013-June 30, 2014, 41.5% of babies born at JPS were exclusively fed breastmilk during their hospitalization and 74.9% of mother's who had a baby at JPS established their infant feeding plan prior to discharge. When establishing the infant's feeding plan, staff educates the patient about the benefits of breastfeeding, the risks associated with formula feeding and documents the infant feeding plan in the EMR. ","Rate of Exclusive Breastfeeding","Inpatient",null,"Rate #1: Newborns that were fed breast milk only since birth.\n","Rate #1: Single term liveborn newborns discharged from the hospital with ICD-9-CM Principal Diagnosis Code for single liveborn newborn ","Rate #2: Newborns that were fed breast milk only since birth.","Rate #2: Single term newborns discharged alive from the hospital excluding those whose mothers chose not to breast feed with ICD-9-CM Principal Diagnosis Code for single liveborn newborn ",null,null,null,null,null,null,null,null,null,null,null,"2.6.1","","all newborns","all newborns whose mothers opted to breast feed",null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2013-07-01","2014-06-30",null,null,"RHP 10_126675104.2.100","RHP 10_126675104.3.104","RHP 10_126675104.2.100_126675104.3.104",{"$f":"COUNTIFS($FI$4:$FI207,FI207)","v":2},"RHP 10_126675104.2.100_2",null,3,2,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR207,FR207)","v":19},"RHP 10_126675104_19"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.100","126675104.3.105","IT-8.14","Exclusive Breastfeeding at 3 Months ","Baseline Approved","Eligible to Report in October DY4","Provide resources and education for expectant, and recently delivered, mothers regarding the health and financial benefits of breastfeeding. The intervention will use both human resources and technological resources to accomplish project goals. Home visits and outpatient lactation visits will be provided which is a new intervention for JPS Health Network","Exclusive Breastfeeding at 3 Months ","In DY4 and DY5, the provider will report the percentage of caregivers of children born in a cohort year at JPS who indicate their child was exclusively breastfed (given nothing but breast milk) through 3 months of age over all children born in the same cohort year at JPS.  In DY5, the provider will demonstrate improvement on Timeliness of Prenatal and Postnatal Care (PP.9). ","Facility ","Number of children born at JPS during the same cohort year. ","P4R","PP.9","PM-8","Submission of Category 3 DY3 Status Report",81971.715143666675,"Yes/No","RHP 10_126675104.3.105_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",81971.715143666675,"Yes/No","RHP 10_126675104.3.105_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",181867.31735200001,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",212907.31017390001,"Yes/No","NA","AM-3.1","Achievement of DY5 performance goal for PFP measure",212907.31017390001,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"%",0.269231,28,104,"CY 2014 (1): January 1, 2014 - June 30, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Our denominator were determined by narrowing our scope from the total number of babies born between 1/1/14-6/30/14 to 9 clinics where babies and newborns are seen to babies that had at least 3 visits in 6 months following their birth. Our numerator was determined by reporting the number of 3 month old babies that were being exclusively fed breastmilk at their 4 month wellness visit. ","During the measurement period January 1, 2014-June 30, 2014, we found that 26.9% of babies born at JPS were being exclusively fed breast milk during their 4 month wellness visit. We used the 4 month wellness visit to establish our baseline because there is no 3 month wellness visit, however, the 26.9% relfects 3 month old babies that were exclusively being fed breastmilk. ","Exclusive Breastfeeding at 3 Months ","ambulatory",null,"Number of caregivers of children born in a cohort year who indicate their child was exclusively breastfed (given nothing but breast milk) through 3 months of age.","Number of children born in the same cohort year.",null,null,null,null,null,null,null,null,null,null,null,"PFP baseline not yet reported",null,"2.6.1","","Exclusive Breastfeeding at 3 Months ",null,null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2014-01-01","2014-06-30",null,null,"RHP 10_126675104.2.100","RHP 10_126675104.3.105","RHP 10_126675104.2.100_126675104.3.105",{"$f":"COUNTIFS($FI$4:$FI208,FI208)","v":3},"RHP 10_126675104.2.100_3",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR208,FR208)","v":20},"RHP 10_126675104_20"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.101","126675104.3.107","IT-8.12","Pre-term birth rate ","Baseline Approved","Eligible to Report in October DY4","The Preconception/Interconception (PI) Care approach will focus on linking low income women in Tarrant County who may be at risk for unintended pregnancies. Efforts must be made to shift our focus from prenatal and infant care to a broader emphasis on overall women’s health.  Medical services will be provided at our JPS Health Center for Women Clinics and other JPS Clinics providing prenatal services and will be inclusive of: reproductive health services, contraceptive services, primary care services and chronic disease management.","Pre-term birth rate ","In DY4 and DY5, the provider will improve the percentage of term singleton live births delivered with less than 37 completed weeks of gestation over all births at JPS","Facility ","Our denominator subset will be total # of births at JPS.  ","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",180579.75623900004,"Yes/No","RHP 10_126675104.3.107_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",180579.75623900004,"Yes/No","RHP 10_126675104.3.107_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",200322.49,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",200322.49,"Numeric",8.0968143000000006E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",938049.18,"Numeric",7.6706999999999997E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",8.523E-2,412,4834,"07/01/13 - 06/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,8.0968143000000006E-2,null,7.6706999999999997E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Our denominator was determined by reporting the total number of all live births at JPS between 7/1/13-6/30/14 and our numerator was determined by reporting the number of singleton live births delivered with less than 37 completed weeks of gestation. ","For the measurement period 7/1/13-6/30/14, 8.52% of babies born at JPS were delievered with less than 37 completed weeks of gestation. ","Pre-term birth rate ","Multiple",null,"Number of singleton livebirths delivered with less than 37 completed weeks of gestation. \n","All live births. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.6.1","","Pre-term birth rate ",null,null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2013-07-01","2014-06-30",null,null,"RHP 10_126675104.2.101","RHP 10_126675104.3.107","RHP 10_126675104.2.101_126675104.3.107",{"$f":"COUNTIFS($FI$4:$FI209,FI209)","v":1},"RHP 10_126675104.2.101_1",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR209,FR209)","v":21},"RHP 10_126675104_21"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.102","126675104.3.109","IT-3.22","Risk Adjusted All-Cause Readmission","Baseline Approved","Eligible to Report in October DY4","This project will address the need for access to, and coordination of, care for Medicaid and uninsured individuals who need long-term care.  It will create partnerships between JPS Health Network (537 acute beds and 15 SNF beds) and Medicaid long-term care providers within Tarrant County so that care may be provided in an appropriate setting","Risk Adjusted All-Cause Readmission","In DY4 and DY5, provider will improve the ratio of observed to expected readmissions that occur within 30 days following discharge from an index admission for any reason from JPS to a long term care facility for patients 18 years and older. ","Facility ","JPS patients discharged to long-term care facilities based on their index discharge disposition within the defined reporting timeframe. ","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",223682.96438650001,"Yes/No","RHP 10_126675104.3.109_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",223682.96438650001,"Yes/No","RHP 10_126675104.3.109_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",248138.155,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",248138.16,"Numeric",0.58154205599999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1161955.3899999999,"Numeric",0.55093499999999995,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",0.61214999999999997,0.13100000000000001,0.214,"07/01/13 - 06/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.58154205599999997,null,0.55093499999999995,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator value (observed rate) is the total number of admissions (index stay) in the denominator population with at least one subsequent readmission (hospital stay) for any reason within 30 days of discharge during the measurement year divided by the  number of index admissions of acute care inpatient encounters during the meausrement year for patients 18 years and older.  The denominator value (expected rate) was determined using an Indirect Standardization model using vendor provided normative data.  Data reported by the Dallas/Fort Worth Hospital Council (DFWHC) is reported by APR DRG, SOI, and age > = 85. All inpatient discharges from 70 hospitals in North Texas have been included in the normative data set. Step 1: All eligible Index Admission cases are identified. Step 2: Individual index cases are categorized by APR DRG, SOI, and age > = 85. Step 3. All Index Admissions that resulted in a readmission within 30 days of discharge are flagged as an Observed Readmission. Step 4: The Observed Readmission Rate is calculated by dividing the number of actual readmissions from Step 3 by the number of Index Admissions from step 1. Step 5. Using DFWHC data, the expected rate of readmission for each index admission is determined. A value is assigned to each eligible Index admission of the likelihood to be readmitted based on matching APR DRG, SOI, and age > = 85 in the normative data set. Step 6: Calculate the Expected number of readmissions by summing the values of step 5 for all Index Admissions. Step 7: Calculate the Expected Readmission Rate by dividing the number of Expected Readmissions in Step 6 by the number of Index Admissions from step 1. Step 8: Calculate the Risk Adjusted Readmission Rate by dividing the Observed Readmission Rate from step 4 by the Expected Readmission Rate from step 7 to determine the Observed to Expected Ratio.  ","The baseline number represents the ratio of Observed rate of readmissions (13.1%) divided by Expected rate of readmissions (21.4%).  The timeframe represented is 7/1/2013 - 6/30/2014 for all payers for the Observed rate and January 1, 2013 – December 31, 2013 for the Expected rate.  ","Risk Adjusted All-Cause Readmission","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk admissions during the measurement period.","Expected (risk-adjusted) rate of readmissions for all-causes during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.12.1","","Risk Adjusted All-Cause Readmission",null,null,null,null,"DFW Hospital Council All Cause \nReadmission data for 70 hospitals in North Texas\n","2014-07-01","2015-06-30","2015-07-01","2016-06-30","2013-07-01","2014-06-30",null,null,"RHP 10_126675104.2.102","RHP 10_126675104.3.109","RHP 10_126675104.2.102_126675104.3.109",{"$f":"COUNTIFS($FI$4:$FI210,FI210)","v":1},"RHP 10_126675104.2.102_1",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR210,FR210)","v":22},"RHP 10_126675104_22"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.102","126675104.3.110","IT-12.4","Pneumonia vaccination status for older adults ","Baseline Approved","Eligible to Report in October DY4","This project will address the need for access to, and coordination of, care for Medicaid and uninsured individuals who need long-term care.  It will create partnerships between JPS Health Network (537 acute beds and 15 SNF beds) and Medicaid long-term care providers within Tarrant County so that care may be provided in an appropriate setting","Pneumonia vaccination status for older adults ","In DY4 and DY5, the provider will improve the percentage of inpatient discharges who were screened for PPV23 status and received PPV23 prior to discharge if indicated over all inpatient discharges 65 years of age and older and 6-64 years of age who have a high risk condition",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",223682.96438650001,"Yes/No","RHP 10_126675104.3.110_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",223682.96438650001,"Yes/No","RHP 10_126675104.3.110_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",248138.155,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",248138.16,"Numeric",0.8013673,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1161955.3899999999,"Numeric",0.80343759999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.79929700000000004,1820,2277,"07/01/13 - 06/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.8013673,null,0.80343759999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator Desrciption: The number of patients who responded “Yes” or “No” to the question “Have you ever had a pneumonia shot? This shot is usually given only once or twice in a person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.”\n\nDenominator Inclusions: Eligible Population: Patients 65 years of age and older as of January 1 (July 1, 2013) start of the measurement year (July 1, 2013- June 30, 2014) period with at least one encounter in the 12-month period prior to the measurement year (July 1, 2013- June 30, 2014) period.\n\nDenominator Exclusions: Patients with documentation of medical reason(s) for not ever receiving pneumococcal vaccination. Exclusion from denominator population only applied if patient did not ever receive a pneumococcal immunization.\n\nNumerator Description: The number of patients in the denominator who responded “Yes” to the question “Have you ever had a pneumonia shot? This shot is usually given only once or twice in the person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.”\n\nNumerator Inclusion: N/A\n\nNumerator Exclusion: N/A","The baseline rate, 80%, represents 1,820 vaccines administered out of a total of 2,277 patients indicated to receive the vaccine. The timeframe represented is 7/1/2013 - 6/30/2014 for all payers. ","Pneumonia vaccination status for older adults ","Ambulatory/Inpatient",null,"The number of patients in the denominator who responded “Yes” to the question “Have you ever had a pneumonia shot? This shot is usually given only once or twice in the person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.”","The number of patients who responded “Yes” or “No” to the question “Have you ever had a pneumonia shot? This shot is usually given only once or twice in a person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.” ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.12.1","","Pneumonia vaccination status for older adults ",null,null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2013-07-01","2014-06-30",null,null,"RHP 10_126675104.2.102","RHP 10_126675104.3.110","RHP 10_126675104.2.102_126675104.3.110",{"$f":"COUNTIFS($FI$4:$FI211,FI211)","v":2},"RHP 10_126675104.2.102_2",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR211,FR211)","v":23},"RHP 10_126675104_23"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.104","126675104.3.114","IT-11.27","Vocational Rehabilitation for Schizophrenia ","Baseline Approved","Eligible to Report in October DY4","Deliver community based behavioral health services targeted to individuals in Tarrant County with serious mental illness and concomitant circumstances such as chronic physical health conditions, chronic or intermittent homelessness, cognitive issues resulting from severe mental illness, or forensic involvement","Vocational Rehabilitation for Schizophrenia ","In DY4 and DY5, the provider will improve the percentage of individuals in the denominator who: i) report participating in a program to help them find a job or vocational rehabilitation is prescribed in their treatment plan; or ii) report receiving assistance from an employment specialist over all individuals at the Psychiatric Rehab Facility, 18 years or older, in active treatment for schizophrenia who at a specified point in time: i) report in a survey that they are currently employed and they have a prior work history or are actively looking for a job; or ii) are currently employed","Facility ","Only patients in Psych Rehab Facility (Name TBD)","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",36297.438440000005,"Yes/No","RHP 10_126675104.3.114_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",36297.438440000005,"Yes/No","RHP 10_126675104.3.114_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",40265.824999999997,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",40265.824999999997,"Numeric",0.159615384,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",188552.6,"Numeric",0.203846154,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.115385,3,26,"March 1, 2014 - August 31, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"proxy",0.159615384,null,0.203846154,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The Psychiatric Day Rehabilitation Facility was not operational until 8/4/14 which would not have allowed enough time to collect six months worth of baseline data. With that in mind we requested and received approval to include our traditional outpatient individuals served in our behavioral health clinics in addition to these new facilities for this measure from 3/1/14 – 8/31/14 to get a better representation of data for these measures. After the baseline setting, the provider would then report their DY4 and DY5 achievement with their proposed facility subsets which were approved during the Category 3 feedback setting processes.  Without this proxy population, the provider would not have a full 6 months’ worth of data for their current subset denominator population.","Denominator: Individuals, 18 years or older, in active treatment for schizophrenia who at a specified point in time:  i) report in a survey that they are currently employed and they have a prior work history or are actively looking for a job; or ii) are currently employed.\nNumerator: Those individuals in the denominator who:  i) report participating in a program to help them find a job or vocational rehabilitation is prescribed in their treatment plan; or ii) report receiving assistance from an employment specialist.","Sum of numerator / sum of denominator * 100","Vocational Rehabilitation for Schizophrenia ","ambulatory",null,"Individuals in the denominator who: \ni) Report participating in a program to help them find a job or vocational rehabilitation is prescribed in their treatment plan; or \nii) Report receiving assistance from an employment specialist\n","Individuals, 18 years or older, in active treatment for schizophrenia who at a specified point in time:\ni) Report in a survey that they are currently employed and they have a prior work history or are actively looking for a job; or \nii) Are currently employed\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.13.1","","Vocational Rehabilitation for Schizophrenia ",null,null,null,null,null,"2014-09-01","2015-08-31","2015-09-01","2016-08-31","2014-03-01","2014-08-31",null,null,"RHP 10_126675104.2.104","RHP 10_126675104.3.114","RHP 10_126675104.2.104_126675104.3.114",{"$f":"COUNTIFS($FI$4:$FI212,FI212)","v":1},"RHP 10_126675104.2.104_1",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR212,FR212)","v":24},"RHP 10_126675104_24"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.104","126675104.3.115","IT-11.28","Housing Assessment for Individuals with Schizophrenia ","Baseline Approved","Eligible to Report in October DY4","Deliver community based behavioral health services targeted to individuals in Tarrant County with serious mental illness and concomitant circumstances such as chronic physical health conditions, chronic or intermittent homelessness, cognitive issues resulting from severe mental illness, or forensic involvement","Housing Assessment for Individuals with Schizophrenia ","In DY4 and DY5, the provider will report the percentage of individuals in the denominator whose housing quality was assessed with medical record documentation indicating that a trained professional (e.g., social worker, visiting nurse) saw the quality of the individual's housing and/or made an effort to modify the individual's housing situation over all enrollees at the Psychiatric Rehab Facility who had either one inpatient admission or two outpatient visits with a primary diagnosis of schizophrenia within a 12 month period. In addition, in DY5 provider will complete Stretch Activity #3 (SA3)- Outcome Evaluation.","Facility ","Only patients in Psych Rehab Facility (Name TBD)","P4R","SA3","PM-8","Submission of Category 3 DY3 Status Report",36297.438440000005,"Yes/No","RHP 10_126675104.3.115_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",36297.438440000005,"Yes/No","RHP 10_126675104.3.115_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",80531.653439999995,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",94276.29970800002,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",94276.29970800002,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",2.1052999999999999E-2,12,570,"March 1, 2014 - August 31, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"proxy","P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The Psychiatric Day Rehabilitation Facility was not operational until 8/4/14 which would not have allowed enough time to collect six months worth of baseline data. With that in mind we requested and received approval to include our traditional outpatient individuals served in our behavioral health clinics in addition to these new facilities for this measure from 3/1/14 – 8/31/14 to get a better representation of data for these measures. After the baseline setting, the provider would then report their DY4 and DY5 achievement with their proposed facility subsets which were approved during the Category 3 feedback setting processes.  Without this proxy population, the provider would not have a full 6 months’ worth of data for their current subset denominator population.","Denominator: Patients who had either one inpatient admission or two outpatient visits with a primary diagnosis of schizophrenia within a 6 month period.\nNumerator: The number of individuals in the denominator whose housing quality was assessed with medical record documentation indicating that a trained professional (e.g., social worker, visiting nurse) saw the quality of the individual's housing and/or made an effort to modify the individual's housing situation.\n","Sum of numerator / sum of denominator * 100","Housing Assessment for Individuals with Schizophrenia ","Ambulatory/Inpatient",null,"The number of individuals in the denominator whose housing quality was assessed with medical record documentation indicating that a trained professional (e.g., social worker, visiting nurse) saw the quality of the individual's housing and/or made an effort to modify the individual's housing situation.","Patients who had either one inpatient admission or two outpatient visits with a primary diagnosis of schizophrenia within a 12 month period.",null,null,null,null,null,null,null,null,null,null,"Current activites have included discussions about which stretch activity to select for this measure and how to implement. The activity is a measure of program outcomes and improvements specifcally related to the Category 2 project. The improvement of patient outcomes in this project are related to the overall collection projects through reducing beahvioral health readmissions, increasing outpatient utlization for behavioral health care, and improving consumer satifaction for access to care. ",null,null,"2.13.1","","Housing Assessment for Individuals with Schizophrenia ",null,null,null,null,null,"2014-09-01","2015-08-31","2015-09-01","2016-08-31","2014-03-01","2014-08-31",null,null,"RHP 10_126675104.2.104","RHP 10_126675104.3.115","RHP 10_126675104.2.104_126675104.3.115",{"$f":"COUNTIFS($FI$4:$FI213,FI213)","v":2},"RHP 10_126675104.2.104_2",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR213,FR213)","v":25},"RHP 10_126675104_25"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.104","126675104.3.116","IT-11.29","Independent Living Skills Assessment for Individuals with Schizophrenia","Baseline Approved","Eligible to Report in October DY4","Deliver community based behavioral health services targeted to individuals in Tarrant County with serious mental illness and concomitant circumstances such as chronic physical health conditions, chronic or intermittent homelessness, cognitive issues resulting from severe mental illness, or forensic involvement","Independent Living Skills Assessment for Individuals with Schizophrenia","In DY4 and DY5, the provider will report the percentage of patients in the denominator who received an assessment of independent living skills over all enrollees at the Psychiatric Rehab Facility who had either one inpatient admission or two outpatient visits with a primary diagnosis of schizophrenia within a 12 month period. In addition, in DY5 provider will complete Stretch Activity #3 (SA3)- Outcome Evaluation.","Facility ","Only patients in Psych Rehab Facility (Name TBD)","P4R","SA3","PM-8","Submission of Category 3 DY3 Status Report",36297.438440000005,"Yes/No","RHP 10_126675104.3.116_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",36297.438440000005,"Yes/No","RHP 10_126675104.3.116_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",80531.653439999995,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",94276.29970800002,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",94276.29970800002,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",5.4385999999999997E-2,31,570,"March 1, 2014 - August 31, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"proxy","P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The Psychiatric Day Rehabilitation Facility was not operational until 8/4/14 which would not have allowed enough time to collect six months worth of baseline data. With that in mind we requested and received approval to include our traditional outpatient individuals served in our behavioral health clinics in addition to these new facilities for this measure from 3/1/14 – 8/31/14 to get a better representation of data for these measures. After the baseline setting, the provider would then report their DY4 and DY5 achievement with their proposed facility subsets which were approved during the Category 3 feedback setting processes.  Without this proxy population, the provider would not have a full 6 months’ worth of data for their current subset denominator population.","Denominator: Patients who had either one inpatient admission or two outpatient visits with a primary diagnosis of schizophrenia within a 6 month period.\nNumerator: Patients in the denominator who received an assessment of independent living skills.\n","Sum of numerator / sum of denominator * 100","Independent Living Skills Assessment for Individuals with Schizophrenia","Ambulatory/Inpatient",null,"Patients in the denominator who received an assessment of independent living skills.","Patients who had either one inpatient admission or two outpatient visits with a primary diagnosis of schizophrenia within a 12 month period.",null,null,null,null,null,null,null,null,null,null,"Current activites have included discussions about which stretch activity to select for this measure and how to implement. The activity is a measure of program outcomes and improvements specifcally related to the Category 2 project. The improvement of patient outcomes in this project are related to the overall collection projects through reducing beahvioral health readmissions, increasing outpatient utlization for behavioral health care, and improving consumer satifaction for access to care. ",null,null,"2.13.1","","Independent Living Skills Assessment for Individuals with Schizophrenia",null,null,null,null,null,"2014-09-01","2015-08-31","2015-09-01","2016-08-31","2014-03-01","2014-08-31",null,null,"RHP 10_126675104.2.104","RHP 10_126675104.3.116","RHP 10_126675104.2.104_126675104.3.116",{"$f":"COUNTIFS($FI$4:$FI214,FI214)","v":3},"RHP 10_126675104.2.104_3",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR214,FR214)","v":26},"RHP 10_126675104_26"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.11","126675104.3.200","IT-6.1.d.ii","CG-CAHPS Visit Survey 2.0: Provider Communication","Baseline Approved","Eligible to Report in April DY4","This project will develop a patient experience focus within JPS Health Network. ","CG-CAHPS Visit Survey 2.0: Provider Communication","In DY4 and DY5 provider will increase the percentage of top box scores on the CG-CAHPS Visit Survey 2.0: Provider Communication over all completed surveys. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",70175.047650666675,"Yes/No","RHP 10_126675104.3.200_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",70175.047650666675,"Yes/No","RHP 10_126675104.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",77847.264999999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",77847.259999999995,"Numeric",0.89,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",364535.03,"Numeric",0.89600000000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.87994899999999998,2089,2374,"DY3 (1): Oct 1st, 2013 - March 31st, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.89,null,0.89600000000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator: Patient mix and survey mode adjusted percent \"top box\" score for a given subdomainas provided by your survey administrator, multiplied by the number of completed CG-CAHPS surveys represented in the \"top box\" score.\nInclusions: Include all top box CGCAHPS survey responses to question number 39130, regarding wait time during the patients most recent visit for patients seen in a JPS Adult Primary Care Clinic during the baseline reporting period.\nExclususions: Exclude all response values not equal to the Top Box response for question 39130.\nDenominator: The denominator is the number of CG-CAHPS surveys completed during the measurement period, between 10/1/13 and 03/31/14. The denominator should be the same as the multplier used in the denominator.\nInclusions: Include all valid CGCAHPS survey responses to question number 39130, regarding wait time during the patients most recent visit for patients seen in a JPS Adult Primary Care Clinic during the baseline reporting period.\nExclusions: Exclude survey responses from patients seen in the Healing Wings or Employee Health Clinics.\n","Provider Communication overall top box score was 88.0% with a percentile ranking of 20% as compared to other healthcare providers in the National Research Corporation (NRC) database. Our DSRIP payer breakout indicated our Medicare / Medicaid population at 88.9% and JPS Connection population at 88.0% , scoring us slightly better than  Selfpay population at 85.3% . Our lowest scoring populations were Medicaid at 84.7% and CHIP  at 80.0%. CHIP had very small sample sizes indicating that the data is not statistically significant. NRC states that sample sizes need to have a minimum of 40 returns per year to be considered significant.","CG-CAHPS Visit Survey 2.0: Provider Communication","Ambulatory",null,"Patient-mix and survey mode adjusted percent \"top box\" score for a given subdomain as provided by your survey administrator, multiplied by the number of completed CG-CAHPS surveys represented in the \"top box\" score.","The number of CG-CAHPS surveys completed during the measurement period as reported by your survey administrator. The denominator should be the same as the multiplier used in the numerator. The denominator should be the same as the multiplier used in the numerator. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.4.1","","CG-CAHPS Visit Survey 2.0: Provider Communication",null,null,null,null,null,"2014-04-01","2015-03-31","2015-04-01","2016-03-31","2013-10-01","2014-03-31",null,null,"RHP 10_126675104.2.11","RHP 10_126675104.3.200","RHP 10_126675104.2.11_126675104.3.200",{"$f":"COUNTIFS($FI$4:$FI215,FI215)","v":1},"RHP 10_126675104.2.11_1",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR215,FR215)","v":27},"RHP 10_126675104_27"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.11","126675104.3.201","IT-6.1.d.iv","CG-CAHPS Visit Survey 2.0: Overall Provider Rating","Baseline Approved","Eligible to Report in April DY4","This project will develop a patient experience focus within JPS Health Network. ","CG-CAHPS Visit Survey 2.0: Overall Provider Rating","In DY4 and DY5 provider will increase the percentage of top box scores on the CG-CAHPS Visit Survey 2.0: Overall Provider Rating over all completed surveys. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",70175.047650666675,"Yes/No","RHP 10_126675104.3.201_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",70175.047650666675,"Yes/No","RHP 10_126675104.3.201_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",77847.264999999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",77847.259999999995,"Numeric",0.76,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",364535.03,"Numeric",0.77300000000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.74354600000000004,1757,2363,"DY3 (1): Oct 1st, 2013 - March 31st, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.76,null,0.77300000000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator: Patient-mix and survey mode adjusted percent \"top box\" score for a given subdomain asprovided by your survey adminstrator, multiplied by the number of completed CG-CAHPS surveys represented in the \"top box\" score.\nInclusions: Include all Top Box CGCAHPS survey responses to question number 39137, rating your provider from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible.\nExclusions: Exclude all response values equal to the Top Box response for question 39137.\nDenominator: The denominator the number of CG-CAHPS surveys completed during the measurement period, between 10/1/13 and 03/31/14. The denominator should be the same as the multiplier used in numerator.\nInclusion: Include all valid CG-CAHPS survey responses to question number 39137, rating your provider from 0 to 10, where 0 is the worst provider possible and 10 is the best possible.\nExclusion: Exclude survey responses from patients seen in the Healing Wings or Employee Health Clinics.\n","Overall provider rating  top box score was 74.4% with a percentile ranking of 24% as compared to other healthcare providers in the National Research Corporation (NRC) database. Our DSRIP payer breakout indicated our SelfPay population at 90.3% and Medicare / Medicaid population at 79.0% , scoring us slightly better than  JPS Connection population at 73.1% . Our lowest scoring populations were Medicaid at 72.4% and CHIP  at 60.0%. CHIP had very small sample sizes indicating that the data is not statistically significant. NRC states that sample sizes need to have a minimum of 40 returns per year to be considered significant.","CG-CAHPS Visit Survey 2.0: Overall Provider Rating","Ambulatory",null,"Patient-mix and survey mode adjusted percent \"top box\" score for a given subdomain as provided by your survey administrator, multiplied by the number of completed CG-CAHPS surveys represented in the \"top box\" score.","The number of CG-CAHPS surveys completed during the measurement period as reported by your survey administrator. The denominator should be the same as the multiplier used in the numerator. The denominator should be the same as the multiplier used in the numerator. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.4.1","","CG-CAHPS Visit Survey 2.0: Overall Provider Rating",null,null,null,null,null,"2014-04-01","2015-03-31","2015-04-01","2016-03-31","2013-10-01","2014-03-31",null,null,"RHP 10_126675104.2.11","RHP 10_126675104.3.201","RHP 10_126675104.2.11_126675104.3.201",{"$f":"COUNTIFS($FI$4:$FI216,FI216)","v":2},"RHP 10_126675104.2.11_2",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR216,FR216)","v":28},"RHP 10_126675104_28"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.11","126675104.3.34","IT-6.1.d.i","CG-CAHPS Visit Survey 2.0: Timeliness of Appointments, Care, & Information","Baseline Approved","Eligible to Report in April DY4","This project will develop a patient experience focus within JPS Health Network. ","CG-CAHPS Visit Survey 2.0: Timeliness of Appointments, Care, & Information","In DY4 and DY5 provider will increase the percentage of top box scores on the CG-CAHPS Visit Survey 2.0: Timeliness of Appointments, Care, & Information over all completed surveys. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",70175.047650666675,"Yes/No","RHP 10_126675104.3.34_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",70175.047650666675,"Yes/No","RHP 10_126675104.3.34_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",77847.264999999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",77847.259999999995,"Numeric",0.721801527,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",364535.03,"Numeric",0.72604580200000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.717557,1692,2358,"DY3 (1): Oct 1st, 2013 - March 31st, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.721801527,null,0.72604580200000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator: Patient mix and survey mode adjusted percent \"top box\" score for a given subdomainas provided by your survey administrator, multiplied by the number of completed CG-CAHPS surveys represented in the \"top box\" score.\nInclusions: Include all top box CGCAHPS survey responses to question number 39127, regarding wait time during the patients most recent visit for patients seen in a JPS Adult Primary Care Clinic during the baseline reporting period.\nExclususions: Exclude all response values not equal to the Top Box response for question 39127.\nDenominator: The denominator is the number of CG-CAHPS surveys completed during the measurement period, between 10/1/13 and 03/31/14. The denominator should be the same as the multplier used in the denominator.\nInclusions: Include all valid CGCAHPS survey responses to question number 39127, regarding wait time during the patients most recent visit for patients seen in a JPS Adult Primary Care Clinic during the baseline reporting period.\nExclusions: Exclude survey responses from patients seen in the Healing Wings or Employee Health Clinics\n","Timeliness of appointment overall top box score was 71.8% with a percentile ranking of 19% as compared to other healthcare providers in the National Research Corporation (NRC) database. Our DSRIP payer breakout indicated our Medicare / Medicaid population at 75.6% and Medicaid population at 75.0%, scoring us slightly better than the JPS Connection at 70.5% . Our lowest scoring populations were Selfpay at 64.7% and CHIP  at 20.0%. CHIP had very small sample sizes indicating that the data is not statistically significant. NRC states that sample sizes need to have a minimum of 40 returns per year to be considered significant.","CG-CAHPS Visit Survey 2.0: Timeliness of Appointments, Care, & Information","Ambulatory",null,"Patient-mix and survey mode adjusted percent \"top box\" score for a given subdomain as provided by your survey administrator, multiplied by the number of completed CG-CAHPS surveys represented in the \"top box\" score.","The number of CG-CAHPS surveys completed during the measurement period as reported by your survey administrator. The denominator should be the same as the multiplier used in the numerator. The denominator should be the same as the multiplier used in the numerator. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.4.1","","CG-CAHPS Visit Survey 2.0: Timeliness of Appointments, Care, & Information",null,null,null,null,null,"2014-04-01","2015-03-31","2015-04-01","2016-03-31","2013-10-01","2014-03-31",null,null,"RHP 10_126675104.2.11","RHP 10_126675104.3.34","RHP 10_126675104.2.11_126675104.3.34",{"$f":"COUNTIFS($FI$4:$FI217,FI217)","v":3},"RHP 10_126675104.2.11_3",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR217,FR217)","v":29},"RHP 10_126675104_29"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.12","126675104.3.53","IT-4.14","Intensive Care: In-hospital mortality rate ","Baseline Approved","Eligible to Report in April DY4","Implement an evidence-based early detection and treatment plan for patients presenting in the ED with sepsis; the intended outcome of the project is to reduce the mortality rate associated with sepsis.  JPS’ goal is to improve the reliability with the identification and application of the Sepsis Bundles for patients who meet the specified criteria in the ED.","Intensive Care: In-hospital mortality rate ","In DY4 and DY5, the provider will improve the percentage of eligible patients whose hospital outcome is death over all eligible patients who are discharged (including deaths and transfers) from the intensive care unit (ICU) after admitted to ICU from ED with diagnosis of Severe Sepsis, Septic Shock, or Lactate > 4 mmol/L","Comorbid Condition ","Patients admitted to ICU from ED with diagnosis of Severe Sepsis, Septic Shock, or Lactate > 4 mmol/L.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",799451.08164100011,"Yes/No","RHP 10_126675104.3.53_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",799451.08164100011,"Yes/No","RHP 10_126675104.3.53_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",886854.83499999996,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",886854.83,"Numeric",0.181739131,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",4152871,"Numeric",0.17217399999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.191304,22,115,"CY2013 (1): January 1, 2013- June 30, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.181739131,null,0.17217399999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"All Patients admitted to the ICU from the ED with a diagnosis of Severe Sepsis, Septic Shock, or a Lactate level > 4 mmol/L were included in the denominator.  The numerator is the number of patients admitted to the ICU from the ED with a diagnosis of Severe Sepsis, Septic Shock, or Lactate level > 4mmol/L whose disposition from the hospital on this admission was death.","The baseline of 01/01/2013 0 06/30/2013 was used because this was the timeframe before all the new processes were implemented, so it is an accurate reflection of the baseline of the program.","Intensive Care: In-hospital mortality rate ","inpatient",null,"Total number of eligible patients whose hospital outcome is death","Total number of eligible patients who are discharged (including deaths and transfers) from the intensive care unit (ICU).",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.8.11","","Intensive Care: In-hospital mortality rate ",null,null,null,null,null,"2013-07-01","2014-06-30","2014-07-01","2015-06-30","2013-01-01","2013-06-30",null,null,"RHP 10_126675104.2.12","RHP 10_126675104.3.53","RHP 10_126675104.2.12_126675104.3.53",{"$f":"COUNTIFS($FI$4:$FI218,FI218)","v":1},"RHP 10_126675104.2.12_1",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR218,FR218)","v":30},"RHP 10_126675104_30"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.13","126675104.3.41","IT-13.1","Hospice and Palliative Care – Pain assessment ","Baseline Approved","Eligible to Report in April DY4","Implement an inpatient comprehensive palliative care consultation program for patients with serious or life-threatening illnesses","Hospice and Palliative Care – Pain assessment ","In DY4 and DY5, the provider will improve the percentage of patients who received a comprehensive clinical assessment to determine the severity, etiology and impact of their pain within 24 hours of screening positive for pain over all patients enrolled in hospice OR receiving palliative care who report pain when pain screening is done on the admission evaluation / initial encounter",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",169388.04605333335,"Yes/No","RHP 10_126675104.3.41_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",169388.04605333335,"Yes/No","RHP 10_126675104.3.41_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",187907.19,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",187907.19,"Numeric",0.30909090900000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",879912.13,"Numeric",0.34545500000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.272727,9,33,"DY3 (1): Oct 1st, 2013 - March 31st, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.30909090900000002,null,0.34545500000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator: Patients enrolled in hospice or receiving palliative care who report pain when pain screening is done on the admission evaluation/initial encounter.   \nNumerator: Palliative Care used first pain screening after order has been placed.Patients who received a comprehensive clinical assessment to determine the severity, etiology, and impact of their pain within 24 hours of screening positive for pain.\n","Sum of numerator / sum of denominator * 100","Hospice and Palliative Care – Pain assessment ","Ambulatory/Inpatient",null,"Patients who received a comprehensive clinical assessment to determine the severity, etiology, and impact of their pain within 24 hours of screening positive for pain","Patients enrolled in hospice or receiving palliative care who report pain when pain screening is done on the admission evaluation/initial encounter",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.10.1","","Hospice and Palliative Care – Pain assessment ",null,null,null,null,null,"2014-04-01","2015-03-31","2015-04-01","2016-03-31","2013-10-01","2014-03-31",null,null,"RHP 10_126675104.2.13","RHP 10_126675104.3.41","RHP 10_126675104.2.13_126675104.3.41",{"$f":"COUNTIFS($FI$4:$FI219,FI219)","v":1},"RHP 10_126675104.2.13_1",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR219,FR219)","v":31},"RHP 10_126675104_31"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.13","126675104.3.42","IT-13.5","Hospice and Palliative Care – documentation of spiritual/religions concerns ","Baseline Approved","Eligible to Report in October DY4","Implement an inpatient comprehensive palliative care consultation program for patients with serious or life-threatening illnesses","Hospice and Palliative Care – Percentage of patients receiving hospice or palliative care services with documentation in the clinical record of a discussion of spiritual/religions concerns or documentation that the patient/caregiver did not want to discuss ","In DY4 and DY5, the provider will improve the percentage of patients with clinical record documentation of spiritual/religious concerns or documentation that the patient/family did not want to discuss over all patient’s discharged from hospice or palliative care within JPS inpatient settings during the designated reporting period","Comorbid Condition ","Hospice and Palliative Care Patients in JPS Hospital","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",169388.04605333335,"Yes/No","RHP 10_126675104.3.42_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",169388.04605333335,"Yes/No","RHP 10_126675104.3.42_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",187907.19,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",187907.19,"Numeric",0.73853210999999996,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",879912.13,"Numeric",0.75229400000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.72477100000000005,158,218,"March 1, 2014 - August 31, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.73853210999999996,null,0.75229400000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator: Total number of patient’s discharged from hospice and/or palliative care during the designated reporting period.\nNumerator: Number of patients with clinical record documentation of spiritual/religious concerns or documentation that the patient/family did not want to discuss.","Sum of numerator / sum of denominator * 100","Hospice and Palliative Care – documentation of spiritual/religions concerns ","Ambulatory/Inpatient",null,"Number of patient with clinical record documentation of spiritual/religious concerns or documentation that the patient/family did not want to discuss","Total number of patient’s discharged from hospice care and/or palliative care during the designated reporting period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.10.1","","Hospice and Palliative Care – documentation of spiritual/religions concerns ",null,null,null,null,null,"2014-09-01","2015-08-31","2015-09-01","2016-08-31","2014-03-01","2014-08-31",null,null,"RHP 10_126675104.2.13","RHP 10_126675104.3.42","RHP 10_126675104.2.13_126675104.3.42",{"$f":"COUNTIFS($FI$4:$FI220,FI220)","v":2},"RHP 10_126675104.2.13_2",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR220,FR220)","v":32},"RHP 10_126675104_32"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.13","126675104.3.43","IT-13.6","Palliative Care:  documentation of interdisciplinary family meeting","Baseline Approved","Eligible to Report in October DY4","Implement an inpatient comprehensive palliative care consultation program for patients with serious or life-threatening illnesses","Palliative Care:  Percent of patients who have documentation in the medical record that an interdisciplinary family meeting was conducted on or before day five of ICU admission ","In DY4 and DY5, the provider will improve the percentage of patients who have documentation in the medical record that an interdisciplinary family meeting was conducted on or before Day Five of intensive care unit (ICU) admission over all patients with an intensive care unit (ICU) length of stay greater than or equal to 5 days",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",169388.04605333335,"Yes/No","RHP 10_126675104.3.43_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",169388.04605333335,"Yes/No","RHP 10_126675104.3.43_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",187907.19,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",187907.19,"Numeric",8.4146340999999999E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",879912.13,"Numeric",0.13234899999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",3.5943999999999997E-2,28,779,"10/01/13 - 06/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,8.4146340999999999E-2,null,0.13234899999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator: Total number of patients with an intensive care unit (ICU) length of stay greater than or equal to 5 days\nNumerator: Number of patients who have documentation in the medical record that an interdisciplinary family meeting was conducted on or before Day Five of intensive care unit (ICU) admission\n","Sum of numerator / sum of denominator * 100","Palliative Care:  documentation of interdisciplinary family meeting","Ambulatory/Inpatient",null,"Number of patients who have documentation in the medical record that an interdisciplinary family meeting was conducted on or before Day Five of intensive care unit (ICU) admission","Total number of patients with an intensive care unit (ICU) length of stay greater than or equal to 5 days",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.10.1","","Palliative Care:  documentation of interdisciplinary family meeting",null,null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2013-10-01","2014-06-30",null,null,"RHP 10_126675104.2.13","RHP 10_126675104.3.43","RHP 10_126675104.2.13_126675104.3.43",{"$f":"COUNTIFS($FI$4:$FI221,FI221)","v":3},"RHP 10_126675104.2.13_3",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR221,FR221)","v":33},"RHP 10_126675104_33"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.14","126675104.3.44","IT-5.1.e","Improved Cost Savings: Cost Benefit Analysis","Baseline Approved","Eligible to Report in October DY4","Develop a payment model that is based on outcomes instead of Fee for Service for approximately 46,000 Connection enrolled patients. The project is a new intervention that will reduce medical costs. The providers that participate in the Connections program are reimbursed on a Fee for Service basis.  This program allows itself a perfect opportunity to transition to an outcome based program.  JPS Health Network can work with the providers to transform the care and payment options for both the patients and providers. This will allow for an improvement in access, quality, cost, and improve outcomes.  ","Improved Cost Savings: Demonstrate cost savings in care delivery - Cost Benefit Analysis","In DY4 and DY5, the provider will improve the cost-benefit ratio or net cost (benefit) by demonstrating cost savings in care delivery among JPS uninsured/Connections patients","Payer ","Patients eligible for JPS Connection Program","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",558073.11601500004,"Yes/No","RHP 10_126675104.3.44_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",558073.11601500004,"Yes/No","RHP 10_126675104.3.44_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",619087.08499999996,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",619087.08499999996,"Numeric",0.84712600000000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",2898996.22,"Numeric",0.85517200000000004,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",0.83908000000000005,73,87,"07/01/13 - 06/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.84712600000000005,null,0.85517200000000004,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Many medical services that best practices indicate should be Ambulatory based are currently being provided in the JPS Hospital environment. Shifting potentially avoidable hospital visits to the more appropriate ambulatory setting will improve patient quality outcomes and decrease the overall cost of care. This shift will increase Ambulatory-based costs, but will decrease Hospital-based costs. Using the Crimson Population Health Management system, we have measured Ambulatory Costs with a Medicaid benchmark adjustment as the Numerator of our Cost / Benefit Analysis, and have measured Hospital Costs with a Medicaid benchmark adjustment as our Denominator.","The baseline Cost / Benefit Ratio reported here compares the benchmark adjusted ratio of Ambulatory  to Hospital costs. The 0.84 result indicates that the Adjusted Hospital Costs are significantly higher than the Adjusted Ambulatory cost. As we succeed in shifting cost to the more appropriate setting, this ratio will increase towards a value of 1.0 which indicates a more balanced cost of care.","Improved Cost Savings: Cost Benefit Analysis","Multiple",null,"Formula 1: Cost Benefit Ratio Approach\nCost Benefit Ratio Approach Numerator:\n$CostInt - $CostComp \nAbbreviations: Int: Intervention; Comp: Comparator\n\nOR \n\nFormula 2: Cost-Benefit, Net Benefit Approach\nCost-Benefit, Net Benefit Approach:\nCB Net = ($CostInt - $CostComp) – ($BenefitInt - $BenefitComp)\n","Formula 1: Cost Benefit Ratio Approach\nCost Benefit Ratio Approach Denominator: $BenefitInt - $BenefitComp\nAbbreviations: Int: Intervention; Comp: Comparator\n\nFormula 2: Cost Benefit, Net Benefit Approach\nNet Benefit Approach is not reported as a ratio, so there is no applicable denominator\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.5.1 ","","Improved Cost Savings: Cost Benefit Analysis",null,null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2013-07-01","2014-06-30",null,null,"RHP 10_126675104.2.14","RHP 10_126675104.3.44","RHP 10_126675104.2.14_126675104.3.44",{"$f":"COUNTIFS($FI$4:$FI222,FI222)","v":1},"RHP 10_126675104.2.14_1",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR222,FR222)","v":34},"RHP 10_126675104_34"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.15","126675104.3.45","IT-8.1","Timeliness of Prenatal/Postnatal Care","Pending Approval","Eligible to Report in October DY4","Centering Pregnancy (to provide Comprehensive Perinatal Services Program and Group visits in clinics with high numbers of pregnant women) Maternity Medical Home (to provide pregnant women enhanced services through health care coordination and navigation in those clinics with small numbers of pregnant women).","Timeliness of Prenatal/Postnatal Care","In DY4 and DY5, the provider will improve the percentage of deliveries of live births for which women receive timely prenatal in the first trimester and postpartum care on or between 21 and 56 days after delivery over all JPS deliveries of live births between November 6 of the year prior to the measurement year and November 5 of the measurement year","Facility ","JPS deliveries","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",218692.06660100003,"Yes/No","RHP 10_126675104.3.45_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",218692.06660100003,"Yes/No","RHP 10_126675104.3.45_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",242601.605988,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- Prenatal Care",121300.802994,"Numeric","TBD","AM-1.2","Achievement of DY4 performance goal- Postnatal Care",121300.802994,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- Prenatal Care",568014.70574070001,"Numeric","TBD","AM-2.2","Achievement of DY5 performance goal- Postnatal Care",568014.70574070001,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator is the number of patients who were seen for prenatal care prior to 12 weeks or less of gestational age and the number of patients receiving a postpartum visit between 21 and 56 days following delivery.  The denominator is patients giving birth at JPS Health Network.","25.83 percent of deliveries received prenatal care at twelve weeks or less gestational age and  58.99 percent of women received a postpartum visit between 21 and 56 days following delivery.","Timeliness of Prenatal/Postnatal Care","ambulatory",null,"Received a prenatal care visit as a patient of the organization in the first trimester \n","Deliveries of live births between the sixth day of Month 11of the year prior to the measurement year and the fifth day of Month 11 of the measurement year.","Had a postpartum visit for a pelvic exam or postpartum care on or between 21 and 56 days after delivery.","Deliveries of live births between the sixth day of Month 11of the year prior to the measurement year and the fifth day of Month 11 of the measurement year.",null,null,null,null,null,null,null,null,null,null,null,"2.7.3 ","","Prenatal Care","Postnatal Care",null,null,null,null,"2014-07-07","2015-07-06","2015-07-07","2016-07-06","2013-07-07","2014-07-06",null,null,"RHP 10_126675104.2.15","RHP 10_126675104.3.45","RHP 10_126675104.2.15_126675104.3.45",{"$f":"COUNTIFS($FI$4:$FI223,FI223)","v":1},"RHP 10_126675104.2.15_1",null,3,2,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR223,FR223)","v":35},"RHP 10_126675104_35"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.15","126675104.3.46","IT-8.12","Pre-term birth rate ","Baseline Approved","Eligible to Report in October DY4","Centering Pregnancy (to provide Comprehensive Perinatal Services Program and Group visits in clinics with high numbers of pregnant women) Maternity Medical Home (to provide pregnant women enhanced services through health care coordination and navigation in those clinics with small numbers of pregnant women).","Pre-term birth rate ","In DY4 and DY5, the provider will improve the percentage of term singleton live births delivered with less than 37 completed weeks of gestation ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",218692.06660100003,"Yes/No","RHP 10_126675104.3.46_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",218692.06660100003,"Yes/No","RHP 10_126675104.3.46_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",242601.60500000001,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",242601.61,"Numeric",7.9345372999999997E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1136029.4099999999,"Numeric",7.5169E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",8.3520999999999998E-2,37,443,"September 1, 2013 -August 31, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,7.9345372999999997E-2,null,7.5169E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator is the number of pre-term births at JPS Health Network, and the denominator is the number of singleton live births delivered prior to 37 weeks gestational age.","8.35 percent of singleton live births at JPS Health Network were born prior to 37 weeks gestational age.","Pre-term birth rate ","Multiple",null,"Number of singleton livebirths delivered with less than 37 completed weeks of gestation. \n","All live births. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.7.3 ","","Pre-term birth rate ",null,null,null,null,null,"2014-09-01","2015-08-31","2015-09-01","2016-08-31","2013-09-01","2014-08-31",null,null,"RHP 10_126675104.2.15","RHP 10_126675104.3.46","RHP 10_126675104.2.15_126675104.3.46",{"$f":"COUNTIFS($FI$4:$FI224,FI224)","v":2},"RHP 10_126675104.2.15_2",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR224,FR224)","v":36},"RHP 10_126675104_36"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.16","126675104.3.47","IT-1.29","Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents","Baseline Approved","Eligible to Report in October DY4","The multidisciplinary Wagner Chronic Care Model will be utilized to effectively approach the care and management of childhood and adolescent asthma and obesity/diabetes in our community with the goal of improving outcomes, preventing complications and reducing potentially preventable ED visits and inpatient readmissions.","Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents","In DY4 and DY5, the provider will improve the percentage of children 3-17 years of age who had an outpatient visit with a primary care physician (PCP) or an OB/GYN at a JPS School-based clinic and who had evidence of body mass index (BMI) percentile documentation, counseling for nutrition and counseling for physical activity during the measurement year","Facility ","JPS School-based clinics","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",9981.7955710000024,"Yes/No","RHP 10_126675104.3.47_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",9981.7955710000024,"Yes/No","RHP 10_126675104.3.47_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",11073.102348,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- BMI documentation",3691.0341160000003,"Numeric",0.9308457,"AM-1.2","Achievement of DY4 performance goal- Counseling for nutrition",3691.0341160000003,"Numeric",0.42820000000000003,"AM-1.3","Achievement of DY4 performance goal- Counseling for physical activity",3691.0341160000003,"Numeric",0.31630000000000003,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- BMI documentation",17283.9882798,"Numeric",0.93448540000000002,"AM-2.2","Achievement of DY5 performance goal- Counseling for nutrition",17283.9882798,"Numeric",0.46299000000000001,"AM-2.3","Achievement of DY5 performance goal- Counseling for physical activity",17283.9882798,"Numeric",0.34954000000000002,null,null,null,null,null,null,null,null,null,null,3,"%",0.92720599999999997,8827,9520,"07/1/13 - 06/30/14",7.1534E-2,681,9520,"07/1/13 - 06/30/14",4.9579999999999999E-2,472,9520,"Other: provider to specify",null,0,0,null,null,0,0,null,null,0.9308457,null,0.93448540000000002,null,0.42820000000000003,null,0.46299000000000001,null,0.31630000000000003,null,0.34954000000000002,null,null,null,null,null,null,null,null,null,null,null,"Numerator: Children ages 3-17 with evidence of each of the following: documented body mass index (BMI) percentile, counseling for nutrition, and counseling for physicial activity during the measurement year. Denominator: Children 3-17 years of age with at least one outpatient visit with a primary care physician (PCP) or obstetrician-gynecologist (OB-GYN) during the measurement period.  ","The calculation is the percentage of children 3-17 year of age who had an outpatient visit with a primary care physician (PCP) documented body mass index (BMI) percentile, counseling for nutrition, and counseling for physical activity.","Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents","Ambulatory",null,"Children ages 3-17 with evidence of each of the following:\nRate #1: Documented body mass index (BMI) percentile \n","Children 3-17 years of age with at least one outpatient visit with a primary care physician (PCP) or obstetrician-gynecologist (OB-GYN) during the measurement period.","Children ages 3-17 with evidence of each of the following:\nRate #2: Counseling for nutrition \n","Children 3-17 years of age with at least one outpatient visit with a primary care physician (PCP) or obstetrician-gynecologist (OB-GYN) during the measurement period.","Children ages 3-17 with evidence of each of the following:\nRate #3: Counseling for physical activity during the measurement year","Children 3-17 years of age with at least one outpatient visit with a primary care physician (PCP) or obstetrician-gynecologist (OB-GYN) during the measurement period.",null,null,null,null,null,null,null,null,null,"2.2.1 ","","BMI documented","Counseling for Nutrition","Counseling for physical activity ",null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2013-07-01","2014-06-30",null,null,"RHP 10_126675104.2.16","RHP 10_126675104.3.47","RHP 10_126675104.2.16_126675104.3.47",{"$f":"COUNTIFS($FI$4:$FI225,FI225)","v":1},"RHP 10_126675104.2.16_1",null,4,3,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR225,FR225)","v":37},"RHP 10_126675104_37"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.16","126675104.3.48","IT-6.2.a","Client Satisfaction Questionnaire 8 (CSQ-8)","Pending Approval","Eligible to Report in October DY4","The multidisciplinary Wagner Chronic Care Model will be utilized to effectively approach the care and management of childhood and adolescent asthma and obesity/diabetes in our community with the goal of improving outcomes, preventing complications and reducing potentially preventable ED visits and inpatient readmissions.","Client Satisfaction Questionnaire 8 (CSQ-8)","In DY4 and DY5, the provider will improve the average score on the CSQ-8 over all completed surveys by children in the Chronic Care program seen at the JPS School based clinics. ","Facility ","JPS School-based clinics","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",9981.7955710000024,"Yes/No","RHP 10_126675104.3.48_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",9981.7955710000024,"Yes/No","RHP 10_126675104.3.48_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",11073.102348,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",11073.102348,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",51851.964839400003,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator is the \"overall score\" for all CSQ-8 surveys completed during the measurement period.  The denominator is the total number of CSQ-8 surveys completed during the measurement period.","Of the 74 patients survey, the average satisfaction rate with the program at the time of survey was 3.89 out of a total score of 4.0.","Client Satisfaction Questionnaire 8 (CSQ-8)","Ambulatory",null,"The sum of the \"overall score\" for all CSQ-8 surveys completed during the measurement period.  ","The total number of CSQ-8 surveys completed during the measurement period. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.1 ","","Client Satisfaction Questionnaire 8 (CSQ-8)",null,null,null,null,null,"2014-09-01","2015-08-31","2015-09-01","2016-08-31","2014-08-01","2014-08-31",null,null,"RHP 10_126675104.2.16","RHP 10_126675104.3.48","RHP 10_126675104.2.16_126675104.3.48",{"$f":"COUNTIFS($FI$4:$FI226,FI226)","v":2},"RHP 10_126675104.2.16_2",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR226,FR226)","v":38},"RHP 10_126675104_38"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.17","126675104.3.49","IT-4.11","Risk-Adjusted Average Length of Inpatient Hospital Stay\n","Baseline Approved","Eligible to Report in October DY4","Create new specialized inpatient rehabilitation purposes for uninsured individuals of Tarrant County.  An estimated 420 vulnerable uninsured low-income Tarrant County residents requiring inpatient rehabilitation after stroke, hip replacement or hip fracture will receive specialty inpatient rehabilitation services through this intervention.","Risk-Adjusted Average Length of Inpatient Hospital Stay\n","In DY4 and DY5, the provider will improve the rate of excess in-hospital days for patients admitted for hip fracture, hip replacement, stroke or those in the rehab transitions program.","Facility, Comorbid Condition "," subset denominator of hip fractures, hip replacements and strokes also includes those in the rehab transitions program.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",114790.64906650002,"Yes/No","RHP 10_126675104.3.49_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",114790.64906650002,"Yes/No","RHP 10_126675104.3.49_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",127340.675,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",127340.68,"Numeric",1.4458424240000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",596297.6,"Numeric",1.369745,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"time (days)",1.5219389999999999,1255.5999999999999,825,"08/01/13 - 07/31/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,1.4458424240000001,null,1.369745,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator was the number of inpatient admissions in the Stroke, Hip Replacement, and Hip Fracture MS DRGs. Numerator was the number of excessive Inpatient days based on Observed LOS - MS DRG Geo Mean LOS. Rate was the Sum of Excessive Days divided by Number of cases in the Denominator.","For the specific cohort of patients in the Stroke, Hip Replacement, and Hip Fracture MS DRGs, the average observed LOS was 1.52 days higher then the expected LOS based on the MS DRG Geo Mean LOS.","Risk-Adjusted Average Length of Inpatient Hospital Stay\n","inpatient",null,"Number of excess in-hospital days in a given inpatient population","Patients admitted to a hospital",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.12.1","","Risk-Adjusted Average Length of Inpatient Hospital Stay\n",null,null,null,null,null,"2014-08-01","2015-07-31","2015-08-01","2016-07-31","2013-08-01","2014-07-31",null,null,"RHP 10_126675104.2.17","RHP 10_126675104.3.49","RHP 10_126675104.2.17_126675104.3.49",{"$f":"COUNTIFS($FI$4:$FI227,FI227)","v":1},"RHP 10_126675104.2.17_1",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR227,FR227)","v":39},"RHP 10_126675104_39"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.17","126675104.3.50","IT-4.5","Patient Fall Rate","Baseline Approved","Eligible to Report in October DY4","Create new specialized inpatient rehabilitation purposes for uninsured individuals of Tarrant County.  An estimated 420 vulnerable uninsured low-income Tarrant County residents requiring inpatient rehabilitation after stroke, hip replacement or hip fracture will receive specialty inpatient rehabilitation services through this intervention.","Patient Fall Rate","In DY4 and DY5, the provider will improve the rate of documented falls, with or without injury, experienced by patients on eligible unit types at JPS Hospital. Measure contains two rates reported as: \nRate 1: Total Falls per 1,000 Patient Days, and \nRate 2: Unassisted Falls per 1000 Patient Days.\n\n","Facility ","John Peter Smith Hospital","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",114790.64906650002,"Yes/No","RHP 10_126675104.3.50_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",114790.64906650002,"Yes/No","RHP 10_126675104.3.50_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",127340.677002,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- Total Falls",63670.338500999998,"Numeric",3.5337813539999998,"AM-1.2","Achievement of DY4 performance goal- Unassisted Falls",63670.338500999998,"Numeric",3.3202600000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- Total Falls",298148.79782655003,"Numeric",3.3477929999999998,"AM-2.2","Achievement of DY5 performance goal- Unassisted Falls",298148.79782655003,"Numeric",3.1455090000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"number per 1K",3.7197698462644966,331,88984,"08/01/13 - 07/31/14",3.495010338937337,311,88984,"08/01/13 - 07/31/14",null,0,0,null,null,0,0,null,null,0,0,null,null,3.5337813539999998,null,3.3477929999999998,null,3.3202600000000002,null,3.1455090000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator: Description: Patient days by inpatient hospital unit. Numerator 1 (Total Falls): All documented falls in the reporting period (with and without injury, and with and without assistance). Numerator 2 (Total Unassisted Falls): All documented unassisted falls in the reporting period (with and without injury, but without assistance). \nInclusions: • Time frame for inpatient stays – 08/01/2013 thru 07/30/2014\n• Encounter Type: Inpatient\n• Patients of any age on an eligible reporting unit are included in the patient day count.\nAll patient days from the following inpatient units:\n JPS EIGHTH FLOOR MAIN\n JPS ELEVENTH FLOOR MAIN\n JPS FIFTH FLOOR MAIN\n JPS FIFTH FLOOR PAVILION\n JPS FOURTH FLOOR PAVILION\n JPS INTENSIVE CARE PAVILION\n JPS PROGRESSIVE CARE MAIN\n JPS SECOND FLOOR MAIN\n JPS SEVENTH FLOOR MAIN\n JPS SIXTH FLOOR MAIN\n JPS SKILLED NURSING MAIN\nExclusions: • All patient days from inpatient departments that are not included in the inclusion list; pediatric, psychiatric, obstetrical\n• All observation patient days\n\nNumerator\nDescription: All fall events from the selected time frame, within the included inpatient unit list multiplied by 1,000.\n\nInclusions: All fall events within reporting period, under the denominator inpatient units.\nExclusions: None\n","There were 3.7 total falls per 1000 Inpatient Days. There were 3.49 unassisted falls per 1000 Inpatient Days. ","Patient Fall Rate","inpatient",null,"Rate #1 (Total Falls): Total number of patient falls (with or without injury to the patient and whether or not assisted by a staff member) by hospital unit during the measurement period","Patient days by hospital unit ","Rate #2 (Total Unassisted Falls): Total number of patient falls (with or without injury to the patient) that were not not assisted by a staff member by hospital unit during the measurement period","Patient days by hospital unit ",null,null,null,null,null,null,null,null,null,null,null,"2.12.1","","Total Falls","Unassisted Falls",null,null,null,null,"2014-08-01","2015-07-31","2015-08-01","2016-07-31","2013-08-01","2014-07-31",null,null,"RHP 10_126675104.2.17","RHP 10_126675104.3.50","RHP 10_126675104.2.17_126675104.3.50",{"$f":"COUNTIFS($FI$4:$FI228,FI228)","v":2},"RHP 10_126675104.2.17_2",null,3,2,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR228,FR228)","v":40},"RHP 10_126675104_40"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.2","126675104.3.13","IT-9.2","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","Baseline Approved","Eligible to Report in October DY4","Implement the patient-centered medical home model in the primary care clinics at JPS Health Network","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","In DY4 and DY5, the provider will improve the rate of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period over all ED visits for individuals 18 years or older during the measurement period",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",266483.69388033339,"Yes/No","RHP 10_126675104.3.13_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",266483.69388033339,"Yes/No","RHP 10_126675104.3.13_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",295618.28000000003,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",295618.28000000003,"Numeric",0.13754523499999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1384290.33,"Numeric",0.13030600000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.144784,14123,97545,"7/1/2013 - 6/30/2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.13754523499999999,null,0.13030600000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator includes total number of ED visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period. Results included patients with grand mal status and other epilecptic convulsions, chronic obstructive pulmonary diseases, asthma, heart failure and pulmonary edema, hypertension, angina, or diabetes. The denominator includes total number of ED visits for individuals 18 years or older during the measurement period. ","The baseline rate is above national benchmark and will be improved. ","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","ED",null,"Total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.1.1 ","","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ",null,null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2013-07-01","2014-06-30",null,null,"RHP 10_126675104.2.2","RHP 10_126675104.3.13","RHP 10_126675104.2.2_126675104.3.13",{"$f":"COUNTIFS($FI$4:$FI229,FI229)","v":1},"RHP 10_126675104.2.2_1",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR229,FR229)","v":41},"RHP 10_126675104_41"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.2","126675104.3.14","IT-12.3","Colorectal Cancer Screening ","Baseline Approved","Eligible to Report in October DY4","Implement the patient-centered medical home model in the primary care clinics at JPS Health Network","Colorectal Cancer Screening ","In DY4 and DY5 provider will improve (increase) the percentage of patients 50–75 years of age who had appropriate screening for colorectal cancer and receiving services at JPS primary care clinics submitting for NCQA designation. ","Facility ","JPS primary care clinics submitting for NCQA designation. ","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",266483.69388033339,"Yes/No","RHP 10_126675104.3.14_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",266483.69388033339,"Yes/No","RHP 10_126675104.3.14_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",295618.28000000003,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",295618.28000000003,"Numeric",0.51,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1384290.33,"Numeric",0.53300000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.46914699999999998,14111,30078,"7/1/2013 - 6/30/2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.51,null,0.53300000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The Numerator includes Patient Centered Medical Home patients 50-75 years of age who had appropriate screening for colorectal cancer. An appropriate screening is one of the following; 1. Fecal Occult Blood Test (FOBT) within 1 year from anchor date, 2. Flexible sigmoidoscopy within 5 years from the anchor date, or 3. Flexible Colonoscopy within 10 years from the anchor date. Completed tests are indicated with one of the following; 1. procedure ordered with order status of \"resulted\" or \"completed,\" transaction charge with quantity > 1, ICD 9 Procedure Code, or Health Maintenance Topic Overrides reason to indicate that test was satisfied. The Denominator includes patients 51-75 years old during the measurement period who had at least one (1) outpatient Patient Centered Medical Home Clinic encounter in the prior 12-month period. ","Baseline indicates JPS is below the 25th percentile ranking as compared to the national benchmark (source: NCQA).","Colorectal Cancer Screening ","ambulatory",null,"One or more screenings for colorectal cancer. Any of the following meet the criteria: \n\n• Fecal occult blood test (FOBT) during the measurement year. For administrative data, assume the required number of samples were returned regardless of FOBT type.\n• Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year.\n• Colonoscopy during the measurement year or the nine years prior to the measurement year.\n","Patients 51–75 years of age as of the end of the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.1.1 ","","Colorectal Cancer Screening ",null,null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2013-07-01","2014-06-30",null,null,"RHP 10_126675104.2.2","RHP 10_126675104.3.14","RHP 10_126675104.2.2_126675104.3.14",{"$f":"COUNTIFS($FI$4:$FI230,FI230)","v":2},"RHP 10_126675104.2.2_2",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR230,FR230)","v":42},"RHP 10_126675104_42"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.2","126675104.3.15","IT-12.2","Cervical Cancer Screening ","Baseline Approved","Eligible to Report in October DY4","Implement the patient-centered medical home model in the primary care clinics at JPS Health Network","Cervical Cancer Screening ","In DY4 and DY5 provider will improve (increase) the percentage of women 21–64 years of age who were screened for cervical cancer at JPS primary care clinics submitting for NCQA designation using either of the following criteria: - Women age 21–64 who had cervical cytology performed every 3 years. - Women age 30–64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years","Facility ","JPS primary care clinics submitting for NCQA designation. ","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",266483.69388033339,"Yes/No","RHP 10_126675104.3.15_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",266483.69388033339,"Yes/No","RHP 10_126675104.3.15_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",295618.28000000003,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",295618.28000000003,"Numeric",0.68369999999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1384290.33,"Numeric",0.69384000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.60988799999999999,14927,24475,"7/1/2013 - 6/30/2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.68369999999999997,null,0.69384000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The Numerator includes women 21-64 years of age who were screened for cervical cancer using either of the following; 1. Women age 21-64 who had cervical cystology performed every 3 years, 2. Women age 30-64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years.  Completed tests are indicated with one of the following; 1. pap smear and pap smear with HPV test with order status of \"resulted\" or \"completed,\" ICD 9 PX indicating pap smear was completed, or overrides resolution relating to pap smear thru the health maintenance section that was done (excluding declined status).","Baseline indicates JPS is below the 25th percentile ranking as compared to the national benchmark (source: NCQA).","Cervical Cancer Screening ","ambulatory",null,"The number of women who were screened for cervical cancer during the measurement year or the two years prior to the measurement year.","Women 24-64 years of age as of the end of the measurement year ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.1.1 ","","Cervical Cancer Screening ",null,null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2013-07-01","2014-06-30",null,null,"RHP 10_126675104.2.2","RHP 10_126675104.3.15","RHP 10_126675104.2.2_126675104.3.15",{"$f":"COUNTIFS($FI$4:$FI231,FI231)","v":3},"RHP 10_126675104.2.2_3",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR231,FR231)","v":43},"RHP 10_126675104_43"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.3","126675104.3.18","IT-9.2","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","Baseline Approved","Eligible to Report in October DY4","Improve care transition and health outcomes for the Tarrant County population designated as Homeless.  Multi-disciplinary teams of medical, behavioral health, advanced practices, paramedics, and care transition support staff will be deployed to provide services to individuals living on the streets, shelters, or in supportive housing.","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","In DY4 and DY5, the provider will improve the rate of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period over all ED visits for individuals 18 years or older during the measurement period who qualify for charity-like care related to homeless status. ","Payer ","payer and will be inclusive of patients who qualify for charity-like care related to homeless status.  These patients are classified as homeless by the definition of HUD and receive charity support through multiple organizations in the Tarrant County community for a broad array of medical and social services.  The population of those receiving homeless services are matched up against the JPS EMR system to identify the intersection and measure healthcare utilization.   The intervention group will be 15-25% of those classified as homeless in a given year and receiving charity-like care for homelessness.\n","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",58983.337465000004,"Yes/No","RHP 10_126675104.3.18_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",58983.337465000004,"Yes/No","RHP 10_126675104.3.18_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",65431.97,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",65431.97,"Numeric",0.200217477,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",306397.96999999997,"Numeric",0.18967999999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.210755,1066,5058,"07/01/13 - 06/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.200217477,null,0.18967999999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator includes any ED visits for patients 18 and older with a primary or secondary ACSC diagnosis during the measurement period. Denominator includes all ED visits for individuals 18 years and older during the measurement period.","During the period of 7/1/2013 through 6/30/2014 21.8 percent of TCHC patients flagged as possibly homeless who presented at the JPS emergency department had a primary or secondary diagnosis of an ambulatory care sensitive condition.","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","ED",null,"Total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.12.2","","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ",null,null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2013-07-01","2014-06-30",null,null,"RHP 10_126675104.2.3","RHP 10_126675104.3.18","RHP 10_126675104.2.3_126675104.3.18",{"$f":"COUNTIFS($FI$4:$FI232,FI232)","v":1},"RHP 10_126675104.2.3_1",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR232,FR232)","v":44},"RHP 10_126675104_44"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.4","126675104.3.19","IT-3.3","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","Baseline Approved","Eligible to Report in April DY4","Implementing an outpatient congestive heart failure (CHF) clinic program. Inpatients with CHF who are at high risk of readmission for CHF will be enrolled in the program, which we have named Care Transitions.","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","In DY4 and DY5, provider will improve the ratio of observed to expected readmissions that occur within 30 days following discharge from an index admission for CHF for patients 18 years of age and older. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",13611.539415000003,"Yes/No","RHP 10_126675104.3.19_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",13611.539415000003,"Yes/No","RHP 10_126675104.3.19_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",15099.684999999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",15099.69,"Numeric",0.83025210100000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",70707.22,"Numeric",0.786555,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",0.87395,20.8,23.8,"CY 2013: Jan 1st, 2013 - Dec 31st, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.83025210100000002,null,0.786555,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"JPS Hospital is using an Indirect Standardization model using vendor provided normative data.  Data reported by the Dallas/ Fort Worth Hospital Council (DFWHC) is reported by APR DRG, SOI, and age >= 85. All inpatient discharges from 70 hospitals in North Texas have been included in the normative data set.\n\nStep 1.  All eligible Index Admission cases are identified \n\nStep 2.  Individual index cases are categorized by APR DRG, SOI, and age > = 85\n\nStep 3.  All Index Admissions that resulted in a readmission within 30 days of discharge are flagged as an Observed Readmission.\n\nStep 4.  The Observed Readmission Rate is calculated by dividing the number of actual readmissions from step 3 by the number of Index Admissions from step 1.\n\nStep 5.  Using DFWHC data, the expected rate of readmission for each index admission is determined.  A value is assigned to each eligible Index admission of the likelihood to be readmitted based on matching APR DRG, SOI, and age >= 85 in the normative data set.\n\nStep 6.  Calculate the Expected number of readmission by summing the values of step 5 for all Index Admissions.\n\nStep 7.  Calculate the Expected Readmission Rate by dividing the number of Expected Readmissions in Step 6 by the number of Index Admissions from step 1.\n\nStep 8. Calculate the Risk Adjusted Readmission Rate by dividing the Observed Readmission Rate from step 4 by the Expected Readmission Rate from step 7 to determine the Observed to Expected Ratio.\n","The baseline O/E ratio is 0.87.  The observed rate from JPS to JPS only readmissions is 13% less than the expected rated across all hospitals in the DFW Hospital Council region for similar patients.","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission for CHF during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk CHF admissions during the measurement period.\n","Expected (risk-adjusted) rate of readmissions for CHF during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc. \n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.12.1","","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate",null,null,null,null,"DFW Hospital Council data representing 70 North Texas Region hospitals","2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 10_126675104.2.4","RHP 10_126675104.3.19","RHP 10_126675104.2.4_126675104.3.19",{"$f":"COUNTIFS($FI$4:$FI233,FI233)","v":1},"RHP 10_126675104.2.4_1",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR233,FR233)","v":45},"RHP 10_126675104_45"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.4","126675104.3.20","IT-6.2.b","Visit-Specific Satisfaction Instrument (VSQ-9)","Baseline Approved","Eligible to Report in October DY4","Implementing an outpatient congestive heart failure (CHF) clinic program. Inpatients with CHF who are at high risk of readmission for CHF will be enrolled in the program, which we have named Care Transitions.","Visit-Specific Satisfaction Instrument (VSQ-9)","In DY4 and DY5, the provider will improve the average score on the Visit-Specific Satisfaction Instrument (VSQ-9) survey out of all surveys completed by CHF patients in the Cardiology Clinic. ","Facility, Comorbid Condition ","CHF patients with Cardiology Clinic Encounters","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",13611.539415000003,"Yes/No","RHP 10_126675104.3.20_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",13611.539415000003,"Yes/No","RHP 10_126675104.3.20_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",15099.684999999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",15099.69,"Numeric",90.438070400000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",70707.22,"Numeric",90.941329859999996,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",89.934809999999999,344900,3835,"04/01/14 - 08/31/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,90.438070400000001,null,90.941329859999996,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator\nDescription: The total number VSQ-9 surveys completed during the measurement period. Providers must report a minimum of 30 cases per measure during a 12-month measurement period (15 cases for a 6-month measurement period)\nInclusions: Surveys completed in the CHF Clinic during the measurement period.  The CHF Clinic is located in the JPS Cardiology Clinic, 1400 South Main Street, Fort Worth, Texas 76104\nExclusions: None\n\nNumerator\nDescription: Sum of all the \"overall score\" of all VSQ-9 surveys completed during the measurement period. \nInclusions: Overall score from all surveys.\nExclusions: None\n","The results will yield the overall patient satisfaction score for all Congestive Heart Failure (CHF) patients surveyed during the measurement period.\nTo score the VSQ-9, the responses from each individual should be transformed linearly to a 0 to 100 scale, with 100 corresponding to \"excellent\" and 0 corresponding to \"poor.\" \n\nPoor               Fair                Good               Very Good           Excellent\n  0                    25                    50                       75                        100\n\nResponses to the 9 VSQ-9 items should then be averaged together to create a VSQ-9 \"overall score\" for each person. \n\n","Visit-Specific Satisfaction Instrument (VSQ-9)","Ambulatory",null,"Sum of all the \"overall score\" of all VSQ-9 surveys completed during the measurement period. ","The total number VSQ-9 surveys completed during the measurement period. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.12.1","","Visit-Specific Satisfaction Instrument (VSQ-9)",null,null,null,null,null,"2014-09-01","2015-08-31","2015-09-01","2016-08-31","2014-04-01","2014-08-31",null,null,"RHP 10_126675104.2.4","RHP 10_126675104.3.20","RHP 10_126675104.2.4_126675104.3.20",{"$f":"COUNTIFS($FI$4:$FI234,FI234)","v":2},"RHP 10_126675104.2.4_2",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR234,FR234)","v":46},"RHP 10_126675104_46"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.5","126675104.3.21","IT-3.22","Risk Adjusted All-Cause Readmission","Baseline Approved","Eligible to Report in October DY4","Implement a comprehensive, safe and effective discharge planning and discharge support program. Interventions will include hospital visits, home visits, care transitioning to various care settings, patient/family role coaching, preparing for doctor’s visits, education related to medications, responding to red flags, obtaining follow up appointments, etc.","Risk Adjusted All-Cause Readmission","In DY4 and DY5, provider will improve the ratio of observed to expected readmissions that occur within 30 days following discharge from an index admission for any reason for  patients 18 years and older.  ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",105262.57147600001,"Yes/No","RHP 10_126675104.3.21_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",105262.57147600001,"Yes/No","RHP 10_126675104.3.21_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",116770.895,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",116770.895,"Numeric",0.67762237700000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",546802.54,"Numeric",0.64195800000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",0.713287,0.10199999999999999,0.14299999999999999,"07/01/13 - 06/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.67762237700000005,null,0.64195800000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator value or Observed Readmission Rate was calculated by dividng the number of actual readmission from All Index Admissions that resulted in a readmission within 30 days of discharge from all eligible Index Admission cases identified.  Denominator value or Expected Readmission Rate was calculated by dividing, the sum of the values for the DFWHC data where the expected rate of readmission for each index admissoin is determined, by all eligible Index Admission cases identied.","Using data report from  Dallas/  Fort Worth Council this rate reflects unplanned all- cause readmissions after admission for any eligible codition within 30 days of hospital discharge forpatients aged 18 years and older.","Risk Adjusted All-Cause Readmission","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk admissions during the measurement period.","Expected (risk-adjusted) rate of readmissions for all-causes during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.12.1","","Risk Adjusted All-Cause Readmission",null,null,null,null,"Dallas/ Fort Worth Hospital Council","2014-07-01","2015-06-30","2015-07-01","2016-06-30","2013-07-01","2014-06-30",null,null,"RHP 10_126675104.2.5","RHP 10_126675104.3.21","RHP 10_126675104.2.5_126675104.3.21",{"$f":"COUNTIFS($FI$4:$FI235,FI235)","v":1},"RHP 10_126675104.2.5_1",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR235,FR235)","v":47},"RHP 10_126675104_47"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.5","126675104.3.22","IT-2.21","Ambulatory Care Sensitive Conditions Admissions Rate","Pending Approval","Eligible to Report in October DY4","Implement a comprehensive, safe and effective discharge planning and discharge support program. Interventions will include hospital visits, home visits, care transitioning to various care settings, patient/family role coaching, preparing for doctor’s visits, education related to medications, responding to red flags, obtaining follow up appointments, etc.","Ambulatory Care Sensitive Conditions Admissions Rate","In DY4 and DY5, the provider will improve the rate of acute care hospitalizations for ambulatory care sensitive conditions out of all patients receiving care through the JPS System (ambulatory and inpatients) ages 18-75 years old. ","Facility","JPS System (inpatient and ambulatory)","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",105262.57147600001,"Yes/No","RHP 10_126675104.3.22_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",105262.57147600001,"Yes/No","RHP 10_126675104.3.22_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",116770.89748799999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",116770.89748799999,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",546802.53830639995,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator determined by total number of acute care hospitalizations for ambulatory care sensitive conditions younger than age 75 years.  Inclusions are based on a list of conditoins develped Billings et al., any one most responsible diagnosis code of gran mal status and other epileptic convulsions, chronic obstructive pulmonary diseases, asthma, heart failure and pulmonary edema, hypertension, angina or diabetes.  Exclusions include individuals age 75 and older, and death before discharge. Denominator determined by total mid-measurement period population younger than age 75 years with Inclusions or total mid-measurement period population younger than age 75 years and exclusions of the Measure Steward does not identify specific denominator exclusions beyond what is described in teh denominator description.","This baseline rate is reflecting overall results to improve upon for ambulatory case sensitive conditions: age-standardized acute care hospitalization rate conditions where appropriate ambulatory care prevents or reduces the need for admission to the hospital, per 100,000 population younger than age 75 years.","Ambulatory Care Sensitive Conditions Admissions Rate","inpatient",null,"Total number of acute care hospitalizations for ambulatory care sensitive conditions younger than age 75 years ","Total mid-measurement period population younger than age 75",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.12.1","","Ambulatory Care Sensitive Conditions Admissions Rate",null,null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2013-07-01","2014-06-30",null,null,"RHP 10_126675104.2.5","RHP 10_126675104.3.22","RHP 10_126675104.2.5_126675104.3.22",{"$f":"COUNTIFS($FI$4:$FI236,FI236)","v":2},"RHP 10_126675104.2.5_2",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR236,FR236)","v":48},"RHP 10_126675104_48"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.6","126675104.3.23","IT-1.8","Screening and Treatment Plan for Clinical Depression ","Baseline Approved","Eligible to Report in April DY4","Fully integrated behavioral health services embedded within the primary care medical home so that patients receive whole-person care through their medical home team. Behavioral health care will be integrated into the fabric of primary care services. Clinical algorithms will be developed and implemented in primary care to ensure that those patients with high medical needs but low behavioral health needs can still receive quality medical interventions for depression and anxiety.","Depression management: Screening and Treatment Plan for Clinical Depression ","In DY4 and DY5, the provider will improve the percentage of patient's screened for clinical depression is documented and follow up plan is documented over all patient 18 years of age and older seen at a PCP in a PCMH facility within the JPS networks ","Facility ","Individuals seen by a PCP in the PCMH facilities within JPS Health Network","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",192830.14171250004,"Yes/No","RHP 10_126675104.3.23_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",192830.14171250004,"Yes/No","RHP 10_126675104.3.23_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",213912.20499999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",213912.2,"Numeric",0.494867787,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1001685.68,"Numeric",0.521453693,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.46828199999999998,3595,7677,"CY2013 (1): January 1, 2013- June 30, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.494867787,null,0.521453693,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator: Patients age 18 and older in the PCMH clinics \nNumerator Quality-Data Coding Options for Reporting Satisfactorily: Individuals screened for depression using the following criteria:\nScreening for Clinical Depression Documented as Positive, AND Follow-Up Plan Documented \n(One quality-data code [G8431or G8510] is required on the claim form to submit this numerator option) \nG8431: Screening for clinical depression is documented as being positive AND a follow-up plan is documented \nOR \nScreening for Clinical Depression Documented as Negative, Follow-Up Plan not Required \nG8510: Screening for clinical depression is documented as negative, a follow-up plan is not required \nOR \nScreening for Clinical Depression not Documented, Patient not Eligible \n(One quality-data code [G8433 or G8940] is required on the claim form to submit this numerator option) \nG8433: Screening for clinical depression not documented, documentation stating the patient is not eligible \nOR \nScreening for Clinical Depression Documented as Positive, Follow-Up Plan not Documented, Patient not Eligible \nG8940: Screening for clinical depression documented as positive, a follow-up plan not documented, documentation stating the patient is not eligible \nOR \nScreening for Clinical Depression not Documented, Reason not Given \n(One quality-data code [G8432 or G8511] is required on the claim form to submit this numerator option) \nG8432: Clinical depression screening not documented, reason not given \nVersion 8.0 CPT only copyright 2013 American Medical Association. All rights reserved. 12/13/13 271 of 613 \n OR \nScreening for Clinical Depression Documented as Positive, Follow-Up Plan not Documented, Reason not Given \nG8511: Screening for clinical depression documented as positive, follow-up plan not documented, reason not given\nwith a depression screening and follow up plan noted.","The percentage rate will be calculated by getting a count all patients screening and follow-up plan documented for the numerator and dividing that amount by all cases in the denominator and multiplying the result by 100 to get a percentage.","Screening and Treatment Plan for Clinical Depression ","Multiple",null,"Patient’s screening for clinical depression using a standardized tool AND follow-up plan is documented","All patients aged 18 years and older",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.15.1","","Screening and Treatment Plan for Clinical Depression ",null,null,null,null,null,"2013-07-01","2014-06-30","2014-07-01","2015-06-30","2013-01-01","2013-06-30",null,null,"RHP 10_126675104.2.6","RHP 10_126675104.3.23","RHP 10_126675104.2.6_126675104.3.23",{"$f":"COUNTIFS($FI$4:$FI237,FI237)","v":1},"RHP 10_126675104.2.6_1",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR237,FR237)","v":49},"RHP 10_126675104_49"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.6","126675104.3.24","IT-1.10","Diabetes care: HbA1c poor control (>9.0%) ","Baseline Approved","Eligible to Report in October DY4","Fully integrated behavioral health services embedded within the primary care medical home so that patients receive whole-person care through their medical home team. Behavioral health care will be integrated into the fabric of primary care services. Clinical algorithms will be developed and implemented in primary care to ensure that those patients with high medical needs but low behavioral health needs can still receive quality medical interventions for depression and anxiety.","Diabetes care: HbA1c poor control (>9.0%) ","In DY4 and DY5, the provider will improve the percentage of patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year over all patients seen by a PCP in a PCMH facility in the JPS network, 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year","Facility ","Individuals seen by a PCP in the PCMH facilities within JPS Health Network","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",192830.14171250004,"Yes/No","RHP 10_126675104.3.24_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",192830.14171250004,"Yes/No","RHP 10_126675104.3.24_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",213912.20499999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",213912.20499999999,"Numeric",0.3512186602307511,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1001685.68,"Numeric",0.3443610313162232,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.358076289145279,6083,16988,"07/01/13 - 06/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.3512186602307511,null,0.3443610313162232,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator: Patient 18-75 years old during the measurement period who had at least one (1) outpatient PCMH Clinic encounter in the prior 12-month period with diagnosis diabetes (type 1 and type 2)\nNumerator: PCMH patients 18–75 years of age with diabetes (type 1 and type 2) who had HbA1c > 9.0%","Numerator = sum(PCMH Patient HgbA1c result greater than 9.0 or not completed)\nDenominator = sum(PCMH patient 18 thru 75 yrs old with 1 ov in pcmh clinic in prior 12 m dx diabetic minus poly cyst ova/gest diab exclusion)\nRate = Numerator / Denominator x 100\n","Diabetes care: HbA1c poor control (>9.0%) ","ambulatory",null,"Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.15.1","","Diabetes care: HbA1c poor control (>9.0%) ",null,null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2013-07-01","2014-06-30",null,null,"RHP 10_126675104.2.6","RHP 10_126675104.3.24","RHP 10_126675104.2.6_126675104.3.24",{"$f":"COUNTIFS($FI$4:$FI238,FI238)","v":2},"RHP 10_126675104.2.6_2",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR238,FR238)","v":50},"RHP 10_126675104_50"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.7","126675104.3.26","IT-3.14","Behavioral Health /Substance Abuse 30-day Readmission Rate ","Baseline Approved","Eligible to Report in October DY4","Create a comprehensive Behavioral Health Discharge Management Program based on evidence-based models. Psychiatric professionals will be responsible for proactive pre- and post-discharge interaction, intervention, and coordination with patients discharged from Trinity Springs Pavilion (JPS’ 96 bed psychiatric facility) as they return to the community","Behavioral Health /Substance Abuse 30-day Readmission Rate ","In DY4 and DY5, the provider will report the rate of readmission for any cause within 30 days of the discharge date for the index hospitalization related to BH/SA from Trinity Springs Pavilion, excluding a specified set of planned readmissions. In addition, in DY5 provider will complete Stretch Activity #3 (SA3)- Outcome Evaluation.","Facility "," Same facility readmits to Trinity Springs Pavilion only","P4R","SA3","PM-8","Submission of Category 3 DY3 Status Report",132485.65030600003,"Yes/No","RHP 10_126675104.3.26_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",132485.65030600003,"Yes/No","RHP 10_126675104.3.26_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",293940.53505599999,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",344108.49393420003,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",344108.49393420003,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.1090146750524109,104,954,"CY 2014 (1): January 1, 2014 - June 30, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator: Total number of hospital stays for HB/SA during the measurement year for patients 18 years of age and older.\nNumerator: Total number of admissions (index stay) with at least one subsequent readmission (hospital stay) for any reason within 30 days during the measurement year.","The percentage rate will be calculated by adding all TSP index records with a readmit flag in the numerator and dividing it by all the TSP discharges in the denominator and multiplying the result by 100 to a percentage.","Behavioral Health /Substance Abuse 30-day Readmission Rate ","inpatient",null,"Total number of admissions (index stay) with at least one subsequent readmission (hospital stay) for any reason within 30 days during the measurement year","Total number of hospital stays for BH/SA during the measurement year for patients 18 years of age and older.",null,null,null,null,null,null,null,null,null,null,"Current activites have included discussions about which stretch activity to select for this measure and how to implement. The activity is a measure of program outcomes and improvements specifcally related to the Category 2 project. The improvement of patient outcomes in this project are related to the overall collection projects through reducing beahvioral health readmissions, increasing outpatient utlization for behavioral health care, and improving consumer satifaction for access to care. ",null,null,"2.17.1","","Behavioral Health /Substance Abuse 30-day Readmission Rate ",null,null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2014-01-01","2014-06-30",null,null,"RHP 10_126675104.2.7","RHP 10_126675104.3.26","RHP 10_126675104.2.7_126675104.3.26",{"$f":"COUNTIFS($FI$4:$FI239,FI239)","v":1},"RHP 10_126675104.2.7_1",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR239,FR239)","v":51},"RHP 10_126675104_51"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.7","126675104.3.27","IT-1.18","Follow-Up After Hospitalization for Mental Illness ","Baseline Approved","Eligible to Report in October DY4","Create a comprehensive Behavioral Health Discharge Management Program based on evidence-based models. Psychiatric professionals will be responsible for proactive pre- and post-discharge interaction, intervention, and coordination with patients discharged from Trinity Springs Pavilion (JPS’ 96 bed psychiatric facility) as they return to the community","Follow-Up After Hospitalization for Mental Illness ","In DY4 and DY5, the provider will improve the percentage of individuals with an outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 7- and 30-days after discharge over all patients 6 years and older as of the date of discharge who were discharged alive from  Trinity Springs Pavilion to a JPS Behavioral Health Outpatient Clinic  with a principal diagnosis of mental illness during the first 11 months of the measurement year","Facility ","Only patients discharging from Trinity Springs Pavilion discharges from Trinity Springs Pavilion with a disposition of home or self care to a JPS Behavioral Health Outpatient Clinic for 7 or 30 day follow up;  . ","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",132485.65030600003,"Yes/No","RHP 10_126675104.3.27_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",132485.65030600003,"Yes/No","RHP 10_126675104.3.27_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",146970.267528,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- 7 day follow-up",73485.133763999998,"Numeric",0.18542819999999999,"AM-1.2","Achievement of DY4 performance goal- 30 day follow-up",73485.133763999998,"Numeric",0.3125173,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- 7 day follow-up",344108.49393420003,"Numeric",0.22830039999999999,"AM-2.2","Achievement of DY5 performance goal- 30 day follow-up",344108.49393420003,"Numeric",0.34870060000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"%",0.14255599999999999,406,2848,"07/01/13 - 06/30/14",0.27633400000000002,787,2848,"07/01/13 - 06/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0.18542819999999999,null,0.22830039999999999,null,0.3125173,null,0.34870060000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator: Patients 6 years and older as of the date of discharge who were discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal diagnosis of mental illness during the first 11 months of the measurement year.\nNumerator: \n30-Day Follow-Up:  An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner with 30 days after discharge.\n7-Day Follow-Up:  An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 7 days after discharge.\n","The percentage rate will be calculated by adding all the cases in the numerator and dividing it by all the cases in the denominator and multiplying the result by 100 to a percentage.","Follow-Up After Hospitalization for Mental Illness ","ambulatory",null,"Rate #1: 7-Day Follow-Up: An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 7 days after discharge. ","Patients 6 years and older as of the date of discharge who were discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal diagnosis of mental illness during the first 11 months of the measurement year. ","Rate #2: 30-Day Follow-Up: An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 30 days after discharge. ","Patients 6 years and older as of the date of discharge who were discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal diagnosis of mental illness during the first 11 months of the measurement year. ",null,null,null,null,null,null,null,null,null,null,null,"2.17.1","","7 day follow-up","30 day follow-up",null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2013-07-01","2014-06-30",null,null,"RHP 10_126675104.2.7","RHP 10_126675104.3.27","RHP 10_126675104.2.7_126675104.3.27",{"$f":"COUNTIFS($FI$4:$FI240,FI240)","v":2},"RHP 10_126675104.2.7_2",null,3,2,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR240,FR240)","v":52},"RHP 10_126675104_52"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.8","126675104.3.52","IT-2.21","Ambulatory Care Sensitive Conditions Admissions Rate","Pending Approval","Eligible to Report in October DY4","Navigate patients at risk for potentially preventable emergency department (ED) visits and hospital admissions to more safe and effective settings for their healthcare needs.","Ambulatory Care Sensitive Conditions Admissions Rate","In DY4 and DY5, the provider will improve the rate of acute care hospitalizations for ambulatory care sensitive conditions younger than age 75 years","Facility","JPS System (inpatient and ambulatory)","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",120688.98281300001,"Yes/No","RHP 10_126675104.3.52_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",120688.98281300001,"Yes/No","RHP 10_126675104.3.52_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",133883.87384399999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",133883.87384399999,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",626937.39305820002,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator was determined by the total number of acute care hospitalizations for ambulatory care sensitive conditions in patients younger than age 75 years. Demoninator was determined by the total mid-measurement period population younger than age 75.","During the period of 7/1/2013 through 6/30/2014, 8.19 percent of patients age 75 or younger who had an acute care hospitaliztion at JPS had a primary or secondary diagnosis of an ambulatory care sensitive condition.","Ambulatory Care Sensitive Conditions Admissions Rate","inpatient",null,"Total number of acute care hospitalizations for ambulatory care sensitive conditions younger than age 75 years ","Total mid-measurement period population younger than age 75",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1 ","","Ambulatory Care Sensitive Conditions Admissions Rate",null,null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2013-07-01","2014-06-30",null,null,"RHP 10_126675104.2.8","RHP 10_126675104.3.52","RHP 10_126675104.2.8_126675104.3.52",{"$f":"COUNTIFS($FI$4:$FI241,FI241)","v":1},"RHP 10_126675104.2.8_1",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR241,FR241)","v":53},"RHP 10_126675104_53"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.9","126675104.3.31","IT-1.8","Screening and Treatment Plan for Clinical Depression ","Baseline Approved","Eligible to Report in April DY4","Create a virtual psychiatric and clinical guidance service to 1,802 primary care providers in Region 10. The virtual psychiatric and clinical guidance service will allow medical professionals in primary care settings to access behavioral health professionals (psychiatrists, psychiatric nurses, psychiatric social workers) via telephone, facsimile, and e-mail who will support PCPs delivering services regionally with the necessary resources and guidance to adequately treat patients who present with a wide variety of behavioral health conditions.","Depression management: Screening and Treatment Plan for Clinical Depression ","In DY4 and DY5, the provider will improve the percentage of patients screened for clinical depression is documented and follow up plan is documented over all patients 18 years of age and older and seen by a JPS primary care provider","Facility ","Only patients of JPS Primary Care Providers","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",346640.53710200003,"Yes/No","RHP 10_126675104.3.31_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",346640.53710200003,"Yes/No","RHP 10_126675104.3.31_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",384538.64500000002,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",384538.65,"Numeric",0.494867787,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1800677.32,"Numeric",0.521453693,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.46828199999999998,3595,7677,"CY2013 (1): January 1, 2013- June 30, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.494867787,null,0.521453693,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator: Patients age 18 and older in the PCMH clinics \nNumerator Quality-Data Coding Options for Reporting Satisfactorily: Individuals screened for depression using the following criteria:\nScreening for Clinical Depression Documented as Positive, AND Follow-Up Plan Documented \n(One quality-data code [G8431or G8510] is required on the claim form to submit this numerator option) \nG8431: Screening for clinical depression is documented as being positive AND a follow-up plan is documented \nOR \nScreening for Clinical Depression Documented as Negative, Follow-Up Plan not Required \nG8510: Screening for clinical depression is documented as negative, a follow-up plan is not required \nOR \nScreening for Clinical Depression not Documented, Patient not Eligible \n(One quality-data code [G8433 or G8940] is required on the claim form to submit this numerator option) \nG8433: Screening for clinical depression not documented, documentation stating the patient is not eligible \nOR \nScreening for Clinical Depression Documented as Positive, Follow-Up Plan not Documented, Patient not Eligible \nG8940: Screening for clinical depression documented as positive, a follow-up plan not documented, documentation stating the patient is not eligible \nOR \nScreening for Clinical Depression not Documented, Reason not Given \n(One quality-data code [G8432 or G8511] is required on the claim form to submit this numerator option) \nG8432: Clinical depression screening not documented, reason not given \nVersion 8.0 CPT only copyright 2013 American Medical Association. All rights reserved. 12/13/13 271 of 613 \n OR \nScreening for Clinical Depression Documented as Positive, Follow-Up Plan not Documented, Reason not Given \nG8511: Screening for clinical depression documented as positive, follow-up plan not documented, reason not given\nwith a depression screening and follow up plan noted.","The percentage rate will be calculated by getting a count all patients screening and follow-up plan documented for the numerator and dividing that amount by all cases in the denominator and multiplying the result by 100 to get a percentage.","Screening and Treatment Plan for Clinical Depression ","Multiple",null,"Patient’s screening for clinical depression using a standardized tool AND follow-up plan is documented","All patients aged 18 years and older",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.16.1","","Screening and Treatment Plan for Clinical Depression ",null,null,null,null,null,"2013-07-01","2014-06-30","2014-07-01","2015-06-30","2013-01-01","2013-06-30",null,null,"RHP 10_126675104.2.9","RHP 10_126675104.3.31","RHP 10_126675104.2.9_126675104.3.31",{"$f":"COUNTIFS($FI$4:$FI242,FI242)","v":1},"RHP 10_126675104.2.9_1",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR242,FR242)","v":54},"RHP 10_126675104_54"]
["RHP 10","126675104","John Peter Smith Hospital","126675104.2.9","126675104.3.54","IT-1.9","Depression Remission at Twelve Months  ","Pending Approval","Eligible to Report in October DY4","Create a virtual psychiatric and clinical guidance service to 1,802 primary care providers in Region 10. The virtual psychiatric and clinical guidance service will allow medical professionals in primary care settings to access behavioral health professionals (psychiatrists, psychiatric nurses, psychiatric social workers) via telephone, facsimile, and e-mail who will support PCPs delivering services regionally with the necessary resources and guidance to adequately treat patients who present with a wide variety of behavioral health conditions.","Depression management: Depression Remission at Twelve Months  ","In DY4 and DY5, the provider will improve the percentage adults age 18 and older with a diagnosis of major depression, dysthymia or any depressive disorders including 311.0 for Depression NOS with an initial PHQ-9 score greater than nine who achieve remission at twelve months as demonstrated by a twelve month (+/- 30 days) PHQ-9 score of less than five over all adults seen by a JPS primary care provider age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine ","Facility, Comorbid Condition ","Only Patients of a JPS Primary Care Provider; include all depressive disorders in this measure including 311.0 for Depression NOS","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",346640.53710200003,"Yes/No","RHP 10_126675104.3.54_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",346640.53710200003,"Yes/No","RHP 10_126675104.3.54_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",384538.64517599996,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",384538.64517599996,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1800677.3244228,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator: Adults age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine.\nNumerator: The results will yield a rate for patients who had a positive PHQ-9 screening score > 9 that had a follow-up score < 5  within (12)  (+/- 30 days) months after initial positive screening","NUM / DEN * 100 to get rate.","Depression Remission at Twelve Months  ","ambulatory",null,"Adults age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine who achieve remission at twelve months as demonstrated by a twelve month (+/- 30 days) PHQ-9 score of less than five.","Adults age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine (including, patients who do not have a follow-up PHQ-9 score at twelve months (+/- 30 days)",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.16.1","","Depression Remission at Twelve Months  ",null,null,null,null,null,"2013-07-01","2014-06-30","2014-07-01","2015-06-30","2013-01-01","2013-06-30",null,null,"RHP 10_126675104.2.9","RHP 10_126675104.3.54","RHP 10_126675104.2.9_126675104.3.54",{"$f":"COUNTIFS($FI$4:$FI243,FI243)","v":2},"RHP 10_126675104.2.9_2",null,2,1,1,"RHP 10_126675104",{"$f":"COUNTIFS($FR$4:$FR243,FR243)","v":55},"RHP 10_126675104_55"]
["RHP 10","126686802","UT Southwestern Faculty Practice Plan ","126686802.2.100","126686802.3.100","IT-12.1","Breast Cancer Screening","Baseline Approved","Eligible to Report in October DY4","UTSW-MCI will develop and implement an evidence-based mobile survivorship program, reducing transportation, language and cultural access barriers-to- care by providing post-treatment cancer screening, surveillance and bilingual survivorship services to cancer survivors in rural communities.","Breast Cancer Screening","In DY4 and DY5 Provider will improve the percentage of Medicaid or uninsured women ages 40 to 74 with a prior cancer diagnosis who have had at least one mammogram in the last 2 years. ","Payer, Comorbid Condition, Age, ","The denominator subset accounts for all women, ages 40 - 74, with a previous cancer diagnosis and uninsured or enrolled in Medicaid. ","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",77356.5,"Yes/No","RHP 10_126686802.3.100_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",77356.5,"Yes/No","RHP 10_126686802.3.100_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",82890,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",82890,"Numeric",0.44819999999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",285309,"Numeric",0.46614,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.28933999999999999,57,197,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.44819999999999999,null,0.46614,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator value includes all women enrolled in the program, requiring them to have a cancer diagnosis and either be enrolled in Medicaid or low income uninsured, and who are between 40  and 74 years of age.  Of these women, the numerator then includes only those who have completed a mammogram in the last 2 years (October 1, 2012 - September 30, 2014).","During the defined screening period (October 1, 2012 - September 30, 2014), 28.93% of low-income uninsured and Medicaid enrolled women with a previous diagnosis of cancer have completed a mammogram.  ","Breast Cancer Screening","ambulatory",null,"Women who had mammogram during the measurement year or the 18 months prior to the measurement year.","Women 50-74 years old as of the measurement year who had at least one (1) outpatient encounter in the prior 12-month period. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.7.2","","Breast Cancer Screening",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 10_126686802.2.100","RHP 10_126686802.3.100","RHP 10_126686802.2.100_126686802.3.100",{"$f":"COUNTIFS($FI$4:$FI244,FI244)","v":1},"RHP 10_126686802.2.100_1",null,2,1,1,"RHP 10_126686802",{"$f":"COUNTIFS($FR$4:$FR244,FR244)","v":1},"RHP 10_126686802_1"]
["RHP 10","126686802","UT Southwestern Faculty Practice Plan ","126686802.2.100","126686802.3.101","IT-12.3","Colorectal Cancer Screening ","Pending Approval","Eligible to Report in October DY4","UTSW-MCI will develop and implement an evidence-based mobile survivorship program, reducing transportation, language and cultural access barriers-to- care by providing post-treatment cancer screening, surveillance and bilingual survivorship services to cancer survivors in rural communities.","Colorectal Cancer Screening ","In DY4 and DY5 Provider will improve the percentage of Medicaid/uninsured persons ages 50 to 74 with a prior cancer diagnosis (excluding colon cancer) who have had at least one colorectal screening. ","Payer, Comorbid Condition ","The denominator subset accounts for all persons, ages 50 - 74, with a previous cancer diagnosis, excluding colorectal cancer, and uninsured or enrolled in Medicaid.  ","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",77356.5,"Yes/No","RHP 10_126686802.3.101_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",77356.5,"Yes/No","RHP 10_126686802.3.101_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",82890,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",82890,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",285309,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator value includes all persons enrolled in the program, requiring them to have a cancer diagnosis and either be enrolled in Medicaid or low income uninsured, who are between 50  and 74 years of age, and cancer diagnosis was something other than Colorectal Cancer.  Of these persons, the numerator then includes only those who are current with their Colorecatal Cancer Screening or completed their Colorectal Cancer Screening  in DY3 (October 1, 2013 - September 30, 2014).","During the defined screening period (October 1, 2013 - September 30, 2014), 20.28% of low-income uninsured and Medicaid enrolled persons with a previous diagnosis of cancer other than Colorectal Cancer are current or have completed their Colorectal Cancer Screening.  ","Colorectal Cancer Screening ","ambulatory",null,"One or more screenings for colorectal cancer. Any of the following meet the criteria: \n\n• Fecal occult blood test (FOBT) during the measurement year. For administrative data, assume the required number of samples were returned regardless of FOBT type.\n• Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year.\n• Colonoscopy during the measurement year or the nine years prior to the measurement year.\n","Patients 51–75 years of age as of the end of the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.7.2","","Colorectal Cancer Screening ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 10_126686802.2.100","RHP 10_126686802.3.101","RHP 10_126686802.2.100_126686802.3.101",{"$f":"COUNTIFS($FI$4:$FI245,FI245)","v":2},"RHP 10_126686802.2.100_2",null,2,1,1,"RHP 10_126686802",{"$f":"COUNTIFS($FR$4:$FR245,FR245)","v":2},"RHP 10_126686802_2"]
["RHP 10","126686802","UT Southwestern Faculty Practice Plan ","126686802.2.100","126686802.3.102","IT-12.13","Mammography follow-up rate ","Pending Approval","Eligible to Report in October DY4","UTSW-MCI will develop and implement an evidence-based mobile survivorship program, reducing transportation, language and cultural access barriers-to- care by providing post-treatment cancer screening, surveillance and bilingual survivorship services to cancer survivors in rural communities.","Mammography follow-up rate ","In DY4 and DY5 provider will improve (increase) the percentage of patients with mammography screening studies that are followed within 45 days by a diagnostic mammography or ultrasound of the breast study in an outpatient or office setting.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",77356.5,"Yes/No","RHP 10_126686802.3.102_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",77356.5,"Yes/No","RHP 10_126686802.3.102_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",82890,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",82890,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",285309,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator value includes all women enrolled in the program, requiring them to have a cancer diagnosis and either be enrolled in Medicaid or low income uninsured, and who are between 40  and 74 years of age andhad an abnormal mammogram result in the last 2 years  Of these women, the numerator then includes only those who were navigated to clinical resolution (diagnsotic mammogram, ultrasound, or MRI) within 45 days of the abnormal result.","During the defined screening period (October 1, 2012 - September 30, 2014), 80.0% of low-income uninsured and Medicaid  famle cancer survivors with an abnormal mammogram result were navigated to clinical resolution (diagnsotic mammogram, ultrasound, or MRI) within 45 days.","Mammography follow-up rate ","ambulatory",null,"Number of patients who had a diagnostic mammography study, ultrasound or magnetic resonance imaging (MRI) of the breast study following a screening mammography study with abnormal results within 45 days","The number of patients who had abnormal findings on a screening mammography study.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.7.2","","Mammography follow-up rate ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 10_126686802.2.100","RHP 10_126686802.3.102","RHP 10_126686802.2.100_126686802.3.102",{"$f":"COUNTIFS($FI$4:$FI246,FI246)","v":3},"RHP 10_126686802.2.100_3",null,2,1,1,"RHP 10_126686802",{"$f":"COUNTIFS($FR$4:$FR246,FR246)","v":3},"RHP 10_126686802_3"]
["RHP 10","126686802","UT Southwestern Faculty Practice Plan ","126686802.2.100","126686802.3.103","IT-10.1.f","Functional Assessment of Cancer Therapy (FACT-G)","Baseline Approved","Eligible to Report in October DY4","UTSW-MCI will develop and implement an evidence-based mobile survivorship program, reducing transportation, language and cultural access barriers-to- care by providing post-treatment cancer screening, surveillance and bilingual survivorship services to cancer survivors in rural communities.","Functional Assessment of Cancer Therapy (FACT-G)","In DY4 and DY5 Provider will improve reported FACT-G scores out of all FACT-G assessments administered during the measurement  period.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",77356.5,"Yes/No","RHP 10_126686802.3.103_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",77356.5,"Yes/No","RHP 10_126686802.3.103_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",82890,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",82890,"Numeric",71.493750000000006,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",285309,"Numeric",76.893749999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",66.09375,4230,64,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,71.493750000000006,null,76.893749999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator value includes the total number of survey scores available for the participating population, while the numerator includes the sum of all of the surveys scored in the denominator.  ","During DY3 (October 1, 2013 - September 30, 2014), participants completing the FACT-G survey had on average, a score of 66.09.","Functional Assessment of Cancer Therapy (FACT-G)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.7.2","Scenario 2: Pre Test Only Baseline","Functional Assessment of Cancer Therapy (FACT-G)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 10_126686802.2.100","RHP 10_126686802.3.103","RHP 10_126686802.2.100_126686802.3.103",{"$f":"COUNTIFS($FI$4:$FI247,FI247)","v":4},"RHP 10_126686802.2.100_4",null,2,1,1,"RHP 10_126686802",{"$f":"COUNTIFS($FR$4:$FR247,FR247)","v":4},"RHP 10_126686802_4"]
["RHP 10","127304703","Texas Health Harris Methodist Hospital Azle","127304703.1.1","127304703.3.1","IT-9.2","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","Baseline Approved","Eligible to Report in April DY4","A Walk-in Care Clinic in Azle","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","In DY4 and DY5, the provider will improve the rate of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period over all ED visits for individuals 18 years or older during the measurement period",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",8972.8950000000004,"Yes/No","RHP 10_127304703.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",8972.8950000000004,"Yes/No","RHP 10_127304703.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",11579.64,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",11579.64,"Numeric",0.28419004599999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",49771.38,"Numeric",0.269233,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.299147,6035,20174,"CY2012: January 1, 2012 - December 31, 2012",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.28419004599999997,null,0.269233,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator and Denominator were both pulled from internal electronic health record to specifications outlined in the compendium","29.91% of all THAZ ED visits are related to ASCS conditions.","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","ED",null,"Total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1 ","","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ",null,null,null,null,null,"2013-01-01","2013-12-31","2014-01-01","2014-12-31","2012-01-01","2012-12-31",null,null,"RHP 10_127304703.1.1","RHP 10_127304703.3.1","RHP 10_127304703.1.1_127304703.3.1",{"$f":"COUNTIFS($FI$4:$FI248,FI248)","v":1},"RHP 10_127304703.1.1_1",null,2,1,1,"RHP 10_127304703",{"$f":"COUNTIFS($FR$4:$FR248,FR248)","v":1},"RHP 10_127304703_1"]
["RHP 10","127304703","Texas Health Harris Methodist Hospital Azle","127304703.1.1","127304703.3.200","IT-9.6","Emergency department (ED) visits where patients left without being seen","Pending Approval","Eligible to Report in October DY4","A Walk-in Care Clinic in Azle","Emergency department (ED) visits where patients left without being seen","In DY4 and DY5 provider will improve (decrease) the percentage of patients presenting to the emergency department (ED) who did not wait after having clinical information documented about their presenting complaint, during the time period.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",8972.8950000000004,"Yes/No","RHP 10_127304703.3.200_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",8972.8950000000004,"Yes/No","RHP 10_127304703.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",11579.64,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",11579.64,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",49771.38,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Both numerator and denominator were pulled from the internal electronic health record system using measure specifications outlined in the compendium.","3.61% of all ED visits left without being seen.","Emergency department (ED) visits where patients left without being seen","ED",null,"Number of patients presenting to the emergency department (ED) who did not wait* after having clinical information documented** about their presenting complaint, during the time period","Total number of patients presenting to the emergency department (ED), during the time period",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1 ","","Emergency department (ED) visits where patients left without being seen",null,null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 10_127304703.1.1","RHP 10_127304703.3.200","RHP 10_127304703.1.1_127304703.3.200",{"$f":"COUNTIFS($FI$4:$FI249,FI249)","v":2},"RHP 10_127304703.1.1_2",null,2,1,1,"RHP 10_127304703",{"$f":"COUNTIFS($FR$4:$FR249,FR249)","v":2},"RHP 10_127304703_2"]
["RHP 10","127304703","Texas Health Harris Methodist Hospital Azle","127304703.2.1","127304703.3.2","IT-1.7","Controlling high blood pressure ","Baseline Approved","Eligible to Report in April DY4","The goal of this project is to develop and implement a community-based innovative chronic disease management program to help low-income and unfunded residents of Tarrant and North Parker County better self-manage their chronic conditions with a particular clinical support focus on reducing the rates of uncontrolled diabetes and hypertension among project participants.","Controlling high blood pressure ","In DY4 and DY5 provider will increase the number of patients whose most recent BP is adequately controlled ( <140/90) out of all adult patients (18-85) who had at least one outpatient encounter with a diagnosis of hypertension during the first six months of the measurement year at the HELP clinic. ","Facility ","HELP Clinic Patients","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",21640.5075,"Yes/No","RHP 10_127304703.3.2_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",21640.5075,"Yes/No","RHP 10_127304703.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",27927.37,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",27927.37,"Numeric",0.50109999999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",120036.84,"Numeric",0.52010000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.408163,20,49,"DY2: Oct 1st, 2012 - Sept 30th, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.50109999999999999,null,0.52010000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator includes hypertension patients not in control.  Denominator includes all hypertension patients.  Data was pulled using measure specifications outlined in the compendium document.","40.82% of all hypertension patients seen at the HELP Clinic had adequately controlled in DY 2.","Controlling high blood pressure ","ambulatory",null,"The number of patients in the denominator whose most recent BP is adequately controlled during the measurement year. For a patient’s BP to be controlled, both the systolic and diastolic BP must be <140/90 (adequate control). To determine if a patient’s BP is adequately controlled, the representative BP must be identified.\n","Patients 18 to 85 years of age by the end of the measurement year who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.1 ","","Controlling high blood pressure ",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 10_127304703.2.1","RHP 10_127304703.3.2","RHP 10_127304703.2.1_127304703.3.2",{"$f":"COUNTIFS($FI$4:$FI250,FI250)","v":1},"RHP 10_127304703.2.1_1",null,2,1,1,"RHP 10_127304703",{"$f":"COUNTIFS($FR$4:$FR250,FR250)","v":3},"RHP 10_127304703_3"]
["RHP 10","127373205","Helen Farabee Center","127373205.1.1","127373205.3.1","IT-10.1.a.iv","Assessment of Quality of Life (AQoL-8D) ","Baseline Approved","Eligible to Report in October DY4","Provide substance abuse services in the Wise county region.","Assessment of Quality of Life (AQoL-8D) ","In DY4 and DY5 provider will improve reported scores on the AQoL-8D out of all instruments completed during the measurement period. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",10377,"Yes/No","RHP 10_127373205.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",5188.5,"Yes/No","RHP 10_127373205.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",11101,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",11101,"Numeric",52.907894740000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",48265,"Numeric",57.907894740000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",47.907890000000002,3641,76,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,52.907894740000003,null,57.907894740000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Once the random population was selected the resulting number of cases constitute the denominator. The numerator is the sum of all scores in the population. ","The baseline rate above (47.91) is the average survey score from the random sample of 76 cases  (3641 divided by 76).","Assessment of Quality of Life (AQoL-8D) ","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.12.2","Scenario 2: Pre Test Only Baseline","Assessment of Quality of Life (AQoL-8D) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 10_127373205.1.1","RHP 10_127373205.3.1","RHP 10_127373205.1.1_127373205.3.1",{"$f":"COUNTIFS($FI$4:$FI255,FI255)","v":1},"RHP 10_127373205.1.1_1",null,2,1,1,"RHP 10_127373205",{"$f":"COUNTIFS($FR$4:$FR255,FR255)","v":1},"RHP 10_127373205_1"]
["RHP 10","130606006","Wise Regional Health System","130606006.1.2","130606006.3.7","IT-9.3.a","Pediatric Emergency Department (ED) visits per 100,000","Baseline Approved","Eligible to Report in April DY4","This project will add a pediatrician to serve residents in the service area","Pediatric Emergency Department (ED) visits per 100,000","In DY4 and DY5 provider will improve (decrease) the rate of ED utilization for Pediatric  Ambulatory Care Sensitive Conditions (Pediatric Quality Indicators #14, #15, #16, and #18) out of the total number of pediatric ED visits",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",65597.649999999994,"Yes/No","RHP 10_130606006.3.7_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",65597.649999999994,"Yes/No","RHP 10_130606006.3.7_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",103740.38499999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",103740.39,"Numeric",18896.075707588123,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",479088.89,"Numeric",17901.545407188751,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",19890.606007987499,2291,11518,"DY2: Oct 1st, 2012 - Sept 30th, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,18896.075707588123,null,17901.545407188751,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator: ran report within measure defintions to determine the numerator cases. Used Emergency code, patient DOB and Admission date to filter needed claims from entire population. Denominator: Used census data from 2013 census estimates listed on US Census website (http://quickfacts.census.gov/)  to calculate the 6 thru 17 year olds of the population in Wise County. We took the 2013 estimates of total population, subtracted out the 74.6% over 18, then subtracted out the 6.5% of the total who are under 5, to get 11,518.","For the 6 to 17 year old population of Wise County, Wise Regional saw a rate of 20.07% ED visits to the number of Wise County chilren in this age range. A decreas in this rate could be achieved by a decrease in the number of ED visits by children in Wise County to Wise Regional Health System's ED.","Pediatric Emergency Department (ED) visits per 100,000","ED",null,"Total number of ED Visits during the measurement period for patients aged 6 – 17 years ","Population in Metro Area or county , age 6 – 17 years",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1 ","","Pediatric Emergency Department (ED) visits per 100,000",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,{"$f":"A260&\"_\"&D260","v":"RHP 10_130606006.1.2"},{"$f":"A260&\"_\"&E260","v":"RHP 10_130606006.3.7"},"RHP 10_130606006.1.2_130606006.3.7",{"$f":"COUNTIFS($FI$4:$FI260,FI260)","v":1},"RHP 10_130606006.1.2_1",null,2,{"$f":"IF(DC260=\"\",0,1)+IF(DG260=\"\",0,1)+IF(DK260=\"\",0,1)+IF(DO260=\"\",0,1)+IF(DS260=\"\",0,1)","v":1},1,"RHP 10_130606006",{"$f":"COUNTIFS($FR$4:$FR260,FR260)","v":3},{"$f":"FR260&\"_\"&FS260","v":"RHP 10_130606006_3"}]
["RHP 10","130606006","Wise Regional Health System","130606006.2.2","130606006.3.5","IT-3.22","Risk Adjusted All-Cause Readmission","Baseline Approved","Eligible to Report in October DY4","This project will implement a coordinated care models involving transition coordinators, CHF nurses, cardiac rehab, and local cardiologists","Risk Adjusted All-Cause Readmission","In DY4 and DY5, provider will improve the ratio of observed to expected readmissions that occur within 30 days following discharge from an index admission for any reason from  Wise Regional Health System in Decatur for patients 18 years and older. ","Facility ","Wise Regional Health System in Decatur","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",85276.945000000007,"Yes/No","RHP 10_130606006.3.5_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",85276.945000000007,"Yes/No","RHP 10_130606006.3.5_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",134862.505,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",134862.505,"Numeric",0.87496568399999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",622815.56000000006,"Numeric",0.82891499999999996,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",0.92101699999999997,0.201634276,0.2189258,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.87496568399999997,null,0.82891499999999996,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator: data for 2 years prior was pulled from reporting system, for DY1 and DY2.  This data was used to determine what our likelihood is to readmit based on each MS-DRG. We then pulled the data for DY3 and assigned this likelihood to readmit based on the MS-DRG listed using our normative data.  We discovered there were some new MS-DRGs in DY3 that had not appeared in either of DY1 or DY2, thus we had some MS-DRGs that did not have an assignable likelihood to readmit.  We then found comparable APR-DRGs for all those but 3.  Those three we assigned a liklihood to readmit at 0.  For the remaining likelihood to readmit values we used the Florida Normative values from the HHSC website, assigning the values to those APR-DRGs (18-64) that had been selected to represent the MS-DRGs.  We chose to be conservative on our severity level to be assigned, so we chose 2 (on a scale of 1-4 with 4 being the highest, and with direction from HHSC) for all those APR-DRGs.  The sum of all those values as the likelihood to readmit was then divided by the number of eligible cases for the measurement period, 4528, which calculates to .2189258. This is our numerator.  Denominator: The denominator used the actual observed number of readmits for those cases for DY3. The actual number of readmits during the measurement period (913) was divided by the number of eligible cases (4528) which calculates to .20163428.","The baseline rate is the ratio of the expected readmission rate to the observed readmission rate. A 5% improvement in this rate would be .874966, and 10% improvement would be .8289148.","Risk Adjusted All-Cause Readmission","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk admissions during the measurement period.","Expected (risk-adjusted) rate of readmissions for all-causes during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.12.1","","Risk Adjusted All-Cause Readmission",null,null,null,null,"Internal Data Historical Norms","2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 10_130606006.2.2","RHP 10_130606006.3.5","RHP 10_130606006.2.2_130606006.3.5",{"$f":"COUNTIFS($FI$4:$FI268,FI268)","v":1},"RHP 10_130606006.2.2_1",null,2,1,1,"RHP 10_130606006",{"$f":"COUNTIFS($FR$4:$FR268,FR268)","v":11},"RHP 10_130606006_11"]
["RHP 10","130614405","Texas Health Arlington Memorial Hospital ","130614405.2.1","130614405.3.202","IT-1.20","Comprehensive Diabetes Care LDL Screening","Baseline Approved","Eligible to Report in October DY4","This project expands the current diabetes education program at THAM to include a nurse practitioner run outpatient clinic for patients with diabetes.","Comprehensive Diabetes Care LDL Screening","In DY4 and DY5 provider will improve (increase) the percentage of low-income, uninsured or Medicaid THAM Outpatient  Clinic patients 18-75 years of age with diabetes (type 1 and type 2) who received an LDL-C test during the measurement year.","Facility, Payer ","Diabetic patients who are low-income, uninsured or Medicaid and are receiving  treatment at THAM Outpatient  Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",22594.875,"Yes/No","RHP 10_130614405.3.202_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",22594.875,"Yes/No","RHP 10_130614405.3.202_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",27782.94,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",27782.94,"Numeric",0.72065689700000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",122646.45,"Numeric",0.73441699999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.706897,41,58,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.72065689700000002,null,0.73441699999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator and denominator were abstracted from the internal EMR for diabetic patients and those receiving a LDL screening.  Both pulled based on measure specifications outlined in the compendium","70.7% of all Diabetic clinic patients had an LDL cholesterol screening test performed during the measurement year.","Comprehensive Diabetes Care LDL Screening","ambulatory",null,"Patients who had a low-density cholesterol (LDL-C test) performed during the measurement period.","Patients 18-75 years of age by the end of the measurement period who had a diagnosis of diabetes (type 1 or type 2) during the measurement period or the year prior to the measurement period.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.1 ","","Comprehensive Diabetes Care LDL Screening",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 10_130614405.2.1","RHP 10_130614405.3.202","RHP 10_130614405.2.1_130614405.3.202",{"$f":"COUNTIFS($FI$4:$FI274,FI274)","v":3},"RHP 10_130614405.2.1_3",null,2,1,1,"RHP 10_130614405",{"$f":"COUNTIFS($FR$4:$FR274,FR274)","v":5},"RHP 10_130614405_5"]
["RHP 10","130724106","Pecan Valley Centers","130724106.1.1","130724106.3.1","IT-11.7","Initiation of Depression Treatment","Baseline not yet reported","Eligible to Report in October DY4","This project will implement a redesign to access for services by expanding specialty care access to psychiatrists and other behavioral health providers. By decreasing wait times for services individuals will have less use of emergency rooms for behavioral health issues. This project is an expansion and enhancement of the current intake eligibility assessment process for mental health services. The expansion will be to add additional staff to impact the wait times to receive services. ","Initiation of Depression Treatment","In DY4 and DY5 provider will improve the number of adults individuals who filled at least one antidepressant Rx or had at least 3 psychotherapy visits during the 5 month period after diagnosis out of all patients who had major depression.","Age ","Adults 18 and older","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",69653.125,"Yes/No","RHP 10_130724106.3.1_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",69653.125,"Yes/No","RHP 10_130724106.3.1_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",88475,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",88475,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",378555.25,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Initiation of Depression Treatment","Ambulatory/Inpatient",null,"Patients in the denominator who filled at least one antidepressant prescription or had at least three psychotherapy visits during the 5-month period after diagnosis.","All patients seen in primary care during a specified period who had major depression based on a structured assessment administered independent of the clinical visit.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2 ","","Initiation of Depression Treatment",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 10_130724106.1.1","RHP 10_130724106.3.1","RHP 10_130724106.1.1_130724106.3.1",{"$f":"COUNTIFS($FI$4:$FI282,FI282)","v":1},"RHP 10_130724106.1.1_1",null,2,1,1,"RHP 10_130724106",{"$f":"COUNTIFS($FR$4:$FR282,FR282)","v":1},"RHP 10_130724106_1"]
["RHP 10","135036506","Baylor All Saints Medical Center Ft Worth","135036506.1.1","135036506.3.200","IT-12.3","Colorectal Cancer Screening ","Baseline Approved","Eligible to Report in October DY4","This project will implement increased access to a Patient-Centered Medical Home (PCMH) clinic designed to provide comprehensive and high-quality primary care services to underserved patients. The project is an expansion of Baylor’s Clinic strategy in Fort Worth and Tarrant County. This expansion will focus on the recruitment of more underserved (Medicaid\nand Uninsured) patients from the community at-large and patients awaiting access to other public resources\n","Colorectal Cancer Screening ","In DY4 and DY5 provider will increase the percentage of Medicaid and Uninsured individuals aged 50-75 years receiving services in the clinic that have received appropriate screening for colorectal cancer.  ","Facility, Payer ","Ambulatory Setting- Clinic, include Payer subset (Medicaid and Uninsured)","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",15413.81,"Yes/No","RHP 10_135036506.3.200_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",15413.81,"Yes/No","RHP 10_135036506.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",25939.055,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",25939.06,"Numeric",0.51,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",122373.75,"Numeric",0.53300000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.42465799999999998,155,365,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.51,null,0.53300000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DSRIP base population selection criteria for all metrics: all community care clinic patients, who had at least one office visit during one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the clinics based on their most recent visit location. Numerator: Adults aged 51-75 and at least one colonoscopy observation within 10 years or one FOBT within 1 year prior to the report date. HDIDs: (27, 2323)\n","During DY3 (10/01/2013- 9/30/2014), of those eligble adult, Uninsured/Medicaid clinic patients between the ages of 51-75, 42% of patients received a colorectal cancer screening- most likely an FOBT based on the ambulatory setting criteria. ","Colorectal Cancer Screening ","ambulatory",null,"One or more screenings for colorectal cancer. Any of the following meet the criteria: \n\n• Fecal occult blood test (FOBT) during the measurement year. For administrative data, assume the required number of samples were returned regardless of FOBT type.\n• Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year.\n• Colonoscopy during the measurement year or the nine years prior to the measurement year.\n","Patients 51–75 years of age as of the end of the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","Colorectal Cancer Screening ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 10_135036506.1.1","RHP 10_135036506.3.200","RHP 10_135036506.1.1_135036506.3.200",{"$f":"COUNTIFS($FI$4:$FI293,FI293)","v":2},"RHP 10_135036506.1.1_2",null,2,1,1,"RHP 10_135036506",{"$f":"COUNTIFS($FR$4:$FR293,FR293)","v":2},"RHP 10_135036506_2"]
["RHP 10","135036506","Baylor All Saints Medical Center Ft Worth","135036506.1.2","135036506.3.7","IT-12.2","Cervical Cancer Screening ","Baseline Approved","Eligible to Report in October DY4","This project will increase access to needed specialty care services (i.e. outpatient visits with specialty physicians, hospital-based procedures) for uninsured patients under the care of a Baylor clinic in Fort Worth. This is a new project and will provide access to specialty services previously unattainable for uninsured patients.","Cervical Cancer Screening ","In DY4 and DY5 provider will improve the percentage of Medicaid and Uninsured women aged 21-64 receiving ambulatory services at the clinic who were screened for cervical cancer  using either of the following criteria: - Women age 21–64 who had cervical cytology performed every 3 years. - Women age 30–64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years","Facility, Payer ","Ambulatory Setting- Clinic, include Payer subset (Medicaid and Uninsured)","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",19305.8,"Yes/No","RHP 10_135036506.3.7_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",19305.8,"Yes/No","RHP 10_135036506.3.7_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",32488.665000000001,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",32488.67,"Numeric",0.68369999999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",153273.13,"Numeric",0.69384000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.60796899999999998,473,778,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.68369999999999997,null,0.69384000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DSRIP base population selection criteria for all metrics: all community care clinic patients, who had at least one office visit during one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the clinics based on their most recent visit location. Numerator: Females aged 21-64 and at least one ‘PAP’ observation record within reporting period HDIDs: (73,6759,16048,11438). Denominator: Include: females aged 21-64 Exclude: Hx of radical hysterectomy – ICD Procedure codes: 68.4, 68.6, 68.7. \n","During DY3 (10/01/2013- 9/30/2014), of those eligible female adult, Uninsured/Medicaid clinic patients between the ages of 21-64, 60% of patients had a cervical cancer screen completed. ","Cervical Cancer Screening ","ambulatory",null,"The number of women who were screened for cervical cancer during the measurement year or the two years prior to the measurement year.","Women 24-64 years of age as of the end of the measurement year ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2 ","","Cervical Cancer Screening ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 10_135036506.1.2","RHP 10_135036506.3.7","RHP 10_135036506.1.2_135036506.3.7",{"$f":"COUNTIFS($FI$4:$FI296,FI296)","v":2},"RHP 10_135036506.1.2_2",null,2,1,1,"RHP 10_135036506",{"$f":"COUNTIFS($FR$4:$FR296,FR296)","v":5},"RHP 10_135036506_5"]
["RHP 10","135036506","Baylor All Saints Medical Center Ft Worth","135036506.2.4","135036506.3.203","IT-11.9","Care Planning for Dual Diagnosis","Baseline Approved","Eligible to Report in October DY4","This project will co-locate and integrate outpatient behavioral health services using an LCSW to provide counseling services. Screenings for depression, substance abuse and anxiety will also be an integral part of the program. This is a new project that has not been done before. It will help to serve the less severe behavioral health needs of the Uninsured/Medicaid population.","Care Planning for Dual Diagnosis","In DY4 and DY5 provider will increase the percentage of Medicaid and Uninsured individuals who have documented care plan addressing both diagnosis (BH and SA) out of all individuals 18-75 years old seen in the integrated care clinic.  ","Facility, Payer ","Ambulatory Setting- Clinic, include Payer subset (Medicaid and Uninsured)","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",13101.74,"Yes/No","RHP 10_135036506.3.203_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",13101.74,"Yes/No","RHP 10_135036506.3.203_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",22048.195,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",22048.195,"Numeric",0.79000769199999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",104017.69,"Numeric",0.81078461499999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.769231,10,13,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.79000769199999998,null,0.81078461499999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DSRIP base population selection criteria for all metrics: all community care clinic patients, who had at least one office visit during one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the clinics based on their most recent visit location. Numerator: Number patients 18 to 75 from the denominator for whom a case manager has documented a plan of care (HDID: 410744) that addresses a need for treatment of both a mental disorder and a substance abuse disorder. Denominator:  Number of DSRIP patients 18 to 75 who were diagnosed with both a mental disorder and a substance abuse disorder by either (a) Documented Dual Diagnosis (HDID: 410743); or (b) ICD-9 diagnosis of mental disorder  and an ICD-9 diagnosis of substance abuse disorder\n","During DY3 (4/01/2013- 9/30/2014), of those adult, Uninsured/Medicaid clinic patients with a  dual diagnosis of, 76% of patients received a treatment plan.  ","Care Planning for Dual Diagnosis","Ambulatory/Inpatient",null,"Those individuals from the denominator for whom a case manager has documented a plan of care that addresses the consumer's need for treatment of both conditions.","The number of individuals participating in a case management program who are dually diagnosed with a mental disorder and a substance abuse disorder ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.19.1","","Care Planning for Dual Diagnosis",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 10_135036506.2.4","RHP 10_135036506.3.203","RHP 10_135036506.2.4_135036506.3.203",{"$f":"COUNTIFS($FI$4:$FI304,FI304)","v":3},"RHP 10_135036506.2.4_3",null,2,1,1,"RHP 10_135036506",{"$f":"COUNTIFS($FR$4:$FR304,FR304)","v":13},"RHP 10_135036506_13"]
["RHP 10","136326908","Texas Health Harris Methodist Hospital HEB","136326908.2.3","136326908.3.4","IT-3.15","Risk Adjusted Behavioral Health /Substance Abuse 30-day Readmission Rate ","Baseline Approved","Eligible to Report in April DY4","To integrate behavioral health services in the D/FW Metroplex with primary care services.","Risk Adjusted Behavioral Health /Substance Abuse 30-day Readmission Rate ","In DY4 and DY5, provider will improve the ratio of observed to expected readmissions that occur within 30 days following discharge from an index admission for BH/SA for patients ages 18 and older. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",29018.73,"Yes/No","RHP 10_136326908.3.4_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",29018.73,"Yes/No","RHP 10_136326908.3.4_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",31043.305,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",31043.305,"Numeric",0.99922279792746105,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",148467.97,"Numeric",0.94663212435233157,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",1.0518134715025906,0.11302895322939867,0.10746102449888642,"CY 2013: Jan 1st, 2013 - Dec 31st, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.99922279792746105,null,0.94663212435233157,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator and denominator were abstracted by running Premier's 3M methodology report using measure specifications outlined in the compendium.","THHEB experiences slightly greater than expected 30-day, risk-adjusted readmissions for behavioral health.","Risk Adjusted Behavioral Health /Substance Abuse 30-day Readmission Rate ","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission for BH/SA during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk BH/SA admissions during the measurement period.\n","Expected (risk-adjusted) rate of readmissions for BH/SA during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.15.1","","Risk Adjusted Behavioral Health /Substance Abuse 30-day Readmission Rate ",null,null,null,null,"Premier","2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 10_136326908.2.3","RHP 10_136326908.3.4","RHP 10_136326908.2.3_136326908.3.4",{"$f":"COUNTIFS($FI$4:$FI310,FI310)","v":1},"RHP 10_136326908.2.3_1",null,2,1,1,"RHP 10_136326908",{"$f":"COUNTIFS($FR$4:$FR310,FR310)","v":4},"RHP 10_136326908_4"]
["RHP 10","138980111","UNT Health Science Center","138980111.1.4","138980111.3.15","IT-12.4","Pneumonia vaccination status for older adults ","Baseline not yet reported","Eligible to Report in October DY4","Development of current and future primary care workforce through providing updated primary care training programs including training on the medical home and chronic care models, disease registry use for population health management, patient panel management, oral health, and other identified training needs and/or quality/performance improvement","Pneumonia vaccination status for older adults ","In DY4 and DY5, the provider will improve the percentage of low income/uninsured patients seen at the Cornerstone Charitable Clinic in Fort Worth aged 65 years and older who have ever received a pneumococcal vaccine. ","Facility, Payer ","Payer- low-income, uninsured patients; Facility- Cornerstone Charitable Clinic in Fort Worth","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",40061.768534107192,"Yes/No","RHP 10_138980111.3.15_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",40061.768534107192,"Yes/No","RHP 10_138980111.3.15_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",85783.246192890132,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",186485.26937202655,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"dy4","TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Pneumonia vaccination status for older adults ","Ambulatory/Inpatient",null,"The number of patients in the denominator who responded “Yes” to the question “Have you ever had a pneumonia shot? This shot is usually given only once or twice in the person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.”","The number of patients who responded “Yes” or “No” to the question “Have you ever had a pneumonia shot? This shot is usually given only once or twice in a person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.” ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.2.1 ","","Pneumonia vaccination status for older adults ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 10_138980111.1.4","RHP 10_138980111.3.15","RHP 10_138980111.1.4_138980111.3.15",{"$f":"COUNTIFS($FI$4:$FI318,FI318)","v":1},"RHP 10_138980111.1.4_1",null,1,1,0,"RHP 10_138980111",{"$f":"COUNTIFS($FR$4:$FR318,FR318)","v":3},"RHP 10_138980111_3"]
["RHP 10","138980111","UNT Health Science Center","138980111.2.100","138980111.3.102","IT-1.10","Diabetes care: HbA1c poor control (>9.0%) ","Baseline Approved","Eligible to Report in October DY4","Innovative  primary care model utilizing a clinical pharmacist-led Medication Therapy Management (MTM) model to reach Medicaid eligible persons with chronic diseases (aged 18-75 years) seen by UNTHSC outpatient clinics. This is a new initiative for UNTHSC which utilizes the skills of clinical pharmacist services through increasing clinical-pharmacist led encounters, providing written medication management plans, and conducting improved patient education and medication management for patients with at least one chronic disease","Diabetes care: HbA1c poor control (>9.0%) ","In DY4 and DY5, the provider will improve the percentage of patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year over all Medicaid patients seen in the UNTHSC Eagle Ranch Clinic, 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.","Facility, Payer ","Payer- Medicaid; Facility/Service Setting- UNTHSC Eagle Ranch Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",60092.652801160788,"Yes/No","RHP 10_138980111.3.102_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",60092.652801160788,"Yes/No","RHP 10_138980111.3.102_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",64337.434999999998,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",64337.434999999998,"Numeric",0.39001194700000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",279727.90000000002,"Numeric",0.37884400000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.40117999999999998,136,339,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.39001194700000003,null,0.37884400000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator was determined by using NexGen to identify all patients with the approved denominator subsets (Medicaid, seen at Eagle Ranch Clinic) who were 18-75 years of age by the end of the measurment period who had a diagnosis of diabetes.  The numerator was determined by using NexGen to identify all patients in the denominator who had an HbA1c level greater than 9.0.","During the measurement period (04/01/14 - 09/30/14)  136 of 319 diabetic patients meeting inclusionary criteria whose HbA1c level  was greater than 9.0, resulting in a baseline of 40.12%.","Diabetes care: HbA1c poor control (>9.0%) ","ambulatory",null,"Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.11.2","","Diabetes care: HbA1c poor control (>9.0%) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 10_138980111.2.100","RHP 10_138980111.3.102","RHP 10_138980111.2.100_138980111.3.102",{"$f":"COUNTIFS($FI$4:$FI326,FI326)","v":1},"RHP 10_138980111.2.100_1",null,2,1,1,"RHP 10_138980111",{"$f":"COUNTIFS($FR$4:$FR326,FR326)","v":11},"RHP 10_138980111_11"]
["RHP 10","186221101","Methodist Mansfield Medical Center","186221101.2.2","186221101.3.3","IT-9.4.b","Reduce Emergency Department visits for Diabetes","Baseline Approved","Eligible to Report in April DY4","The primary purpose of this project is to develop and implement a chronic disease management intervention geared toward improving effective management of chronic conditions and ultimately improving patient clinical indicators, health outcomes and quality, and reducing unnecessary acute and emergency care utilization. This project is a new initiative because the hospital does not have standing orders for diabetes protocols, does not offer dedicated diabetes education on self-management and has not received any other federal funding for it.","Reduce Emergency Department visits for Diabetes","In DY4 and DY5 provider will reduce the percentage of adult ED visits for where diabetes is a primary or secondary diagnosis out of the total number of ED visits at Methodist Mansfield Medical Center","Facility ","Methodist Mansfield Medical Center","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",32098.754999999997,"Yes/No","RHP 10_186221101.3.3_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",32098.754999999997,"Yes/No","RHP 10_186221101.3.3_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",34338,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",34338,"Numeric",0.105276919,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",164226,"Numeric",9.9736000000000005E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.110818,4408,39777,"DY2: Oct 1st, 2012 - Sept 30th, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.105276919,null,9.9736000000000005E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ED visits during the measurement period (Oct 2012 - Sept 2013)  with a primary or secondary diagnosis of diabetes were extracted from the EMR based on ICD-9 diagnosis codes 250.0, 250.1, 250.2, 250.3, 250.8, 250.9 for patients 18 years and older and were applied to the numerator. The total number of ED visits (all diagnoses included) at Methodist Dallas were extracted from the EMR for patients 18 years or older and applied to the denominator.","Of the total Emergency Department visits between October 1, 2012 and September 30, 2013,  4408  of those visits had a primary or secondary diagnosis of diabetes resulting in a rate of 11.08 diabetic visits per 100 ED visits for patients 18 years and older.","Reduce Emergency Department visits for Diabetes","ED",null,"Total number of ED Visits with a primary or secondary diagnosis of diabetes for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.2 ","","Reduce Emergency Department visits for Diabetes",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 10_186221101.2.2","RHP 10_186221101.3.3","RHP 10_186221101.2.2_186221101.3.3",{"$f":"COUNTIFS($FI$4:$FI335,FI335)","v":1},"RHP 10_186221101.2.2_1",null,2,1,1,"RHP 10_186221101",{"$f":"COUNTIFS($FR$4:$FR335,FR335)","v":2},"RHP 10_186221101_2"]
["RHP 10","216719901","Glen Rose Medical Center","216719901.1.1","216719901.3.1","IT-3.22","Risk Adjusted All-Cause Readmission","Baseline Approved","Eligible to Report in April DY4","Expand clinic hours to allow residents of Somervell County to receive primary care services in an office environment therefore reducing the amount of ER visits for “clinic” type services & reducing readmissions. This is a new initiative.","Risk Adjusted All-Cause Readmission","In DY4 and DY5, provider will improve the ratio of observed to expected readmissions that occur within 30 days following discharge from an index admission for any reason from Glen Rose Medical Center for patients 18 years and older. ","Facility ","Glen Rose Medical Center readmissions","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",3037.375,"Yes/No","RHP 10_216719901.3.1_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",3037.375,"Yes/No","RHP 10_216719901.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",3250.625,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",3250.63,"Numeric",1.8025641020000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",15546.75,"Numeric",1.707692,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",1.8974359999999999,7.3999999999999996E-2,3.9E-2,"DY3 (1): Oct 1st, 2013 - March 31st, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,1.8025641020000001,null,1.707692,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"To determine the denominator, we first analyzed our historical data from 2 previous fiscal years to determine what DRG's came back as a readmission.  We then calculated our norms from that data.  We then analyzed the data for the current FY and, using the data calculated before, found what accounts could have been expected to come back as a readmission.  For DRG's that didn't have any historical readmission data, but yet were readmitted during the currrent FY, we calculated those risks using the FL all-payer norms, instead of just using 0.  That gave us our expected readmission rate of 0.0366.  We calculated the observed rate by taking the # of readmissions for the year, 50, and divided by the # of eligible cases (669) to give us our acutal readmission rate of .07331.","Our interpretation of the data is that, of the admissions in our facility, about 2% of those come back as a readmission.","Risk Adjusted All-Cause Readmission","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk admissions during the measurement period.","Expected (risk-adjusted) rate of readmissions for all-causes during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","Risk Adjusted All-Cause Readmission",null,null,null,null,"We used our own historical data to calculate the normative data.","2014-04-01","2015-03-31","2015-04-01","2016-03-31","2013-10-01","2014-03-31",null,null,"RHP 10_216719901.1.1","RHP 10_216719901.3.1","RHP 10_216719901.1.1_216719901.3.1",{"$f":"COUNTIFS($FI$4:$FI340,FI340)","v":1},"RHP 10_216719901.1.1_1",null,2,1,1,"RHP 10_216719901",{"$f":"COUNTIFS($FR$4:$FR340,FR340)","v":1},"RHP 10_216719901_1"]
["RHP 11","112692202","Fisher County Hospital District","112692202.1.1","112692202.3.3","IT-1.13","Diabetes care:  Foot exam ","Pending Approval","Eligible to Report in October DY4","This project will expand existing primary care capacity: primary care clinic space; primary care clinic hours; and primary care clinic staffing.","Diabetes care:  Foot exam ","In DY4 and DY5 provider will improve (increase) the percentage of patients 18-75 years of age with diabetes (type 1 and type 2) who received a foot exam (visual inspection with either a sensory exam or a pulse exam) during the measurement year.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",6174.165,"Yes/No","RHP 11_112692202.3.3_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",6174.165,"Yes/No","RHP 11_112692202.3.3_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",8154.5,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",8154.5,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",30477.67,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"35 patients of the 104 diabetic patients enrolled in our chronic care management program received a foot exam","33.65% of our diabetic patients received a foot exam during DY3","Diabetes care:  Foot exam ","ambulatory",null,"Patients who received a comprehensive foot exam (visual inspection with either a sensory exam or a pulse exam) during the measurement year","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2","","Diabetes care:  Foot exam ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 11_112692202.1.1","RHP 11_112692202.3.3","RHP 11_112692202.1.1_112692202.3.3",{"$f":"COUNTIFS($FI$4:$FI348,FI348)","v":2},"RHP 11_112692202.1.1_2",null,2,1,1,"RHP 11_112692202",{"$f":"COUNTIFS($FR$4:$FR348,FR348)","v":2},"RHP 11_112692202_2"]
["RHP 11","127373205","Helen Farabee Center","127373205.1.2","127373205.3.2","IT-10.1.a.iv","Assessment of Quality of Life (AQoL-8D) ","Baseline Approved","Eligible to Report in October DY4","This project expands the hours for psychiatric evaluation by expanding our current contract for telemedicine services. The expanded hours will provide for open‐access (on‐demand) routine psychiatric evaluations for individuals determined eligible to receive services under the Texas Recovery and Resiliency model.","Assessment of Quality of Life (AQoL-8D) ","In DY4 and DY5 provider will improve the reported average score on the AQoL-8. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",2883.75,"Yes/No","RHP 11_127373205.3.2_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",2883.75,"Yes/No","RHP 11_127373205.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",3085,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",3085,"Numeric",55,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",13413,"Numeric",60,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",50,2100,42,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,55,null,60,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator = sum of all test scores from all respondents. Denominator = all respondents. ","The baseline rate above (50) is the average survey score from  population (2100 divided by 42).","Assessment of Quality of Life (AQoL-8D) ","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2 ","Scenario 2: Pre Test Only Baseline","Assessment of Quality of Life (AQoL-8D) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 11_127373205.1.2","RHP 11_127373205.3.2","RHP 11_127373205.1.2_127373205.3.2",{"$f":"COUNTIFS($FI$4:$FI360,FI360)","v":1},"RHP 11_127373205.1.2_1",null,2,1,1,"RHP 11_127373205",{"$f":"COUNTIFS($FR$4:$FR360,FR360)","v":2},"RHP 11_127373205_2"]
["RHP 11","130724106","Pecan Valley Centers","130724106.1.1","130724106.3.201","IT-11.7","Initiation of Depression Treatment","Baseline not yet reported","Eligible to Report in October DY4","Expand specialty care access to psychiatrists & other behavioral health providers, thereby reducing use of ERs for behavioral health issues.  ","Initiation of Depression Treatment","In DY4 and DY5 provider will improve the number of adult (age 18 and older) patients who filled at least one antidepressant prescription or had at least 3 psychotherapy visits during the 5 months after diagnosis of major depression out of all patients diagnosed with major depression.","Age ","Adults 18 and older","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",7122.5,"Yes/No","RHP 11_130724106.3.201_PM-8","Metric Carried Forward in October DY3","PM-9","Validation and submission of baseline performance",7122.5,"Yes/No","RHP 11_130724106.3.201_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",7618,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",7618,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",33123,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Initiation of Depression Treatment","Ambulatory/Inpatient",null,"Patients in the denominator who filled at least one antidepressant prescription or had at least three psychotherapy visits during the 5-month period after diagnosis.","All patients seen in primary care during a specified period who had major depression based on a structured assessment administered independent of the clinical visit.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2 ","","Initiation of Depression Treatment",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 11_130724106.1.1","RHP 11_130724106.3.201","RHP 11_130724106.1.1_130724106.3.201",{"$f":"COUNTIFS($FI$4:$FI362,FI362)","v":2},"RHP 11_130724106.1.1_2",null,2,1,1,"RHP 11_130724106",{"$f":"COUNTIFS($FR$4:$FR362,FR362)","v":2},"RHP 11_130724106_2"]
["RHP 11","136325111","Mitchell County Hospital","136325111.1.2","136325111.3.3","IT-9.2","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","Pending Approval","Eligible to Report in October DY4","To hire two (2) additional Primary Care Providers for our Rural Health Clinic which will allow us to offer additional office visits for our community.","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","In DY4 and DY5 provider will improve the number  of individuals who visit the ED with a primary or secondary diagnosis of an ambulatory care sensitive condition out of the total number of facility ED visits among individuals aged 18 or over.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",15286.75,"Yes/No","RHP 11_136325111.3.3_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",15286.75,"Yes/No","RHP 11_136325111.3.3_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",24555.25,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",24555.25,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",117190,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"All patients who have the oatient class of ED or ES were identified by the EMHR software","The number of patients who are seen in the ED with the primary or secondary ACSC diagnosis is small.","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","ED",null,"Total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 11_136325111.1.2","RHP 11_136325111.3.3","RHP 11_136325111.1.2_136325111.3.3",{"$f":"COUNTIFS($FI$4:$FI374,FI374)","v":1},"RHP 11_136325111.1.2_1",null,2,1,1,"RHP 11_136325111",{"$f":"COUNTIFS($FR$4:$FR374,FR374)","v":1},"RHP 11_136325111_1"]
["RHP 11","137074409","Eastland Memorial Hospital","137074409.1.5","137074409.3.5","IT-3.25","Post-Surgical 30-day Readmission Rate ","Baseline Approved","Eligible to Report in April DY4","This project will expand specialty care services by providing specialty surgery services to the residents of Eastland County and the surrounding area. Eastland Memorial Hospital (EMH) will add Otolaryngology (ENT) and Orthopedic Surgery services.","Post-Surgical 30-day Readmission Rate ","In DY4 and DY5 provider will report the rade of readmissions for any cause within 30 days of the discharge date for the intex hospitalzation, excluding a specified set of planned readmissions. In addition, in DY5 provider will undertake Emergency Department Improvements in accordance with SA4. ",null,null,"P4R","SA4","PM-8","Submission of Category 3 DY3 Status Report",49996.504999999997,"Yes/No","RHP 11_137074409.3.5_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",49996.504999999997,"Yes/No","RHP 11_137074409.3.5_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",133851.20000000001,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",124857.52499999999,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",124857.52499999999,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",8.5106000000000001E-2,8,94,"DY2: Oct 1st, 2012 - Sept 30th, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator: Pulled All Admissions with Surgical Procedures for the timeframe excluded Patients under 18 years of age and Patients who died during the 30 readmission window.  Numerator: Included all patients in the denominator who were readmitted during 30 day timeframe.","8.33% of surgery inpatients were readmitted within 30 days from October 1, 2012 - September 30, 2013","Post-Surgical 30-day Readmission Rate ","inpatient",null,"Total number of admissions (index stay) with at least one subsequent readmission (hospital stay) for any reason within 30 days during the measurement year.","Total number of hospital index admissions Post-Surgical during the measurement year for patients 18 years of age and older.",null,null,null,null,null,null,null,null,null,null,"Appropriate Utilization of the ED - Currently reviewing utilization",null,null,"1.9.2 ","","Post-Surgical 30-day Readmission Rate ",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 11_137074409.1.5","RHP 11_137074409.3.5","RHP 11_137074409.1.5_137074409.3.5",{"$f":"COUNTIFS($FI$4:$FI377,FI377)","v":1},"RHP 11_137074409.1.5_1",null,2,1,1,"RHP 11_137074409",{"$f":"COUNTIFS($FR$4:$FR377,FR377)","v":2},"RHP 11_137074409_2"]
["RHP 11","138644310","Hendrick Medical Center","138644310.2.100","138644310.3.100","IT-2.1","Congestive Heart Failure (CHF) Admission rate","Pending Approval","Eligible to Report in October DY4","The project incorporates chronic care management model activities for heart failure patients.","Congestive Heart Failure (CHF) Admission rate","In DY4 and DY5 provider will report the rate of admissions with a principal diagnosis of heart failure per 100,000 population, ages 18 years and older.  In addition, in DY5 provider will submit a report detailing the regional exchange of public health surveillance data partnerships, coordination infrastructure, mechanisms and types of data exchanged and the resulting regional improvements.  ",null,null,"P4R","SA5","PM-8","Submission of Category 3 DY3 Status Report",133559.25,"Yes/No","RHP 11_138644310.3.100_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",133559.25,"Yes/No","RHP 11_138644310.3.100_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",428506.05,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",509146.2,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",509146.2,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The values reported were determined by using HHSC specific criteria for both the numerator and denominator. We used that criteria to the best of our ability to gather the information in our databases and arrived at the values reported above. ","The baseline rate calculated above is 2.12%. We had 259 in the numerator and 12237 in the denominator and that resulted in the calculated rate of 2.12%. 2.12% of patients, in the measure specifications, had a principal diagnosis code for heart failure.","Congestive Heart Failure (CHF) Admission rate","inpatient",null,"Discharges, for patients ages 18 years and older, with a principal ICD-9-CM diagnosis code for heart failure x 100,000*. ","Population ages 18 years and older in metropolitan area  or county. ",null,null,null,null,null,null,null,null,null,null,"We will be conducting stretch activity SA5.",null,null,"2.2.2","","Congestive Heart Failure (CHF) Admission rate",null,null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 11_138644310.2.100","RHP 11_138644310.3.100","RHP 11_138644310.2.100_138644310.3.100",{"$f":"COUNTIFS($FI$4:$FI384,FI384)","v":1},"RHP 11_138644310.2.100_1",null,2,1,1,"RHP 11_138644310",{"$f":"COUNTIFS($FR$4:$FR384,FR384)","v":6},"RHP 11_138644310_6"]
["RHP 12","065100201","City of Amarillo Department of Public Health","065100201.1.1","065100201.3.201","IT-12.10","Adults (18+ years) Immunization status","Pending Approval","Eligible to Report in October DY4","Development of an Immunization Program for low income adults 19 years and older, purchase vaccine to immunize targeted adult population ages 19 and older who are indigent or Medicaid, employ staff members to provide adult vaccines, and purchase mobile clinic vehicle to operationalize outreach for adult safety-net vaccination events","Adults (18+ years) Immunization status","In DY4 and DY5, the provider will improve the percentage of patients who are up-to-date with following immunizations (Td, Varicella, PPSV23, Herpes zoster/shingles) over all patients 18 years and older during the specified measurement period who are provided services at either the fixed location of the City of Amarillo Public Health Department or the mobile clinic","Facility ","Number of patients 18 years and older during the specified measurement period who are provided services at either the fixed location of the City of Amarillo Public Health Department or the mobile clinic.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",33960.480000000003,"Yes/No","RHP 12_065100201.3.201_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",33960.480000000003,"Yes/No","RHP 12_065100201.3.201_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",36105.434999999998,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",36105.434999999998,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",156239.23000000001,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"the denomiator is based mainly upon our initial start of our program, which was a Mobile Clinic Event called Hablando held at the Amarillo Civic Center. We were part of the larger Hablando event and gave out vaccinations, along with collecting historical data for previous receipt of the pneumonia vaccine, influenza vaccine, and then checked state database and internal Immunization database for IT 12.1 whether patients were up to date with their vaccinations. The baseline will be biased because the event was only open to Hispanic women. This was approved by Jennifer Woodard - and the approval email is uploaded for each Cat 3 outcome for project 65121.1.1.","The denominator consisted of those patients seen during the baseline period that had immunization records already established in either our internal TWICES system and/or the state ImmTrac system. Out of those, the numerator was determined based upon whether their records showed that they were up to date, as described by Outcome 12.10, on their immunizations.","Many people in Amarillo that are low income and do not have insurance or cannot afford their copays/deductibles do not have access to needed immunizations to protect them against disease.","Adults (18+ years) Immunization status","ambulatory",null,"Number of patients who are up-to-date with following immunizations:\n• One tetanus and diphtheria toxoids (Td) vaccine in the last 10 years\n• Varicella – two doses or history of disease up to year 1995\n• Pneumococcal polysaccharide vaccine (PPSV23) for patients 65 and older\n• One influenza dose within the last year\n• Herpes zoster/shingles (patients 60 years and older)\n","Number of patients 18 years and older during the specified measurement period*",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.3",null,"Adults (18+ years) Immunization status",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 12_065100201.1.1","RHP 12_065100201.3.201","RHP 12_065100201.1.1_065100201.3.201",{"$f":"COUNTIFS($FI$4:$FI396,FI396)","v":3},"RHP 12_065100201.1.1_3",null,2,1,1,"RHP 12_065100201",{"$f":"COUNTIFS($FR$4:$FR396,FR396)","v":3},"RHP 12_065100201_3"]
["RHP 12","084563802","Texas Tech Health Sciences Center- Amarillo","084563802.1.3","084563802.3.500","IT-1.30","Hemoglobin A1c (HbA1c) Testing for Pediatric Patients","Baseline Approved","Eligible to Report in October DY4","This project will bring pediatric endocrinology and pediatric urology services for financially disadvantaged children into our community.","Hemoglobin A1c (HbA1c) Testing for Pediatric Patients","In DY4 and DY5 provider will improve the percentage of pediatric patients 5-17 years of age with diabetes who received an HbA1c test during the measurement period out of all patients age 5-17 years with diabetes receiving services at Texas Tech Endocrinology/Urology Specialty Clinic. ","Facility ","Texas Tech Endocrinology/Urology Specialty Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",0,"Yes/No","RHP 12_084563802.3.500_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",21552.837500000001,"Yes/No","RHP 12_084563802.3.500_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",22824.12,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",22824.12,"Numeric",8.9014864999999999E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",98468.66,"Numeric",0.136961,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",4.1068E-2,163,3969,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,8.9014864999999999E-2,null,0.136961,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator is patients who had an HbA1c test performed during the measurement year whether it was a lab or clinic draw.  The denominator is patients age 5 to 17 years old with a diagnosis of diabetes and/or notation of prescribed insulin or oral hypoglycemics/antihyperglycemics for at least 12 months.","4.11% of patients with a diagnosis of diabetes had an HbA1c test performed.","Hemoglobin A1c (HbA1c) Testing for Pediatric Patients","ambulatory",null,"Patients who had an HbA1c test performed during the measurement year.","Patients aged 5-17 years old with a diagnosis of diabetes and/or notation of prescribed insulin or oral hypoglycemics/antihyperglycemics for at least 12 months.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2","","Hemoglobin A1c (HbA1c) Testing for Pediatric Patients",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 12_084563802.1.3","RHP 12_084563802.3.500","RHP 12_084563802.1.3_084563802.3.500",{"$f":"COUNTIFS($FI$4:$FI402,FI402)","v":2},"RHP 12_084563802.1.3_2",null,2,1,1,"RHP 12_084563802",{"$f":"COUNTIFS($FR$4:$FR402,FR402)","v":4},"RHP 12_084563802_4"]
["RHP 12","084599202","Texas Tech Health Sciences Center- Lubbock","084599202.1.100","084599202.3.100","IT-1.10","Diabetes care: HbA1c poor control (>9.0%) ","Baseline Approved","Eligible to Report in October DY4","Use a remote patient monitoring (telemonitoring) system to manage chronically ill adult (18-75) Medicaid and uninsured patients with diabetes.  The system will include a device that is placed in the home of each patient that will transmit clinical data to a monitoring station. Our initial patient monitoring data for this project will be blood glucose, blood pressure, and body weight.  The patient’s data will be reviewed by a nurse or other appropriate medical professional with special diabetes training, at the Combest Center, and when exceeding set parameters, will be forwarded to the patients’ PCP, or the Combest Center providers (if the patient does not have a PCP of record,) for intervention and care coordination","Diabetes care: HbA1c poor control (>9.0%) ","In DY4 and DY5, the provider will improve the percentage of Medicaid/Uninsured patients seen at the Larry Combest Community Health & Wellness Center, 18-75 years of age with diabetes (type 1 and type 2) whose most recent HbA1c level during the measurement year was greater than 9.0% (poor control) or was missing a result, or if an HbA1c test was not done during the measurement year","Facility, Payer ","Three subsets requested. Payer:  both Medicaid/Uninsured; Facility:  The Larry Combest Community Health & Wellness Center;  Targeted Comorbid Conditions:  Diabetes","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",55976.714999999997,"Yes/No","RHP 12_084599202.3.100_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",55976.714999999997,"Yes/No","RHP 12_084599202.3.100_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",59508.144999999997,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",59508.15,"Numeric",0.33059835199999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",257496.69,"Numeric",0.32603199999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.33516499999999999,183,546,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.33059835199999998,null,0.32603199999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator was determined by selecting all Medicaid/low-income uninsured patients 18-75 years of age of the Larry Combest Community Health& Wellness Center who had a diagnosis of diabetes (type 1 or type 2) during the measurement year. The numerator was calculated by counting patients in the denominator whose most recent HbA1c level during the measurement year was greater than 9.0% (poor control) or was missing a result, or if an HbA1c test was not done during the measurement year.","Of all Medicaid/low-income uninsured patients 18-75 years of age of the Larry Combest Community Health& Wellness Center who had a diagnosis of diabetes (type 1 or type 2) during the measurement year, 33.52% of them had their most recent HbA1c level during the measurement year at greater than 9.0% (poor control) or was missing a result, or an HbA1c test was not done during the measurement year.","Diabetes care: HbA1c poor control (>9.0%) ","ambulatory",null,"Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.7.2","","Diabetes care: HbA1c poor control (>9.0%) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 12_084599202.1.100","RHP 12_084599202.3.100","RHP 12_084599202.1.100_084599202.3.100",{"$f":"COUNTIFS($FI$4:$FI410,FI410)","v":1},"RHP 12_084599202.1.100_1",null,2,1,1,"RHP 12_084599202",{"$f":"COUNTIFS($FR$4:$FR410,FR410)","v":4},"RHP 12_084599202_4"]
["RHP 12","084599202","Texas Tech Health Sciences Center- Lubbock","084599202.2.3","084599202.3.200","IT-12.3","Colorectal Cancer Screening ","Baseline Approved","Eligible to Report in October DY4","Design, development, and implementation of a data warehouse which will be used to correlate multiple sources of information and data into  more useable, functional, and proper relational data that can be used for analysis and metric reporting purposes. Design, engineering, and implementation of a Provider Dashboard that will consolidate data in a visually appealing, digestible, and actionable format. Healthcare providers can use the dashboard to gauge their patient population’s outcomes against other internal colleagues’ patient bases and national evidence-based best practices.  The Dashboard will also alert practitioners on which of their patients require immediate attention – either from a preventative measure to maximize optimal health or due to a chronic condition","Colorectal Cancer Screening ","In DY4 and DY5, the provider will improve the percentage patients  who had appropriate screening for colorectal cancer out of all patients 50–75 years of age and receiving services at any of the TTP-LBK 'primary care' service locations in the 4 departments of Family and Community Medicine, Internal Medicine, OB/GYN, and Pediatrics ","Facility ","all TTP-LBK 'primary care' service locations in the 4 departments of Family and Community Medicine, Internal Medicine, OB/GYN, and Pediatrics","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",18658.904999999999,"Yes/No","RHP 12_084599202.3.200_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",18658.904999999999,"Yes/No","RHP 12_084599202.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",19836.05,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",19836.05,"Numeric",0.51,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",85832.23,"Numeric",0.53300000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.17207500000000001,1400,8136,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.51,null,0.53300000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator was determined by selecting all patients 51-75 years of age at Texas Tech Physicians of Lubbock (TTP-LBK) 'primary care' clinics, excluding patients with a diagnosis of colorectal cancer or total colectomy. Numerator was calculated by counting patients in the denominator that were appropriately screened for colorectal cancer by one of the three methods within that method's time frame.","Of all patients 51-75 years of age at Texas Tech Physicians of Lubbock (TTP-LBK) 'primary care' clinics, 17.21% were appropriately screened for colorectal cancer by one of the three methods within that method's time frame.","Colorectal Cancer Screening ","ambulatory",null,"One or more screenings for colorectal cancer. Any of the following meet the criteria: \n\n• Fecal occult blood test (FOBT) during the measurement year. For administrative data, assume the required number of samples were returned regardless of FOBT type.\n• Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year.\n• Colonoscopy during the measurement year or the nine years prior to the measurement year.\n","Patients 51–75 years of age as of the end of the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.8.1","","Colorectal Cancer Screening ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 12_084599202.2.3","RHP 12_084599202.3.200","RHP 12_084599202.2.3_084599202.3.200",{"$f":"COUNTIFS($FI$4:$FI418,FI418)","v":1},"RHP 12_084599202.2.3_1",null,2,1,1,"RHP 12_084599202",{"$f":"COUNTIFS($FR$4:$FR418,FR418)","v":12},"RHP 12_084599202_12"]
["RHP 12","084599202","Texas Tech Health Sciences Center- Lubbock","084599202.2.3","084599202.3.201","IT-12.11","HPV vaccine for adolescents","Baseline Approved","Eligible to Report in October DY4","Design, development, and implementation of a data warehouse which will be used to correlate multiple sources of information and data into  more useable, functional, and proper relational data that can be used for analysis and metric reporting purposes. Design, engineering, and implementation of a Provider Dashboard that will consolidate data in a visually appealing, digestible, and actionable format. Healthcare providers can use the dashboard to gauge their patient population’s outcomes against other internal colleagues’ patient bases and national evidence-based best practices.  The Dashboard will also alert practitioners on which of their patients require immediate attention – either from a preventative measure to maximize optimal health or due to a chronic condition","HPV vaccine for adolescents","In DY4 and DY5, the provider will improve the percentage of female adolescents who had three doses of the human papillomavirus (HPV) vaccine by their 13th birthday out of all  female adolescents who turned 13 years of age during the measurement year and are receiving services at any of the TTP-LBK 'primary care' service locations in the 4 departments of Family and Community Medicine, Internal Medicine, OB/GYN, and Pediatrics ","Facility, Gender ","all TTP-LBK 'primary care' service locations in the 4 departments of Family and Community Medicine, Internal Medicine, OB/GYN, and Pediatrics; female only ","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",18658.904999999999,"Yes/No","RHP 12_084599202.3.201_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",18658.904999999999,"Yes/No","RHP 12_084599202.3.201_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",19836.05,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",19836.05,"Numeric",0.183,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",85832.23,"Numeric",0.2094,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.11747,39,332,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.183,null,0.2094,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator was determined by selecting all female patients 13 years of age at Texas Tech Physicians of Lubbock (TTP-LBK) 'primary care' clinics, excluding patients who had a contraindication for the human papillomavirus (HPV) vaccine. Numerator was calculated by counting patients in the denominator that had at least three doses of the HPV vaccine between their 9th and 13th birthdays.","Of all female patients 13 years of age at Texas Tech Physicians of Lubbock (TTP-LBK) 'primary care' clinics, 11.75%  had at least three doses of the HPV vaccine between their 9th and 13th birthdays.","HPV vaccine for adolescents","ambulatory",null,"Adolescents who had at least three doses of the human papillomavirus (HPV) vaccine between their 9th and 13th birthdays.","Adolescents who turned 13 years of age during the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.8.1","","HPV vaccine for adolescents",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 12_084599202.2.3","RHP 12_084599202.3.201","RHP 12_084599202.2.3_084599202.3.201",{"$f":"COUNTIFS($FI$4:$FI419,FI419)","v":2},"RHP 12_084599202.2.3_2",null,2,1,1,"RHP 12_084599202",{"$f":"COUNTIFS($FR$4:$FR419,FR419)","v":13},"RHP 12_084599202_13"]
["RHP 12","094180903","Lynn County Hospital District","094180903.2.1","094180903.3.1","IT-6.2.d.v","PSQ-III Financial Aspects","Pending Approval","Eligible to Report in October DY4","This project will implement a patient navigator who will oversee the hospital district’s indigent program.","PSQ-III Financial Aspects","In DY4 and DY5 the provider will improve (increase) the Financial Aspects average \"subscale score\"  for the 8 questions on the Patient Satisfaction Questionnaire (PSQ-III) representing improved patient satisfaction with the financial aspects of their care.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",2823,"Yes/No","RHP 12_094180903.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",2823,"Yes/No","RHP 12_094180903.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",4530,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",4530,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",21665,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator: The sum of the selected \"subscale score\" from all PSQ-III or PSQ-18 surveys completed during the measurement period.\nDenominator: The total number of PSQ-III or PSQ-18 surveys completed during the measurement period.","Our average \"Adusted Total Score\" is 13.71 (baseline) out of a possible 40.00.","PSQ-III Financial Aspects","Ambulatory",null,"The sum of the selected \"subscale score\" from all PSQ-III or PSQ-18 surveys completed during the measurement period. ","The total number of PSQ-III or PSQ-18 surveys completed during the measurement period.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1","","PSQ-III Financial Aspects",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 12_094180903.2.1","RHP 12_094180903.3.1","RHP 12_094180903.2.1_094180903.3.1",{"$f":"COUNTIFS($FI$4:$FI432,FI432)","v":1},"RHP 12_094180903.2.1_1",null,2,1,1,"RHP 12_094180903",{"$f":"COUNTIFS($FR$4:$FR432,FR432)","v":1},"RHP 12_094180903_1"]
["RHP 12","126667806","W.J. Mangold Memorial Hospital","126667806.2.100","126667806.3.101","IT-9.2","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","Baseline not yet reported","Eligible to Report in October DY4","The project will provide chronic disease self-management through a home-based Navigation program using individualized interventions to remove obstacles and provide support which will decrease hospital admissions, and prevent non-emergent ED visits and managed chronic conditions. The intervention will be delivered by one patient navigator and one RN care coordinator.","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","In DY4 and DY5 provider will improve (decrease) the rate of adult ED visits for primary or secondary diagnosis of ACSC out of the total number of adult ED visits during the measurement period. ",null,null,"P4P","","PM-8","Submission of Category 3 DY3 Status Report",7596.16,"Yes/No","RHP 12_126667806.3.101_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",7596.16,"Yes/No","RHP 12_126667806.3.101_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",12679.705,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",12679.705,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",49703.981449999999,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","ED",null,"Total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1",null,"\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 12_126667806.2.100","RHP 12_126667806.3.101","RHP 12_126667806.2.100_126667806.3.101",{"$f":"COUNTIFS($FI$4:$FI440,FI440)","v":1},"RHP 12_126667806.2.100_1",null,2,1,1,"RHP 12_126667806",{"$f":"COUNTIFS($FR$4:$FR440,FR440)","v":5},"RHP 12_126667806_5"]
["RHP 12","127313803","Lamb Healthcare Center","127313803.1.1","127313803.3.1","IT-8.19","Post-Partum Follow-Up and Care Coordination","Pending Approval","Eligible to Report in October DY4","This project will add a primary care physician to LHC Family Medicine’s clinic","Post-Partum Follow-Up and Care Coordination","In DY4 and DY5 provider will improve (increase) the percentage of patients, regardless of age, who gave birth during a 12-month period who were seen for post-partum care within 8 weeks of giving birth who received a breast feeding evaluation and education, post-partum depression screening, post-partum glucose screening for gestational diabetes patients, and family and contraceptive planning.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",22208.5,"Yes/No","RHP 12_127313803.3.1_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",22208.5,"Yes/No","RHP 12_127313803.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",35636.5,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",35636.5,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",170436,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator:Patients receiving the following at a post-partum visit: Breast feeding evaluation and education, including patient-reported breast feeding, Post-partum depression screening, Post-partum glucose screening for gestational diabetes patients, and Family and contraceptive planning.\nDenominator: All patients, regardless of age, who gave birth during a 12-month period seen for post-partum care visit before or at 8 weeks of giving birth.","9.09%  of all patients, regardless of age, who gave birth during a 12-month period seen for post-partum care visit before or at 8 weeks of giving birth received all the following: Breast feeding evaluation and education, including patient-reported breast feeding, Post-partum depression screening, Post-partum glucose screening for gestational diabetes patients, and Family and contraceptive planning.","Post-Partum Follow-Up and Care Coordination","ambulatory",null,"Patients receiving the following at a post-partum visit:\n• Breast feeding evaluation and education, including patient-reported breast feeding\n• Post-partum depression screening\n• Post-partum glucose screening for gestational diabetes patients \n• Family and contraceptive planning\n","All patients, regardless of age, who gave birth during a 12-month period seen for post-partum care visit before or at 8 weeks of giving birth.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2","","Post-Partum Follow-Up and Care Coordination",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 12_127313803.1.1","RHP 12_127313803.3.1","RHP 12_127313803.1.1_127313803.3.1",{"$f":"COUNTIFS($FI$4:$FI444,FI444)","v":1},"RHP 12_127313803.1.1_1",null,2,1,1,"RHP 12_127313803",{"$f":"COUNTIFS($FR$4:$FR444,FR444)","v":1},"RHP 12_127313803_1"]
["RHP 12","127378105","Texas Panhandle Centers","127378105.2.1","127378105.3.200","IT-10.1.a.v","Pediatric Quality of Life Inventory (PedsQL)","Baseline Approved","Eligible to Report in October DY4","A Continuum of Care Program providing intensive wraparound services and supports for children and adults with behavioral health needs. Provides interventions and diversion from hospitals, jails, juvenile detention and other restrictive settings through enhanced care coordination, community outreach, social support, and culturally competent care. The CoC Program will consist\nof: CHILD AND ADOLESCENT WRAPAROUND SERVICES‐ an early service delivery model that provides individualized comprehensive services and supports to children/adolescents with serious emotional and/or behavioral disturbance; 30 DAY INTENSIVE OUTPATIENT TREATMENT Targeting adults who have a co‐occurring diagnosis of substance abuse and mental illness and experience homelessness; and the CRIMINAL JUSTICE DIVERSION UNIT‐ created specifically to address current gaps in diversion services, this unit will target adults with\nbehavioral health needs who have repeat contacts with the criminal justice system so they will not return, or not return as frequently.","Pediatric Quality of Life Inventory (PedsQL)","In DY4 and DY5 provider will improve reported scores on the PedsQL out of all questionnaires completed during the measurement period. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",19096.71,"Yes/No","RHP 12_127378105.3.200_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",12731.14,"Yes/No","RHP 12_127378105.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",14310.11,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",14310.11,"Numeric",70.265773199999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",61598.57,"Numeric",75.265773199999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",65.265770000000003,6330.78,97,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,70.265773199999998,null,75.265773199999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator = The sum total of the most recent scores of youth and adolescents who completed the PedsQL pretest survey during the baseline measurement period.\nDenominator= The number of completed PedsQL Surveys completed during the measurement period.\n","The baseline rate = 65.27 which leaves room for singnificant improvement in the perceived quality of life of the children and adolescents we serve in our program.","Pediatric Quality of Life Inventory (PedsQL)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.13.1","Scenario 2: Pre Test Only Baseline","Pediatric Quality of Life Inventory (PedsQL)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 12_127378105.2.1","RHP 12_127378105.3.200","RHP 12_127378105.2.1_127378105.3.200",{"$f":"COUNTIFS($FI$4:$FI454,FI454)","v":2},"RHP 12_127378105.2.1_2",null,2,1,1,"RHP 12_127378105",{"$f":"COUNTIFS($FR$4:$FR454,FR454)","v":4},"RHP 12_127378105_4"]
["RHP 12","130721710","Swisher Memorial Healthcare System","130721710.1.100","130721710.3.201","IT-9.10.b","Median time from admit decision time to time of departure from the ED for ED patients admitted to inpatient status","Pending Approval","Eligible to Report in October DY4","This project will implement a medical advice line with direction to the appropriate level of care.  ","Median time from admit decision time to time of departure from the ED for ED patients admitted to inpatient status","In DY4 and DY5 provider will improve (decrease) the median time from admit decision time to time of departure from the emergency department for emergency department patients admitted to inpatient status",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",2662.5749999999998,"Yes/No","RHP 12_130721710.3.201_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",2662.5749999999998,"Yes/No","RHP 12_130721710.3.201_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",4314.4399999999996,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",4314.4399999999996,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",13951.716133333333,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"time (minutes)",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Prior to implementation of our new EMR on  June 2nd, 2014, our Emergency Department documentation was still completed on paper. During chart review, in which all Emergency Department cases are reviewed, patients that were admitted were captured and review of documentation of the following indicators were entered into a spreadsheet; Date of Service, Patient Identifier, Decision to admit time, time of departure from the Emergency Department, calculated time in minutes. The numerator and denominator cases were identified by patients that were admitted to our facility from the Emergency Department.  The EMR report included the patient name, date of service, time of arrial to the Emergency Department, Decision to Admit time, and time of departure from the Emergency Department. ","Our average time from admit decision time to time of departure from ED for patients admitted is 12.86 minutes.","Median time from admit decision time to time of departure from the ED for ED patients admitted to inpatient status","ED",null,"Median time from admit decision time to time of departure from the ED for ED patients admitted to inpatient status: Continuous variable statement: Time (in minutes) from admit decision time to time of departure from the emergency department (ED) for ED patients admitted to inpatient status",1,null,null,null,null,null,null,null,null,null,null,null,null,null,"1.6.2","","Median time from admit decision time to time of departure from the ED for ED patients admitted to inpatient status",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 12_130721710.1.100","RHP 12_130721710.3.201","RHP 12_130721710.1.100_130721710.3.201",{"$f":"COUNTIFS($FI$4:$FI462,FI462)","v":2},"RHP 12_130721710.1.100_2",null,2,1,1,"RHP 12_130721710",{"$f":"COUNTIFS($FR$4:$FR462,FR462)","v":2},"RHP 12_130721710_2"]
["RHP 12","130725806","West Texas Centers","130725806.1.2","130725806.3.3","IT-10.1.a.i","Assessment of Quality of Life (AQoL-4D) ","Pending Approval","Eligible to Report in October DY4","West Texas Centers will expand its current Mobile Crisis Outreach Team staff by a minimum of one additional\nqualified mental health provider. These additional staffs will effectively double the current capacity of the Centers crisis response\nsystem in these counties. This project will enable WTC to improve our crisis response time providing intervention in the crisis event,\nin many cases avoiding an inappropriate hospital admission or incarceration.","Assessment of Quality of Life (AQoL-4D) ","In DY4 and DY5 provider will improve reported scores on the AQoL-4D out of all questionnaires completed during the measurement year. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",15996.11,"Yes/No","RHP 12_130725806.3.3_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",15996.11,"Yes/No","RHP 12_130725806.3.3_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",17001.310000000001,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",17001.310000000001,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",73553.81,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Per the compendium document for the Assessment of Quality of Life - AQoL-4D, the numerator is the sum of all scores and the denominator is the total number of AQoL-4D's completed.","The baseline rate is the numerator divided by the denominator (2,102/23=91.39).","Assessment of Quality of Life (AQoL-4D) ","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.13.1","Scenario 3: Average Score","Assessment of Quality of Life (AQoL-4D) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 12_130725806.1.2","RHP 12_130725806.3.3","RHP 12_130725806.1.2_130725806.3.3",{"$f":"COUNTIFS($FI$4:$FI469,FI469)","v":1},"RHP 12_130725806.1.2_1",null,2,1,1,"RHP 12_130725806",{"$f":"COUNTIFS($FR$4:$FR469,FR469)","v":3},"RHP 12_130725806_3"]
["RHP 12","130877708","Muleshoe Area Medical Center","130877708.1.1","130877708.3.2","IT-1.10","Diabetes care: HbA1c poor control (>9.0%) ","Baseline Approved","Eligible to Report in April DY4","This project will add an additional clinic/practice in an existing space with a primary care physician","Diabetes care: HbA1c poor control (>9.0%) ","In DY4 and DY5 provider will improve (decrease) the percentage of Medical Clinic of Muleshoe patients 18-75 years of age with diabetes (type 1 and type 2) whose most recent HbA1c level during the measurement year was greater than 9.0% (poor control) or was missing a result, or if an HbA1c test was not done during the measurement year.","Facility ","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year at the Medical Clinic of Muleshoe located at 610 South 1st Street.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",1357.6,"Yes/No","RHP 12_130877708.3.2_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",1357.6,"Yes/No","RHP 12_130877708.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",2178.4549999999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",2178.4549999999999,"Numeric",0.38137718446601943,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",10418.35,"Numeric",0.37116860841423949,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.39158576051779936,121,309,"CY 2013: Jan 1st, 2013 - Dec 31st, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.38137718446601943,null,0.37116860841423949,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator represents the number of patients who had an HbA1C reading above 9.0 during the measurement period. The denominator represents the total number of patients with a diagnosis of type 1 or type 2 diabetes during the measurement year. \n","The baseline represents the percentage of patients with an AbA1C above 9.0 during the measurement period. ","Diabetes care: HbA1c poor control (>9.0%) ","ambulatory",null,"Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1","","Diabetes care: HbA1c poor control (>9.0%) ",null,null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 12_130877708.1.1","RHP 12_130877708.3.2","RHP 12_130877708.1.1_130877708.3.2",{"$f":"COUNTIFS($FI$4:$FI476,FI476)","v":1},"RHP 12_130877708.1.1_1",null,2,1,1,"RHP 12_130877708",{"$f":"COUNTIFS($FR$4:$FR476,FR476)","v":1},"RHP 12_130877708_1"]
["RHP 12","130877708","Muleshoe Area Medical Center","130877708.2.1","130877708.3.1","IT-10.1.b.iii","RAND Short Form 36[1] (SF-36) Health Survey","Baseline Approved","Eligible to Report in April DY4","This project will establish a wellness program directed at the entire hospital district. . Through community awareness events, physician referrals, word of mouth, and various methods of media communication we plan to broaden the scope and involvement of the community served by the hospital district, especially the lower income, Medicaid and indigent populations.","RAND Short Form 36[1] (SF-36) Health Survey","In DY4 and DY5 provider will improve reported scores on the Short Form Health Survey (SF-36v2) out of all instruments administered during the measurement period to individuals receiving Wellness program services. ","Facility ","participants of the Wellness Program","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",3310.9,"Yes/No","RHP 12_130877708.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",3310.9,"Yes/No","RHP 12_130877708.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",5312.7950000000001,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",5312.7950000000001,"Numeric",75.140972222222217,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",25408.16,"Numeric",80.140972222222217,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",70.140972222222217,2525.0749999999998,36,"CY 2013: Jan 1st, 2013 - Dec 31st, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,75.140972222222217,null,80.140972222222217,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator is the total sum of all category totals of all surveys. The denominator is the number of surveys collected during the baseline period.","The baseline rate is the average score of the overall total of the surveys collected during the baseline period. ","RAND Short Form 36[1] (SF-36) Health Survey","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.6.2","Scenario 3: Average Score","RAND Short Form 36[1] (SF-36) Health Survey",null,null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 12_130877708.2.1","RHP 12_130877708.3.1","RHP 12_130877708.2.1_130877708.3.1",{"$f":"COUNTIFS($FI$4:$FI478,FI478)","v":1},"RHP 12_130877708.2.1_1",null,2,1,1,"RHP 12_130877708",{"$f":"COUNTIFS($FR$4:$FR478,FR478)","v":3},"RHP 12_130877708_3"]
["RHP 12","136142011","Plains Memorial Hospital","136142011.2.1","136142011.3.200","IT-9.2.a","Emergency Department (ED) visits per 100,000\n\n","Baseline Approved","Eligible to Report in April DY4","The Patient Care Navigation Program will enable PMH to provide navigation services to patients who are at high risk of disconnect from institutionalized health care. A primary concern is the misuse in the ED; in addition we will attempt to provide education to all at risk patients utilizing the ED.  A Community Health Worker (CHW) will be used to connect patients to primary and preventive care in the right setting. ","Emergency Department (ED) visits per 100,000\n\n","In DY4 and DY5 provider will improve (reduce) ED utilization, reported as total number of adult ED visits (18 years old or more) out of the total number of adults in the metro area or county. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",7668.4949999999999,"Yes/No","RHP 12_136142011.3.200_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",7668.4949999999999,"Yes/No","RHP 12_136142011.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",12304.5,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",12304.5,"Numeric",31518.050541516241,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",58848.99,"Numeric",29859.205776173279,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",33176.895306859202,1838,5540,"DY2: Oct 1st, 2012 - Sept 30th, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,31518.050541516241,null,29859.205776173279,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator: Total number of ED Visits during the measurement period \nDenominator: Population in Metro Area or county, age 18 years and older","Our ED Visits represent 33.18% of our population, age 18 years and older.","Emergency Department (ED) visits per 100,000\n\n","ED",null,"Total number of ED Visits during the measurement period ","Population in Metro Area or county, age 18 years and older",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1","","Emergency Department (ED) visits per 100,000\n\n",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 12_136142011.2.1","RHP 12_136142011.3.200","RHP 12_136142011.2.1_136142011.3.200",{"$f":"COUNTIFS($FI$4:$FI490,FI490)","v":1},"RHP 12_136142011.2.1_1",null,2,1,1,"RHP 12_136142011",{"$f":"COUNTIFS($FR$4:$FR490,FR490)","v":1},"RHP 12_136142011_1"]
["RHP 12","136492909","Sunrise Canyon Hospital","136492909.2.1","136492909.3.501","IT-11.19","Assessment for Psychosocial Issues of Psychiatric Patients ","Pending Approval","Eligible to Report in October DY4","SRCH will open a new integrated primary and behavioral health clinic.","Assessment for Psychosocial Issues of Psychiatric Patients ","In DY4 and DY5 provider will improve the percentage of newly presenting patient for a psychiatric evaluation that includes an assessment of the individual's psychosocial and developmental history. Such an assessment typically includes information about developmental milestones, family and social relationships, educational and work history, and major life events including a history of trauma.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",0,"Yes/No","RHP 12_136492909.3.501_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",38200.628333333334,"Yes/No","RHP 12_136492909.3.501_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",58333.84,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",58333.84,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",268559.34333333332,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"proxy","TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Because this project is new and no services will be provided prior to 1.1.14, Sunrise Canyon Hospital requested and received approval on August 6, 214 by HHSC staff to use a proxy population in determining the baseline rate for this measure.  The primary difference between the proxy population and the denominator population is the \"funding source\" for the services provided.  The proxy population includes services delivered to people who qualify for Department of State Health (DSHS)-funded (level of care 1) services and who received a psychiatric evaluation during the measurement period, where the denominator population includes people who either do not qualify for DSHS-funded services because of capacity (i.e., they are on the DSHS-fuding waiting list) or because they do not have one (1) of the three (3) target populations to be served with DSHS funding.  In comparison, both the proxy population and the denominator population will receive the exact same services (psychiatric evaluations, pharmacotherapy and prescription assistance.)","The numerator and denominator values were determined using data analytics within the EMR described above.  Reports were written and data obtained, yielding the following information:  1.  Denominator = number of people (in level of care 1) who received a psychiatric evaluation during the baseline measurement period & 2.  Numerator =  All people (in level of care 1) who received a psychiatric evaluation during the baseline measurement period for whom there is explicit evidence of psychosocial/developmental assessment.","During State Fiscal Year 2014 (9.1.13 - 8.31.14), of those adults who received a psychiatric evaluation, 100% have a psychosocial history documented in their medical record.","Assessment for Psychosocial Issues of Psychiatric Patients ","Ambulatory/Inpatient",null,"Number of individuals in the denominator whose medical record documents a psychosocial/developmental history.","All individuals age 18 and older who undergo a psychiatric evaluation during the measurement period.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.13.1",null,"Assessment for Psychosocial Issues of Psychiatric Patients ",null,null,null,null,null,"2014-09-01","2015-08-31","2015-09-01","2016-08-31","2013-09-01","2014-08-31",null,null,"RHP 12_136492909.2.1","RHP 12_136492909.3.501","RHP 12_136492909.2.1_136492909.3.501",{"$f":"COUNTIFS($FI$4:$FI498,FI498)","v":3},"RHP 12_136492909.2.1_3",null,2,1,1,"RHP 12_136492909",{"$f":"COUNTIFS($FR$4:$FR498,FR498)","v":3},"RHP 12_136492909_3"]
["RHP 12","137245009","UHS at Amarillo Inc dba Northwest Texas Healthcare System","137245009.1.101","137245009.3.101","IT-9.2","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","Baseline Approved","Eligible to Report in October DY4","This project establishes an after-hours urgent care clinic to provide Amarillo residents with more accessible and lower cost primary, urgent and minor emergency health care so that residents would not need to use the ED for this care.","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","In DY4 and DY5 provider will improve (decrease) the rate of adult ED visits for primary or secondary diagnosis of ACSC out of the total number of adult ED visits during the measurement period at  Northwest Texas Healthcare System Emergency Department. ","Facility ","Narrow denominator to Northwest Texas Healthcare System Emergency Department located at 1501 S Coulter St, Amarillo, TX 79106","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",92593.51,"Yes/No","RHP 12_137245009.3.101_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",92593.51,"Yes/No","RHP 12_137245009.3.101_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",148234.93,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",148234.93,"Numeric",0.3710618891194099,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",636839.5,"Numeric",0.36575986245581682,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.37636391578300293,14694,39042,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.3710618891194099,null,0.36575986245581682,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator was determined by filtering the  number of patients, aged 18 and over, discharged  from the acute setting with a qualified ACSC diagnoses utilizing the following codes:    Grand Mal status 345; COPD 466.0, 491, 492, 494, 496;     Asthma 493;    Heart Failure and pulmonary edema 402.01, 402.11, 402.91, 428, 518.4;     Hypertension 401.0, 401.9, 402.00, 402.10, 402.90;     Angina 411.1, 411.8, 413;       Diabetes 250.0, 250.1, 250.2, 250.3, 250.8, 250.9              The subset denominator was determined by filtering discharged patients between the ages of 21 to 65 years of age with financial class of Charity, Indigent (Wyatt services) and self pay plans  from the acute care setting with a qualified ACSC diagnoses.","During the period (10/01/2013 - 09/30/2014), of those discharged subset patients, 99.18% had a qualified ACSC diagnosis.","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","ED",null,"Total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1","","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 12_137245009.1.101","RHP 12_137245009.3.101","RHP 12_137245009.1.101_137245009.3.101",{"$f":"COUNTIFS($FI$4:$FI503,FI503)","v":1},"RHP 12_137245009.1.101_1",null,2,1,1,"RHP 12_137245009",{"$f":"COUNTIFS($FR$4:$FR503,FR503)","v":2},"RHP 12_137245009_2"]
["RHP 12","137999206","University Medical Center","137999206.1.2","137999206.3.2","IT-9.4.b","Reduce Emergency Department visits for Diabetes","Pending Approval","Eligible to Report in October DY4","This project will implement a Call Center to provide patient access to nurses over the phone that can help them decide the best option to obtain medical treatment. ","Reduce Emergency Department visits for Diabetes","In DY4 and DY5 provider will improve (decrease) the percentage of ED visits for primary or secondary diabetes conditions out of the total number of ED visits during the measurement period. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",149436.73499999999,"Yes/No","RHP 12_137999206.3.2_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",149436.73499999999,"Yes/No","RHP 12_137999206.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",242797.86,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",242797.86,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1116198.811111111,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator: Total number of ED Visits with a primary or secondary diagnosis of diabetes (only 250.0X, 250.1X, 250.2X, 250.3X, 250.8X, 250.9X)  for any individual 18 years and older during the measurement period\nDenominator: Total number of ED visits for individuals 18 years or older during the measurement period","15.22% of our total ED visits during the measurement period for individuals 18 years and older have a primary or secondary diabetes related diagnostic code (250.0X, 250.1X, 250.2X, 250.3X, 250.8X, 250.9X)","Reduce Emergency Department visits for Diabetes","ED",null,"Total number of ED Visits with a primary or secondary diagnosis of diabetes for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.6.2","","Reduce Emergency Department visits for Diabetes",null,null,null,null,null,"2014-05-01","2015-04-30","2015-05-01","2016-04-30","2013-11-01","2014-04-30",null,null,"RHP 12_137999206.1.2","RHP 12_137999206.3.2","RHP 12_137999206.1.2_137999206.3.2",{"$f":"COUNTIFS($FI$4:$FI512,FI512)","v":1},"RHP 12_137999206.1.2_1",null,2,1,1,"RHP 12_137999206",{"$f":"COUNTIFS($FR$4:$FR512,FR512)","v":2},"RHP 12_137999206_2"]
["RHP 12","137999206","University Medical Center","137999206.2.3","137999206.3.8","IT-3.4","Diabetes 30-day Readmission Rate ","Baseline Approved","Eligible to Report in April DY4","This project will implement a pharmacist-provided medication management program to provide enhanced medication reconciliation, discharge medication counseling, individualized patient education, and post hospital follow-up to reduce medication errors and adverse drug events in adult diabetic patients.  ","Diabetes 30-day Readmission Rate ","In DY4 and DY5 provider will report the percentage of hospital admissions (stays) for Diabetes that had at least one subsequent readmission (hospital stay) within 30 days of discharge for Medicaid patients 18 years of age and older from University Medical Center .  In addition, in DY5 provider will demonstrate improvement in a priority population focused area by improving the  Risk adjusted DM 30 day readmission rate (PPR.2).","Facility, Payer ","Medicaid diabetic patients at our hospital, University Medical Center","P4R","PPR.2","PM-8","Submission of Category 3 DY3 Status Report",149436.73499999999,"Yes/No","RHP 12_137999206.3.8_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",149436.73499999999,"Yes/No","RHP 12_137999206.3.8_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",485595.72,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",558099.40555555548,"Yes/No","NA","AM-3.1","Achievement of DY5 performance goal for PFP measure",558099.40555555548,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"%",0.17288100000000001,51,295,"CY2012: January 1, 2012 - December 31, 2012",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator: Total number of admissions (index stay) with at least one subsequent readmission (hospital stay) within 30 days during the measurement year.\nDenominator: Total number of hospital stays during the measurement year for patients 18 years of age and older hospitalized for Diabetes (DRG 420, 405, or 305).  The Medicaid subset was removed because our denominator size would have been less than 30 cases.","17.29% of our diabetic hospital admissions have a subsequent readmission within 30 days.","Diabetes 30-day Readmission Rate ","inpatient",null,"Total number of admissions (index stay) with at least one subsequent readmission (hospital stay) within 30 days during the measurement year","Total number of hospital stays during the measurement year for patients 18 years of age and older.",null,null,null,null,null,null,null,null,null,null,null,"PFP baseline under review",null,"2.11.2","","Diabetes 30-day Readmission Rate ",null,null,null,null,null,"2013-01-01","2013-12-31","2014-01-01","2014-12-31","2012-01-01","2012-12-31",null,null,"RHP 12_137999206.2.3","RHP 12_137999206.3.8","RHP 12_137999206.2.3_137999206.3.8",{"$f":"COUNTIFS($FI$4:$FI520,FI520)","v":1},"RHP 12_137999206.2.3_1",null,2,1,1,"RHP 12_137999206",{"$f":"COUNTIFS($FR$4:$FR520,FR520)","v":10},"RHP 12_137999206_10"]
["RHP 12","139461107","Covenant Medical Center","139461107.2.4","139461107.3.5","IT-13.5","Hospice and Palliative Care – documentation of spiritual/religions concerns ","Baseline Approved","Eligible to Report in October DY4","The project will establish a complementary outpatient, community‐based palliative medicine clinic","Hospice and Palliative Care – Percentage of patients receiving hospice or palliative care services with documentation in the clinical record of a discussion of spiritual/religions concerns or documentation that the patient/caregiver did not want to discuss ","In DY4 and DY5 provider will improve (increase) the percentage of hospice or palliative care patients treated in the Outpatient Palliative Care Clinic with documentation of a discussion of spiritual/religious concerns or documentation that the patient/caregiver/family did not want to discuss.","Facility ","Patients treated in the Outpatient Palliative Care Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",72870.009999999995,"Yes/No","RHP 12_139461107.3.5_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",72870.009999999995,"Yes/No","RHP 12_139461107.3.5_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",116930.92,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",116930.92,"Numeric",0.63055555500000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",559234.15,"Numeric",0.65,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.61111099999999996,33,54,"02/26/14 - 09/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.63055555500000005,null,0.65,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator equals the total number of patients seen at the clinic. The denominator equals the total number of patients with religous preferences documented in the EMR. ","Baselines states that 61.11% of patients seen at the clinic have  religious preferences documented in the EMR. ","Hospice and Palliative Care – documentation of spiritual/religions concerns ","Ambulatory/Inpatient",null,"Number of patient with clinical record documentation of spiritual/religious concerns or documentation that the patient/family did not want to discuss","Total number of patient’s discharged from hospice care and/or palliative care during the designated reporting period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.10.1","","Hospice and Palliative Care – documentation of spiritual/religions concerns ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-02-26","2014-09-30",null,null,"RHP 12_139461107.2.4","RHP 12_139461107.3.5","RHP 12_139461107.2.4_139461107.3.5",{"$f":"COUNTIFS($FI$4:$FI528,FI528)","v":2},"RHP 12_139461107.2.4_2",null,2,1,1,"RHP 12_139461107",{"$f":"COUNTIFS($FR$4:$FR528,FR528)","v":5},"RHP 12_139461107_5"]
["RHP 12","189947801","Medical Arts Hospital","189947801.1.4","189947801.3.4","IT-9.4.a","Reduce Emergency Department visits for Congestive Heart Failure","Pending Approval","Eligible to Report in October DY4","Medical Arts will to expand primary care clinic hours, expand primary clinic space, increase primary clinic staff ","Reduce Emergency Department visits for Congestive Heart Failure","In DY4 and DY5 provider will improve (decrease) the percentage of ED visits for primary or secondary CHF conditions out of the total number of ED visits during the measurement period. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",10742.764999999999,"Yes/No","RHP 12_189947801.3.4_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",10742.764999999999,"Yes/No","RHP 12_189947801.3.4_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",16847.669999999998,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",16847.669999999998,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",79156.69,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"A query was ordered to sample all ER visits for patients 18 and older. That yielded 4540 patients. A query was ordered to sample how many ER visits were for patients who were 18 and older and for whom the primary or secondary diagnosis was for CHF. That yielded 61 patients. ","Our baseline shows that 1.34% of all ER visits for patients 18 and older were for CHF patients.","Reduce Emergency Department visits for Congestive Heart Failure","ED",null,"Total number of ED Visits with a primary or secondary diagnosis of CHF for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2","","Reduce Emergency Department visits for Congestive Heart Failure",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 12_189947801.1.4","RHP 12_189947801.3.4","RHP 12_189947801.1.4_189947801.3.4",{"$f":"COUNTIFS($FI$4:$FI534,FI534)","v":1},"RHP 12_189947801.1.4_1",null,2,1,1,"RHP 12_189947801",{"$f":"COUNTIFS($FR$4:$FR534,FR534)","v":3},"RHP 12_189947801_3"]
["RHP 12","197063401","Golden Plains Community Hospital","197063401.2.1","197063401.3.4","IT-9.2.a","Emergency Department (ED) visits per 100,000\n\n","Baseline Approved","Eligible to Report in April DY4","GPCH will create an alternative service area on the hospital grounds to provide non-emergent care outside of the emergency department to patients who come to the ED with non-emergent conditions","Emergency Department (ED) visits per 100,000\n\n","In DY4 and DY5 provider will improve (reduce) ED utilization, reported as total number of adult ED visits (18 years old or more) out of the total number of adults in Hutchinson County",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",43942.98,"Yes/No","RHP 12_197063401.3.4_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",43942.98,"Yes/No","RHP 12_197063401.3.4_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",80266.604999999996,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",80266.61,"Numeric",50761.05256594126,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",414800.94,"Numeric",48089.418220365405,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",53432.686911517114,8569,16037,"DY2: Oct 1st, 2012 - Sept 30th, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,50761.05256594126,null,48089.418220365405,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator is total ED visits for DY2.  The denominator is total Hutchinson County population aged 18 and over for calendar year 2013 based on census data.","The baseline is ED utilization based on the county's population.","Emergency Department (ED) visits per 100,000\n\n","ED",null,"Total number of ED Visits during the measurement period ","Population in Metro Area or county, age 18 years and older",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.8.6","","Emergency Department (ED) visits per 100,000\n\n",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 12_197063401.2.1","RHP 12_197063401.3.4","RHP 12_197063401.2.1_197063401.3.4",{"$f":"COUNTIFS($FI$4:$FI542,FI542)","v":1},"RHP 12_197063401.2.1_1",null,2,1,1,"RHP 12_197063401",{"$f":"COUNTIFS($FR$4:$FR542,FR542)","v":7},"RHP 12_197063401_7"]
["RHP 12","281514401","Grace Medical Center","281514401.1.1","281514401.3.200","IT-1.11","Diabetes care:  BP control (<140/90mm Hg) ","Baseline Approved","Eligible to Report in April DY4","Grace will recruit new providers, open a new walk‐in clinic location in the HPSA, establish provider and ER benchmarks, and perform a PSDA of the case management intervention and scheduling system.","Diabetes care:  BP control (<140/90mm Hg) ","In DY4 and DY5 provider will improve the percentage of patients 18-75 years of age with at least one visit to the clinic on 50th St during the measurement year with diabetes (type 1 and type 2) whose most recent blood pressure (BP) reading is <140/90 mm Hg during the measurement year.","Facility ","Patients who had at least one outpatient encounter at the clinic facility located at 2412 50th St in Lubbock, Texas.  This area has been designated as a HPSA.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",19584,"Yes/No","RHP 12_281514401.3.200_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",19584,"Yes/No","RHP 12_281514401.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",31425.5,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",31425.5,"Numeric",0.69851692300000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",150296,"Numeric",0.70472599999999996,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.69230800000000003,144,208,"CY 2013: Jan 1st, 2013 - Dec 31st, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.69851692300000001,null,0.70472599999999996,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"We have a Meaningful Use certified EMR and were able to pull the reports from it based on the Outcome Measures correlation with NQF 0061.","Our providers are currently doing a fairly good job of adequately controlling blood pressure in our patients with diabetes but there is still ample room for improvement.","Diabetes care:  BP control (<140/90mm Hg) ","ambulatory",null,"Patients whose most recent BP reading is <140/90 mm Hg during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2","","Diabetes care:  BP control (<140/90mm Hg) ",null,null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 12_281514401.1.1","RHP 12_281514401.3.200","RHP 12_281514401.1.1_281514401.3.200",{"$f":"COUNTIFS($FI$4:$FI545,FI545)","v":2},"RHP 12_281514401.1.1_2",null,2,1,1,"RHP 12_281514401",{"$f":"COUNTIFS($FR$4:$FR545,FR545)","v":2},"RHP 12_281514401_2"]
["RHP 13","121781205","Sutton County Hospital District","121781205.2.2","121781205.3.2","IT-9.2.a","Emergency Department (ED) visits per 100,000\n\n","Baseline Approved","Eligible to Report in October DY4","This project will provide in-home services to patients to reduce re-admissions, unnecessary emergency department admissions and increase compliance with disease management.","Emergency Department (ED) visits per 100,000\n\n","In DY4 and DY5 Provider will reduce the rate of all ED visits per 100K population in the Metro Area or County. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",19266.84,"Yes/No","RHP 13_121781205.3.2_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",19266.84,"Yes/No","RHP 13_121781205.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",23830.55,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",23830.55,"Numeric",14655.51672491263,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",106311.13,"Numeric",13884.173739390913,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",15426.859710434348,618,4006,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,14655.51672491263,null,13884.173739390913,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator and demotinator were determined by overall count of ED visits in relation to the overall population in a six month time-frame. The numerator is the population of Sutton County . The demoninator is ED visits amount patients 18 years of age and older.","The baseline rate is just that--a baseline calculation from which to improve upon during our next reporting period. The number means that approximately 15% of citizens have visited the ED from April 2014 - September 2014. For this particular project, our goal will be to reduce the number (percentage) of overall ED visits among adults 18 years of age and older.","Emergency Department (ED) visits per 100,000\n\n","ED",null,"Total number of ED Visits during the measurement period ","Population in Metro Area or county, age 18 years and older",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1",null,"Emergency Department (ED) visits per 100,000\n\n",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 13_121781205.2.2","RHP 13_121781205.3.2","RHP 13_121781205.2.2_121781205.3.2",{"$f":"COUNTIFS($FI$4:$FI556,FI556)","v":1},"RHP 13_121781205.2.2_1",null,2,1,1,"RHP 13_121781205",{"$f":"COUNTIFS($FR$4:$FR556,FR556)","v":2},"RHP 13_121781205_2"]
["RHP 13","130616905","Pecos County Memorial Hospital","130616905.1.100","130616905.3.201","IT-9.2.a","Emergency Department (ED) visits per 100,000\n\n","Baseline Approved","Eligible to Report in October DY4","This project will implement a primary care clinic to provide patient care to the residents of Marathon, Texas, which has a population of approximately 500. ","Emergency Department (ED) visits per 100,000\n\n","In DY4 and DY5, provider will decrease the total number of Facility ED visits during the measurement period per 100,000 adults population in the county. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",20924.8,"Yes/No","RHP 13_130616905.3.201_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",20924.8,"Yes/No","RHP 13_130616905.3.201_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",29580.9,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",29580.9,"Numeric",3704.7353760445685,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",112048.53,"Numeric",3509.7493036211699,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",3899.7214484679666,14,359,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,3704.7353760445685,null,3509.7493036211699,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"An adhoc report was pulled from our EMR with ED stay type and zip code for this area for the time frame indicated for the numerator. Local census reports were used along with demographic information to extrapolate population in area 18 years and older for the denominator.","According to the baseline rate above, ED utilization at our facility for the stated population from the stated area shows that 3.9% of the denominator are coming to our ED during the stated time frame.","Emergency Department (ED) visits per 100,000\n\n","ED",null,"Total number of ED Visits during the measurement period ","Population in Metro Area or county, age 18 years and older",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2","","Emergency Department (ED) visits per 100,000\n\n",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 13_130616905.1.100","RHP 13_130616905.3.201","RHP 13_130616905.1.100_130616905.3.201",{"$f":"COUNTIFS($FI$4:$FI561,FI561)","v":1},"RHP 13_130616905.1.100_1",null,2,1,1,"RHP 13_130616905",{"$f":"COUNTIFS($FR$4:$FR561,FR561)","v":1},"RHP 13_130616905_1"]
["RHP 13","133340307","Hill Country Community MHMR Center ","133340307.2.1","133340307.3.1","IT-11.25","Daily Living Activities (DLA-20)","Baseline Approved","Eligible to Report in October DY4","This project will implement Co‐occurring Psychiatric and Substance Use Disorder Services within the 5 counties served by Hill Country in RHP13 in order to meet\nthe needs of individuals with psychiatric and substance use issues within the community setting in order to reduce emergency department utilization, inpatient utilization, and incarceration","Daily Living Activities (DLA-20)","In DY4 and DY5, provider will report the average score of all qualifying DLA-20 questionnaires completed during the measurement period for individuals with  a history of trauma. This will be done by reporting the sum total of individual average DLA scores for all DLA-20 questionnaires completed during the measurement period, and the total number of DLA-20 questionnaires completed during the measurement period.  In addition, in DY5 provider will increase the rate of adherence to antipsychotic medications system wide, per the requirements of Population Focused Priority Measure CMHC.5. ","Targeted Comorbid Conditions, Facility ","Individuals with Co-occurring Psychiatric and Substance Use Disorder (COPSD) served in COPSD programs at Hill Country MHDD","P4R","CMHC.5","PM-8","Submission of Category 3 DY3 Status Report",3474.5,"Yes/No","RHP 13_133340307.3.1_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",3474.5,"Yes/No","RHP 13_133340307.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",11085.25,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",7987,"Yes/No","NA","AM-3.1","Achievement of DY5 performance goal for PFP measure",7987,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Score",45.042250000000003,3198,71,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Determined all DLA-20s assessed between October 2013 through September 2014, applied the subset of individuals receiving Co-occurring Psychiatric and Substance Use Disorder Services at Hill Country, flagged first and last DLA-20 on individuals within the subset to ensure only initial and latest DLAs of individuals with multiple assessments were included in measure, created pivot table in Excel to calculate number of assessments and total scores to be included in numerator and demoninator","Individuals receiving the intervention have seen DLA scores increase by 18.5% which means that with the intervention the mental illness and substance use disorder has less interference with their daily functioning","Daily Living Activities (DLA-20)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,"PFP baseline not yet reported",null,"2.13.1","Scenario 1: Pre/Posttest Baseline","Daily Living Activities (DLA-20)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 13_133340307.2.1","RHP 13_133340307.3.1","RHP 13_133340307.2.1_133340307.3.1",{"$f":"COUNTIFS($FI$4:$FI570,FI570)","v":1},"RHP 13_133340307.2.1_1",null,2,1,1,"RHP 13_133340307",{"$f":"COUNTIFS($FR$4:$FR570,FR570)","v":1},"RHP 13_133340307_1"]
["RHP 13","137226005","Shannon West Texas Memorial Hospital","137226005.1.5","137226005.3.10","IT-3.26","Risk Adjusted Post-Surgical 30-day Readmission Rate ","Baseline Approved","Eligible to Report in October DY4","Shannon Medical Center proposes to expand primary care by opening an Access Clinic. Shannon Medical Center will collaborate with Shannon Clinic to coordinate primary care appointments for patients discharged from Shannon that cannot get into a primary care provider. The Access Clinic will be open Monday-Friday 8:00 AM to 5:00 PM with at least two providers on staff.","Risk Adjusted Post-Surgical 30-day Readmission Rate ","In DY4 and DY5, provider will improve the ratio of observed to expected readmissions within 30 days of discharge from an index admission related to Surgical intervention during the measurement year for patients 18 years of age and older.  ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",34685.665000000001,"Yes/No","RHP 13_137226005.3.10_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",36225.48720215659,"Yes/No","RHP 13_137226005.3.10_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",56716.724999999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",56716.72,"Numeric",1.058227848,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",264019.75,"Numeric",1.002532,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",1.1139239999999999,8.8000000000000007,7.9,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,1.058227848,null,1.002532,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"APR DRG: all classified surgical APR DRG’s \nAge 18 -125\nAcute Inpatient\nExcludes all hospice payors and organ sharing\nExcludes BHC, OBV, OP, Sports Med, Day Surg, Dialysis, ER, Home Health, Med Plus, Non Invasive, Non Patient, OAR’s, OBS, Other AR, Outpatient, Pre-op, Recurring, Rehab, Rul Clinic, SNF\n","For the baseline measurement period (04/01/14 – 09/30/14), the baseline rate for risk adjusted post-surgical 30-day readmissions is 1.14.","Risk Adjusted Post-Surgical 30-day Readmission Rate ","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission for post-surgical issues during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk CHF admissions during the measurement period.\n","Expected (risk-adjusted) rate of readmissions for post-surgical issues during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1","","Risk Adjusted Post-Surgical 30-day Readmission Rate ",null,null,null,null,"Florida All-payer Norms","2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 13_137226005.1.5","RHP 13_137226005.3.10","RHP 13_137226005.1.5_137226005.3.10",{"$f":"COUNTIFS($FI$4:$FI578,FI578)","v":1},"RHP 13_137226005.1.5_1",null,2,1,1,"RHP 13_137226005",{"$f":"COUNTIFS($FR$4:$FR578,FR578)","v":3},"RHP 13_137226005_3"]
["RHP 13","137226005","Shannon West Texas Memorial Hospital","137226005.2.3","137226005.3.201","IT-13.5","Hospice and Palliative Care – documentation of spiritual/religions concerns ","Baseline Approved","Eligible to Report in April DY4","The goal of the palliative care program is to serve a broader patient population by expanding the type and volume of patients that are initially considered for palliative care services. The number of palliative care screens will be increased when front line nursing staff identifies palliative care triggers. By providing education for physicians and staff, Shannon Medical Center will have the opportunity to target patients that are seriously ill or have multiple chronic conditions that may benefit from being seen by professionals in the palliative care program","Hospice and Palliative Care – Percentage of patients receiving hospice or palliative care services with documentation in the clinical record of a discussion of spiritual/religions concerns or documentation that the patient/caregiver did not want to discuss ","In DY4 and DY5, the provider will improve the percentage of patients with clinical record documentation of spiritual/religious concerns or documentation that the patient/family did not want to discuss over all patient’s discharged from hospice care during the designated reporting period",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",33033.966666666667,"Yes/No","RHP 13_137226005.3.201_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",34500.464002053894,"Yes/No","RHP 13_137226005.3.201_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",54015.93,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",54015.93,"Numeric",8.4420289999999995E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",251447.38,"Numeric",0.132609,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",3.6232E-2,5,138,"CY2013 (1): January 1, 2013- June 30, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,8.4420289999999995E-2,null,0.132609,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Each palliative care chart notes were reviewed to determine which medical records included documentation of spiritual or religious concerns, or documentation that the patient/family did not want to discuss.","During the baseline measurement period (01/01/13 - 06/30/13), 3.62% of palliative care patients had documentation of spiritual or religious concerns, or documentation that the patient/family did not want to discuss.","Hospice and Palliative Care – documentation of spiritual/religions concerns ","Ambulatory/Inpatient",null,"Number of patient with clinical record documentation of spiritual/religious concerns or documentation that the patient/family did not want to discuss","Total number of patient’s discharged from hospice care and/or palliative care during the designated reporting period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.10.1","","Hospice and Palliative Care – documentation of spiritual/religions concerns ",null,null,null,null,null,"2013-07-01","2014-06-30","2014-07-01","2015-06-30","2013-01-01","2013-06-30",null,null,"RHP 13_137226005.2.3","RHP 13_137226005.3.201","RHP 13_137226005.2.3_137226005.3.201",{"$f":"COUNTIFS($FI$4:$FI583,FI583)","v":2},"RHP 13_137226005.2.3_2",null,2,1,1,"RHP 13_137226005",{"$f":"COUNTIFS($FR$4:$FR583,FR583)","v":8},"RHP 13_137226005_8"]
["RHP 14","081939301","Texas Tech Health Science Center-Permian Basin","081939301.1.4","081939301.3.6","IT-15.6","Chlamydia screening in women ","Pending Approval","Eligible to Report in October DY4","Increase infrastructure and staffing with geographic expansion to underserved areas.","Chlamydia screening in women ","In DY4 and DY5 provider will improve (increase) the percentage of women, seen at Monahans or the FQHC in South Odessa, 16–24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year.","Facility ","Women who were seen in our rural and underserved clinics.  This would include Monahans, our second rural site when opened and the FHC in South Odessa.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",15234.16,"Yes/No","RHP 14_081939301.3.6_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",15234.16,"Yes/No","RHP 14_081939301.3.6_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",16104.25,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",16104.25,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",69566.86,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator is the total number of women in this age range that had a chlamydia test done and the denominator is the total numner of women seen in this clinic in this age range that were identifies as sexualy active.","Out of 17 women seen in this age range 13 of them had a chlaymida test done.","Chlamydia screening in women ","ambulatory",null,"The number of women 16-24 years with at least one chlamydia test during the measurement year.","The number of women 16-24 years of age who were identified as sexually active.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1 ","","Chlamydia screening in women ",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 14_081939301.1.4","RHP 14_081939301.3.6","RHP 14_081939301.1.4_081939301.3.6",{"$f":"COUNTIFS($FI$4:$FI595,FI595)","v":3},"RHP 14_081939301.1.4_3",null,2,1,1,"RHP 14_081939301",{"$f":"COUNTIFS($FR$4:$FR595,FR595)","v":6},"RHP 14_081939301_6"]
["RHP 14","081939301","Texas Tech Health Science Center-Permian Basin","081939301.2.101","081939301.3.203","IT-15.6","Chlamydia screening in women ","Pending Approval","Eligible to Report in October DY4","In this project we will create a patient navigation program that will allow for much needed financial screening and patient guidance through the healthcare system.  ","Chlamydia screening in women ","In DY4 and DY5 provider will improve (increase) the percentage of women seen in the Department of OB/GYN at TTUHSC in Odessa 16–24 years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement year.","Facility ","Women seen in the Department of OB/GYN at TTUHSC in Odessa","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",7148.335,"Yes/No","RHP 14_081939301.3.203_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",7148.335,"Yes/No","RHP 14_081939301.3.203_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",7556.61,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",7556.61,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",32642.91,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The demoninator was determind by running the list of patients that were seen in the OB/Gyn clinic and applying the subset of age and that were identified as sexually active.  The numerator was calculated by running a list from the EMR on orders for chalymida testing.","The demoninator was determind by running the list of patients that were seen in the OB/Gyn clinic and applying the subset of age and that were identified as sexually active.  The numerator was calculated by running a list from the EMR on orders for chalymida testing.","Chlamydia screening in women ","ambulatory",null,"The number of women 16-24 years with at least one chlamydia test during the measurement year.","The number of women 16-24 years of age who were identified as sexually active.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1","","Chlamydia screening in women ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 14_081939301.2.101","RHP 14_081939301.3.203","RHP 14_081939301.2.101_081939301.3.203",{"$f":"COUNTIFS($FI$4:$FI600,FI600)","v":3},"RHP 14_081939301.2.101_3",null,2,1,1,"RHP 14_081939301",{"$f":"COUNTIFS($FR$4:$FR600,FR600)","v":11},"RHP 14_081939301_11"]
["RHP 14","081939301","Texas Tech Health Science Center-Permian Basin","081939301.2.4","081939301.3.10","IT-12.1","Breast Cancer Screening","Baseline Approved","Eligible to Report in October DY4","Expand and improve the existing women’s healthcare ","Breast Cancer Screening","In DY4 and DY5 provider will improve (increase) the percentage of women seen in the Department of OB/GYN at TTUHSC in Odessa 50 to 74 years of age who had a mammogram for breast cancer every two years.","Facility ","Women seen in the Department of OB/GYN at TTUHSC in Odessa","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",5859.29,"Yes/No","RHP 14_081939301.3.10_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",5859.29,"Yes/No","RHP 14_081939301.3.10_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",6193.94,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",6193.94,"Numeric",0.57276000000000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",26756.48,"Numeric",0.57885299999999995,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.56666700000000003,17,30,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.57276000000000005,null,0.57885299999999995,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"For the denominator we used the patient list that we ran for DY3 and applied the appropratie age subset listed.  Fot the numerator we ran a report from our EMR that queried the orders for mammograms.","Of the total women that we saw in the Odessa clinic in the approriate age range (50-74) 56.67 % of those women had mammograms completed during DY3.","Breast Cancer Screening","ambulatory",null,"Women who had mammogram during the measurement year or the 18 months prior to the measurement year.","Women 50-74 years old as of the measurement year who had at least one (1) outpatient encounter in the prior 12-month period. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.6.2 ","","Breast Cancer Screening",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 14_081939301.2.4","RHP 14_081939301.3.10","RHP 14_081939301.2.4_081939301.3.10",{"$f":"COUNTIFS($FI$4:$FI605,FI605)","v":1},"RHP 14_081939301.2.4_1",null,2,1,1,"RHP 14_081939301",{"$f":"COUNTIFS($FR$4:$FR605,FR605)","v":16},"RHP 14_081939301_16"]
["RHP 14","112684904","Reeves County Hospital District","112684904.2.1","112684904.3.3","IT-1.14","Diabetes care: Nephropathy ","Pending Approval","Eligible to Report in October DY4","Implement a Certified Diabetes Education Program geared toward helping those patients diagnosed with diabetes to better manage their chronic condition.","Diabetes care: Nephropathy ","In DY4 and DY5 provider will increase percentage of patients 18-75 years of age with diabetes (type 1 and type 2) at the Reeves County Hospital District Clinic who received a nephropathy screening test or had evidence of nephropathy during the measurement year.","Facility ","Reeves County Hospital District owns and operates a 20,000 square foot clinic with 12 providers.  Our focus for project number 112684904.2.1 shall be all patients seen by this facility.  ","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",7434.3050000000003,"Yes/No","RHP 14_112684904.3.3_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",7434.3050000000003,"Yes/No","RHP 14_112684904.3.3_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",10603.945,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",10603.945,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",38036.01,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator for IT 1.14 was collected using the Hospital's Chartlink system within our electronic medical record. The denominator for metrict IT 1.14 was collected using an adhoc reporting tool within our electronic medical record system.","For DY 3 project number 11264904.2.1, Category 3 Metric IT 1.14 our baseline rate is 62.18%. Our interpretation is that 62.18% of our patients 18-75 years of age treated during the measurement year, diagnosed with diabetes (type 1 and type 2) have received a nephropathy screening test or had evidence of nephropathy during the measuring year.","Diabetes care: Nephropathy ","ambulatory",null,"Patients who received a nephropathy screening test* or had evidence of nephropathy** during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.2 ","","Diabetes care: Nephropathy ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 14_112684904.2.1","RHP 14_112684904.3.3","RHP 14_112684904.2.1_112684904.3.3",{"$f":"COUNTIFS($FI$4:$FI612,FI612)","v":3},"RHP 14_112684904.2.1_3",null,2,1,1,"RHP 14_112684904",{"$f":"COUNTIFS($FR$4:$FR612,FR612)","v":3},"RHP 14_112684904_3"]
["RHP 14","112711003","Odessa Regional Medical Center","112711003.1.2","112711003.3.4","IT-1.28","Screening for High Blood Pressure and Follow-Up Documented","Pending Approval","Eligible to Report in October DY4","Add a Mobile Health Clinic that will serve ORMC’s primary service area, along with outreaching communities that might not have access to primary care services.","Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented","In DY4 and DY5 provider will improve (increase) the percentage of patients seen in the mobile unit aged 18 years and older seen during the measurement period who were screened for high blood pressure (BP) AND a recommended follow-up plan is documented based on the current blood pressure reading as indicated","Facility ","Patients with encounters through our mobile unit will be used in this denominator","P4P","","PM-8","Submission of Category 3 DY3 Status Report",21916.667581847487,"Yes/No","RHP 14_112711003.3.4_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",21916.667581847487,"Yes/No","RHP 14_112711003.3.4_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",35291.667500000003,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",35291.667500000003,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",165525.60227593075,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"","The denominator (1235) was determined through utilizing the patient registry for all patients screened by the mobile van.  The numerator (1235) was determined through inclusion of patient education and discussion of results both normal and abnormal provided to each patient upon completion of the screening exam.  Each patient is provided with an information packet which also contains physician referral information.  ","Baseline is interpreted as 100%","Screening for High Blood Pressure and Follow-Up Documented","Ambulatory",null,"Patients who were screened for high blood pressure and a recommended follow-up plan is documented as indicated if the blood pressure is pre-hypertensive or hypertensive","All patients aged 18 years and older at the beginning of the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.3 ",null,"Screening for High Blood Pressure and Follow-Up Documented",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 14_112711003.1.2","RHP 14_112711003.3.4","RHP 14_112711003.1.2_112711003.3.4",{"$f":"COUNTIFS($FI$4:$FI619,FI619)","v":3},"RHP 14_112711003.1.2_3",null,2,1,1,"RHP 14_112711003",{"$f":"COUNTIFS($FR$4:$FR619,FR619)","v":5},"RHP 14_112711003_5"]
["RHP 14","127298103","Permian Regional Medical Center","127298103.1.1","127298103.3.1","IT-9.10","ED throughput Measure bundle","Pending Approval","Eligible to Report in October DY4","We will offer prompt care in an extended hours setting and provide additional primary care capacity to meet the needs of non emergent visits to the emergency department.","ED throughput Measure bundle","In DY4 and DY5 provider will reduce the median wait time for 1.) Median Time from ED Arrival to ED Departure for Discharged ED Patients, 2.) Median time from admit decision time to time of departure from the ED for ED patients admitted to inpatient status and 3.) Median time from ED arrival to time of departure from the emergency room for patients admitted to the facility from the ED. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",41821.75,"Yes/No","RHP 14_127298103.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",41821.75,"Yes/No","RHP 14_127298103.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",87774.699999999968,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- ED Arrival to ED Departure for Discharged ED Patients",29258.233333333323,"Numeric","TBD","AM-1.2","Achievement of DY4 performance goal- admit decision to departure for ED patients admitted",29258.233333333323,"Numeric","TBD","AM-1.3","Achievement of DY4 performance goal- arrival to departure for ED patients admitted",29258.233333333323,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- ED Arrival to ED Departure for Discharged ED Patients",186842.96,"Numeric","TBD","AM-2.2","Achievement of DY5 performance goal- admit decision to departure for ED patients admitted",186842.96,"Numeric","TBD","AM-2.3","Achievement of DY5 performance goal- arrival to departure for ED patients admitted",186842.96,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,3,"time (minutes)",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,"TBD",null,"TBD",null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,"Ran a report from Meditech to select all ED visits.    1) is 116 minutes  2) is 51 minutes 3) 214 minutes","Total number of patients served by category divided by the number of minutes.","ED throughput Measure bundle","ED",null,"Rate #1: Median Time from ED Arrival to ED Departure for Discharged ED Patients: Continuous Variable Statement: Time (in minutes) from ED arrival to ED departure for patients discharged from the emergency department. ",1,"Rate #2: Median time from admit decision time to time of departure from the ED for ED patients admitted to inpatient status: Continuous variable statement: Time (in minutes) from admit decision time to time of departure from the emergency department (ED) for ED patients admitted to inpatient status",1,"Rate #3: Median time from ED arrival to time of departure from the emergency room for patients admitted to the facility from the ED: Continuous variable statement: Time (in minutes) from emergency department (ED) arrival to ED departure for patients admitted to the facility from the ED",1,null,null,null,null,null,null,null,null,null,"1.1.2","","ED arrival to ED departure for ED discharge","admit decision time to ED departure for admitted patients","ED arrival to ED departure for admitted patients",null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 14_127298103.1.1","RHP 14_127298103.3.1","RHP 14_127298103.1.1_127298103.3.1",{"$f":"COUNTIFS($FI$4:$FI627,FI627)","v":1},"RHP 14_127298103.1.1_1",null,4,3,1,"RHP 14_127298103",{"$f":"COUNTIFS($FR$4:$FR627,FR627)","v":1},"RHP 14_127298103_1"]
["RHP 14","135235306","Medical Center Hospital","135235306.1.3","135235306.3.3","IT-8.19","Post-Partum Follow-Up and Care Coordination","Baseline Approved","Eligible to Report in October DY4","This project will implement a new Women’s Initiative for MCHS by implementing a new OB/GYN group that will cover an on-site clinic and cover the Family Health Clinics as well. Health literacy will play a key role in this initiative. We will also attempt to implement a program focused on centering concepts at both Family Health Clinic sites.   ","Post-Partum Follow-Up and Care Coordination","In DY4 and DY5 provider will improve (increase) the percentage of MCHS ProCare Women's Clinic patients, regardless of age, who gave birth during a 12-month period who were seen for post-partum care within 8 weeks of giving birth who received a breast feeding evaluation and education, post-partum depression screening, post-partum glucose screening for gestational diabetes patients, and family and contraceptive planning.","Facility ","MCHS ProCare Women's Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",83871.41,"Yes/No","RHP 14_135235306.3.3_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",83871.41,"Yes/No","RHP 14_135235306.3.3_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",134611.54999999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",134611.54999999999,"Numeric",0.41416666600000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",635342.05000000005,"Numeric",0.44500000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.38333299999999998,23,60,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.41416666600000002,null,0.44500000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator were mothers who had delivered that received all 4 services at theirpost-partum visit. Denominator was all mothers who delivered with Dr. Garcia in this time frame.","The baseline is a nice start, but we still have work to do on developing a more consistent process to ensure compliance. We only had one patient with gestational diabetes, but that patient had the necessary sreening. Breast feeding education appears to be an opportunity.","Post-Partum Follow-Up and Care Coordination","ambulatory",null,"Patients receiving the following at a post-partum visit:\n• Breast feeding evaluation and education, including patient-reported breast feeding\n• Post-partum depression screening\n• Post-partum glucose screening for gestational diabetes patients \n• Family and contraceptive planning\n","All patients, regardless of age, who gave birth during a 12-month period seen for post-partum care visit before or at 8 weeks of giving birth.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1 ","","Post-Partum Follow-Up and Care Coordination",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 14_135235306.1.3","RHP 14_135235306.3.3","RHP 14_135235306.1.3_135235306.3.3",{"$f":"COUNTIFS($FI$4:$FI637,FI637)","v":1},"RHP 14_135235306.1.3_1",null,2,1,1,"RHP 14_135235306",{"$f":"COUNTIFS($FR$4:$FR637,FR637)","v":3},"RHP 14_135235306_3"]
["RHP 14","135235306","Medical Center Hospital","135235306.2.100","135235306.3.100","IT-3.16","Chronic Obstructive Pulmonary Disease (COPD) 30-day Readmission Rate ","Baseline Approved","Eligible to Report in October DY4","This project will initiate a pharmacist driven medication reconciliation process for all patients admitted to MCH. ","Chronic Obstructive Pulmonary Disease (COPD) 30-day Readmission Rate ","In DY4 and DY5 provider will improve ratio of observed to expected readmissions that occur within 30 days following discharge from an index admission for Chronic Obstructive Pulmonary Disease (COPD) with at least one readmission within 30 days of discharge.   In addition, in DY5 the provider will describe alternative approaches to program and outcome linkages  (Stretch Activity 3).",null,null,"P4R","SA3","PM-8","Submission of Category 3 DY3 Status Report",83871.41,"Yes/No","RHP 14_135235306.3.100_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",83871.41,"Yes/No","RHP 14_135235306.3.100_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",269223.09999999998,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",317671.02500000002,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",317671.02500000002,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.141066,45,319,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator is patients readmitted within the 30 days with COPD exacerbations. Denominator is all patients admitted with COPD","We have done a decent job of identifying patients with COPD, but there is still work to be done. The population is identified and now we need to work on interventions to continue to drive down this rate.","Chronic Obstructive Pulmonary Disease (COPD) 30-day Readmission Rate ","inpatient",null,"Total number of admissions (index stay) with at least one subsequent readmission (hospital stay) for any reason within 30 days during the measurement year","The total number of hospital stays for COPD during the measurement year for patients 18 years of age and older.",null,null,null,null,null,null,null,null,null,null,"We continue to work with HEB for our stretch activity. We believe that it will have a significant impact on our target population.",null,null,"2.11.2","","Chronic Obstructive Pulmonary Disease (COPD) 30-day Readmission Rate ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 14_135235306.2.100","RHP 14_135235306.3.100","RHP 14_135235306.2.100_135235306.3.100",{"$f":"COUNTIFS($FI$4:$FI641,FI641)","v":1},"RHP 14_135235306.2.100_1",null,2,1,1,"RHP 14_135235306",{"$f":"COUNTIFS($FR$4:$FR641,FR641)","v":7},"RHP 14_135235306_7"]
["RHP 14","135235306","Medical Center Hospital","135235306.2.7","135235306.3.11","IT-1.25","Adult tobacco use ","Baseline Approved","Eligible to Report in October DY4","The establishment of a Congregational Health Network and the employment of a Faith Community Navigator would effectively bridge the professional care system and the local church. Liaisons MCHS would identify a registered nurse to serve as the Faith Community Navigator and be employed by the hospital.","Adult tobacco use ","In DY4 and DY5 provider will report the prevalence of adult tobacco use for Faith and Health Network members.  In addition, in DY5 the provider will describe alternative approaches to program and outcome linkages  (Stretch Activity 3).","Facility ","Faith and Health Network Members","P4R","SA3","PM-8","Submission of Category 3 DY3 Status Report",83871.41,"Yes/No","RHP 14_135235306.3.11_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",83871.41,"Yes/No","RHP 14_135235306.3.11_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",269223.09999999998,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",317671.02500000002,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",317671.02500000002,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",1.6948999999999999E-2,1,59,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"From returned surveys","We don't feel that this is a true reflection of the smoking status of our FHN, but we are limited by to the number of surveys that are returned. We feel confident that we will make a positive impact on this measure as we move forward and we are already seeing results from the congregational health fairs. ","Adult tobacco use ","ambulatory",null,"Number of adults aged 18 years and older who report the use of cigarettes, chewing tobacco, snuff, or cigars in the past 30 days. ","Number of adults aged 18 years and older in the service area. ",null,null,null,null,null,null,null,null,null,null,"We are working to further develop our stretch activity. This program will allow us to dive into population health behaviors more than any other project we have in the waiver. We will provide a full report in DY5 as we develop the program.",null,null,"2.6.3 ","","Adult tobacco use ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 14_135235306.2.7","RHP 14_135235306.3.11","RHP 14_135235306.2.7_135235306.3.11",{"$f":"COUNTIFS($FI$4:$FI649,FI649)","v":1},"RHP 14_135235306.2.7_1",null,2,1,1,"RHP 14_135235306",{"$f":"COUNTIFS($FR$4:$FR649,FR649)","v":15},"RHP 14_135235306_15"]
["RHP 14","136143806","Midland Memorial Hospital","136143806.1.2","136143806.3.2","IT-9.2","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","Baseline Approved","Eligible to Report in April DY4","Promote the “68NURSE” telephone nurse triage program, via a toll free number and various local marketing initiatives; establish a provider referral system","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","In DY4 and DY5 provider will decrease the percentage ACSC ED visits out of the total number of adult ED visits at Midland Memorial Hospital","Facility ","Midland Memorial Hospital","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",105164.395,"Yes/No","RHP 14_136143806.3.2_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",105450.39500091838,"Yes/No","RHP 14_136143806.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",256062.78,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",256062.78,"Numeric",0.37726594699999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",809009.43,"Numeric",0.35741000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.39712199999999998,13578,34191,"CY 2013: Jan 1st, 2013 - Dec 31st, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.37726594699999999,null,0.35741000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"There were several steps involved.\n(1)  A delimited file of all outpatient cases for CY13 was dumped so it could be uploaded into Excel.\n(2)  An Excel table was created listing all the ACSC diagnoses.\n(3)  A delimited files of all outpatient diagnoses with associated accounts for CY13 was dumped so it could be uploaded into Excel.\n(4)  Using a VLOOKUP formula - accounts were tagged that had the specific ACSC diagnoses in the diagnoses file.\n(5)  Using a VLOOKUP formula - accounts in the main file were tagged as among those having the specified ACSC diagnoses.\n(6)  Then using the modified file, pivot charges were created that filtered on several factors --  a. Service (ER or ERT), Age (Age CD = Y, Age =>18), ACSC = Yes, Status = all but X which are cancelled accounts.  The result = number of adult patients 18 years of age and older that visited the ED with an ACSC diagnosis(es) in their file for that visit.\n(7)  A copy of the pivot chart was used with one filter removed - ACSC and the total number of ED visits for patients 18 years of age and older was obtained.\n(8) No filtering was done on patient residence - so visits include all patients not just those from Midland County or RHP14. \n","Just over 14% of the patients that were seen and released from the ED in CY2013 - did so for ACSC reasons.  It is our hope that our project will be able to impact this number by triaging and directing these patients to more appropriate \nsources of care.","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","ED",null,"Total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.6.2 ","","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ",null,null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 14_136143806.1.2","RHP 14_136143806.3.2","RHP 14_136143806.1.2_136143806.3.2",{"$f":"COUNTIFS($FI$4:$FI654,FI654)","v":1},"RHP 14_136143806.1.2_1",null,2,1,1,"RHP 14_136143806",{"$f":"COUNTIFS($FR$4:$FR654,FR654)","v":5},"RHP 14_136143806_5"]
["RHP 14","136143806","Midland Memorial Hospital","136143806.2.3","136143806.3.9","IT-13.1","Hospice and Palliative Care – Pain assessment ","Baseline Approved","Eligible to Report in October DY4","New program to integrate a palliative care consult team so patients with serious illness experience better quality of life  by having supportive care to manage physical symptoms; psychosocial, cultural/spiritual concerns and to assist with decision-making. Support is provided for physicians and nursing staff by assisting with time-intensive patient/family conversations and ongoing education.","Hospice and Palliative Care – Pain assessment ","In DY4 and DY5 provider will improve (increase) the percentage of hospice or palliative care patients in the Palliative Care Program at Midland Memorial Hospital who screened positive for pain and who received a clinical assessment of pain within 24 hours of screening.","Facility ","Palliative Care Program at Midland Memorial Hospital","P4P","SA3","PM-8","Submission of Category 3 DY3 Status Report",35054.798333333332,"Yes/No","RHP 14_136143806.3.9_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",35150.131666972797,"Yes/No","RHP 14_136143806.3.9_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",85354.260000255104,"Yes/No","NA","PM-12","Sustained high performance level",85354.260000255104,"Yes/No","Maintain",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-12","Sustain high performance level",134834.90499940477,"Yes/No","Maintain","PM-11","Successful Achievment of Stretch Activity",134834.90499940477,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.98333300000000001,118,120,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"Maintenance","Maintain",null,"Maintain",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"All patients whose record in the database indicate that they reported positive for pain or required pain management if non-communicative constitutes the denominator.  The numerator represents all patients with \ndocumentation in the database that a clinical assessment was done within 24 hours.","Since our precentage last year was lower, we are getting better at our protocols but fall short of 100%.","Hospice and Palliative Care – Pain assessment ","Ambulatory/Inpatient",null,"Patients who received a comprehensive clinical assessment to determine the severity, etiology, and impact of their pain within 24 hours of screening positive for pain","Patients enrolled in hospice or receiving palliative care who report pain when pain screening is done on the admission evaluation/initial encounter",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.10.1","","Hospice and Palliative Care – Pain assessment ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 14_136143806.2.3","RHP 14_136143806.3.9","RHP 14_136143806.2.3_136143806.3.9",{"$f":"COUNTIFS($FI$4:$FI663,FI663)","v":3},"RHP 14_136143806.2.3_3",null,2,1,1,"RHP 14_136143806",{"$f":"COUNTIFS($FR$4:$FR663,FR663)","v":14},"RHP 14_136143806_14"]
["RHP 14","176354201","Culberson Hospital","176354201.2.1","176354201.3.1","IT-9.2","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","Pending Approval","Eligible to Report in October DY4","Transform the Rural Health Clinic currently operated alongside the hospital to a Patient-Centered Medical Home (PCMH). Implementation will use evidence based practices in promoting a patient-centered care focus on community wellness and enhanced coordination of care in rural and underserved area.","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","In DY4 and DY5 provider will decrease the percentage ACSC ED visits out of the total number of adult ED visits.",null,null,"P4P","","PM-8","Submission of Category 3 DY3 Status Report",8312.5,"Yes/No","RHP 14_176354201.3.1_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",8312.5,"Yes/No","RHP 14_176354201.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",13338.5,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",13338.5,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",63792,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"","Total number of ED visits with a primary or secondary ACSC diagnosis as the numerator with a denominator of total number of ED visits. ","Percentage of ED visits involving a primary of secondary ACSC diagnosis. ","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","ED",null,"Total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.1.3",null,"\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 14_176354201.2.1","RHP 14_176354201.3.1","RHP 14_176354201.2.1_176354201.3.1",{"$f":"COUNTIFS($FI$4:$FI671,FI671)","v":1},"RHP 14_176354201.2.1_1",null,2,1,1,"RHP 14_176354201",{"$f":"COUNTIFS($FR$4:$FR671,FR671)","v":1},"RHP 14_176354201_1"]
["RHP 15","065086301","City of El Paso Department of Public Health","065086301.2.1","065086301.3.207","IT-12.3","Colorectal Cancer Screening ","Baseline not yet reported","Eligible to Report in October DY4","The City of El Paso Department of Public Health through the El Paso Fire Department proposes to improve Medicaid and uninsured access to health education, health promotion, and disease prevention services by using Emergency Medical Services (EMS) personnel as providers of screening/vaccination services and the 35 neighborhood fire stations as service venues. ","Colorectal Cancer Screening ","In DY4 and DY5 provider will improve (increase) the percentage of Medicaid/uninsured patients 50–75 years of age  that are participating in the Neighborhood Fire Station Colorectal Cancer Screening Program","Payer, Facility","Payer: Medicaid or do not have public or private insurance.   Facility- Neighborhood Fire Station Colorectal Cancer Screening Program","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",41183.25,"Yes/No","RHP 15_065086301.3.207_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",41183.25,"Yes/No","RHP 15_065086301.3.207_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",91554.99,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",124950.5066666667,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"DY4","TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Colorectal Cancer Screening ","ambulatory",null,"One or more screenings for colorectal cancer. Any of the following meet the criteria: \n\n• Fecal occult blood test (FOBT) during the measurement year. For administrative data, assume the required number of samples were returned regardless of FOBT type.\n• Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year.\n• Colonoscopy during the measurement year or the nine years prior to the measurement year.\n","Patients 51–75 years of age as of the end of the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.7.1","","Colorectal Cancer Screening ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 15_065086301.2.1","RHP 15_065086301.3.207","RHP 15_065086301.2.1_065086301.3.207",{"$f":"COUNTIFS($FI$4:$FI679,FI679)","v":2},"RHP 15_065086301.2.1_2",null,1,1,0,"RHP 15_065086301",{"$f":"COUNTIFS($FR$4:$FR679,FR679)","v":8},"RHP 15_065086301_8"]
["RHP 15","084597603","Texas Tech Health Science Center","084597603.1.100","084597603.3.100","IT-10.1.a.v","Pediatric Quality of Life Inventory (PedsQL)","Baseline Approved","Eligible to Report in October DY4","The goal of this project is to increase the capacity to provide pediatric diabetes and endocrinology specialty care and increase the number of current pediatric endocrinology specialists to better accommodate the high demand for these pediatric specialty services.  ","Pediatric Quality of Life Inventory (PedsQL)","In DY4 and DY5 provider will improve reported scores on the PedsQL out of all surveys administered during the measurement period to patients seen at the Texas Tech Pediatrics Facilities. ","Facility ","Patients seen in the Texas Tech Pediatrics Facilities.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",16970.48,"Yes/No","RHP 15_084597603.3.100_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",16970.48,"Yes/No","RHP 15_084597603.3.100_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",18076.724999999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",18076.724999999999,"Numeric",73.695652170000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",78593.649999999994,"Numeric",78.695652170000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",68.695650000000001,9480,138,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,73.695652170000002,null,78.695652170000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator was created from the total number of surveys given in the Clinic during the DY as recorded in EMR (Electronic Medical Record).  It represents all surveys provided to the patients.  The numerator was determined from the sum of all of the scores (normalized on a scale of 0-100) that were collected in the EMR.","\nThe data shows that the patient perception of their service at this clinic is at a scale of 69 out of 100 (slightly above average).  This will establish the baseline upon which we will improve.\n","Pediatric Quality of Life Inventory (PedsQL)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2","Scenario 3: Average Score","Pediatric Quality of Life Inventory (PedsQL)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 15_084597603.1.100","RHP 15_084597603.3.100","RHP 15_084597603.1.100_084597603.3.100",{"$f":"COUNTIFS($FI$4:$FI685,FI685)","v":1},"RHP 15_084597603.1.100_1",null,2,1,1,"RHP 15_084597603",{"$f":"COUNTIFS($FR$4:$FR685,FR685)","v":4},"RHP 15_084597603_4"]
["RHP 15","084597603","Texas Tech Health Science Center","084597603.1.6","084597603.3.202","IT-8.22","Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life","Baseline Approved","Eligible to Report in October DY4","This project will develop the infrastructure and personnel to provide health maintenance exams in the setting of an existing acute care, walk in clinic to eligible patients presenting for an acute care visit AND to their siblings.","Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life","In DY4 and DY5 provider will improve (increase) the percentage of Texas Tech Pediatrics Facilities patients 3–6 years of age who received one or more well-child visits with a PCP during the measurement year.","Facility ","Patients seen in the Texas Tech Pediatrics Facilities.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",22627.305,"Yes/No","RHP 15_084597603.3.202_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",22627.305,"Yes/No","RHP 15_084597603.3.202_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",24102.294999999998,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",24102.3,"Numeric",0.68468834499999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",104791.53,"Numeric",0.70076700000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.66860900000000001,2524,3775,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.68468834499999998,null,0.70076700000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," The denominator was determined from the total number of unique patients seen in the Pediatrics Department between 3 to 6 years of age during the demonstration year.\nThe numerator was determined from the total number of unique patients seen in the Pediatrics Department between 3 to 6 years of age during the demonstration year and who received one or more well child exams\n","The data shows that the Department of Pediatrics provided well child exams to slightly above 60% of the patient population between the ages of 3 and 6 years old","Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life","ambulatory",null,"Received at least one well-child visit with a PCP during the measurement year.","Patients age 3-6 years of age.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","Well-Child Visits in the Third, Fourth, Fifth and Sixth Years of Life",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 15_084597603.1.6","RHP 15_084597603.3.202","RHP 15_084597603.1.6_084597603.3.202",{"$f":"COUNTIFS($FI$4:$FI693,FI693)","v":1},"RHP 15_084597603.1.6_1",null,2,1,1,"RHP 15_084597603",{"$f":"COUNTIFS($FR$4:$FR693,FR693)","v":12},"RHP 15_084597603_12"]
["RHP 15","094109802","Las Palmas Del Sol Healthcare","094109802.1.3","094109802.3.3","IT-3.5","Risk Adjusted Diabetes 30-day Readmission Rate ","Baseline Approved","Eligible to Report in April DY4","This project will establish a Clinical Information System (registry) to structure, organize, and trend patient data for registries, performance measurements, and prevention services.","Risk Adjusted Diabetes 30-day Readmission Rate ","In DY4 and DY5 provider will improve the ratio of observed to expected readmissions that occur within 30 days following discharge for an index admission for diabetes  from LPDS. ","Facility ","LPDS will limit this outcome to readmissions at its own facility.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",110675.035,"Yes/No","RHP 15_094109802.3.3_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",110695.98577700934,"Yes/No","RHP 15_094109802.3.3_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",177505.7,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",177505.7,"Numeric",1.425442077,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",848214.28,"Numeric",1.350419,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",1.5004649999999999,0.159609,0.106373,"DY2: Oct 1st, 2012 - Sept 30th, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,1.425442077,null,1.350419,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator is the total number of patients discharged in the measurement period for Diabetes. Numertor is the number of eligible readmissions.","LPDS actual to expected ratio is 150%","Risk Adjusted Diabetes 30-day Readmission Rate ","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission for Diabetes during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk Diabetes admissions during the measurement period.\n","Expected (risk-adjusted) rate of readmissions for Diabetes during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.3.1 ","","Risk Adjusted Diabetes 30-day Readmission Rate ",null,null,null,null,"Florida All-payer Norms","2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 15_094109802.1.3","RHP 15_094109802.3.3","RHP 15_094109802.1.3_094109802.3.3",{"$f":"COUNTIFS($FI$4:$FI704,FI704)","v":1},"RHP 15_094109802.1.3_1",null,2,1,1,"RHP 15_094109802",{"$f":"COUNTIFS($FR$4:$FR704,FR704)","v":4},"RHP 15_094109802_4"]
["RHP 15","094109802","Las Palmas Del Sol Healthcare","094109802.2.1","094109802.3.5","IT-3.22","Risk Adjusted All-Cause Readmission","Baseline Approved","Eligible to Report in April DY4","This project will establish case management and coordinated discharge planning processes","Risk Adjusted All-Cause Readmission","In DY4 and DY5 provider will improve the ratio of observed to expected readmissions that occur within 30 days following discharge for an index admission for any reason for adults from LPDS. ","Facility ","LPDS will limit this outcome to its own facility readmissions.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",110675.035,"Yes/No","RHP 15_094109802.3.5_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",110695.98577700934,"Yes/No","RHP 15_094109802.3.5_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",177505.7,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",177505.7,"Numeric",1.2125924830000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",848214.28,"Numeric",1.1487719999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",1.2764131396875875,0.10307123331725358,8.0750683389612471E-2,"04/01/2013-09/31/2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,1.2125924830000001,null,1.1487719999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator is all index admission in the measurement period. Numerator is all readmissions within 30 days of an eligible admission.","LPDS actual to expected ratio is 128%","Risk Adjusted All-Cause Readmission","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk admissions during the measurement period.","Expected (risk-adjusted) rate of readmissions for all-causes during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.12.2","","Risk Adjusted All-Cause Readmission",null,null,null,null,"Florida All-payer Norms","2013-10-01","2014-09-30","2014-10-01","2015-09-30","2013-04-01","2013-09-30",null,null,"RHP 15_094109802.2.1","RHP 15_094109802.3.5",{"$f":"A707&\"_\"&D707&\"_\"&E707","v":"RHP 15_094109802.2.1_094109802.3.5"},{"$f":"COUNTIFS($FI$4:$FI707,FI707)","v":1},{"$f":"FI707&\"_\"&FL707","v":"RHP 15_094109802.2.1_1"},null,2,1,1,{"$f":"A707&\"_\"&RIGHT(\"000000000\"&B707,9)","v":"RHP 15_094109802"},{"$f":"COUNTIFS($FR$4:$FR707,FR707)","v":7},"RHP 15_094109802_7"]
["RHP 15","127376505","Emergence Health Network","127376505.1.2","127376505.3.2","IT-6.2.a","Client Satisfaction Questionnaire 8 (CSQ-8)","Baseline not yet reported","Eligible to Report in October DY4","This new EHN initiative will develop and expand the community’s capacity to overcome recruitment challenges of behavioral health providers to the region.","Client Satisfaction Questionnaire 8 (CSQ-8)","In DY4 and DY5 provider will improve (increase) the average overall score on the Client Satisfaction Questionnaire 8 out of all surveys administered during the measurement year.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",104018.26,"Yes/No","RHP 15_127376505.3.2_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",104018.26,"Yes/No","RHP 15_127376505.3.2_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",110537.925,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",110537.925,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",480599.97,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Client Satisfaction Questionnaire 8 (CSQ-8)","Ambulatory",null,"The sum of the \"overall score\" for all CSQ-8 surveys completed during the measurement period.  ","The total number of CSQ-8 surveys completed during the measurement period. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.14.1","","Client Satisfaction Questionnaire 8 (CSQ-8)",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 15_127376505.1.2","RHP 15_127376505.3.2","RHP 15_127376505.1.2_127376505.3.2",{"$f":"COUNTIFS($FI$4:$FI713,FI713)","v":1},"RHP 15_127376505.1.2_1",null,2,1,1,"RHP 15_127376505",{"$f":"COUNTIFS($FR$4:$FR713,FR713)","v":4},"RHP 15_127376505_4"]
["RHP 15","138951211","University Medical Center of El Paso","138951211.1.1","138951211.3.1","IT-14.6","Percent of trainees who have spent at least 5 years living in a health‐ professional shortage area (HPSA) or medically underserved area ","Baseline Approved","Eligible to Report in October DY4","This project will create new Fellowship and Residency slots that will train at UMC and treat our patients (via Texas Tech Residency and Fellowship Programs).","Percent of trainees who have spent at least 5 years living in a health‐ professional shortage area (HPSA) or medically underserved area ","In DY4 and DY5 provider will report the percentage of trainees who have spent at least 5 years living in a health‐ professional shortage area (HPSA) or medically underserved area (MUA). In addition, in DY5 provider will demonstrate improvement by improving (decreasing) the  30-day all-cause readmission following health failure (HF) hospitalization (PP.3). ",null,null,"P4R","PP.3","PM-8","Submission of Category 3 DY3 Status Report",30580.375,"Yes/No","RHP 15_138951211.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",30580.375,"Yes/No","RHP 15_138951211.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",97755.3,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",116631.1,"Yes/No","NA","AM-3.1","Achievement of DY5 performance goal for PFP measure",116631.1,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"%",0.58571399999999996,41,70,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator includes all trainees who reported having lived for 5 yrs at an address that was registered as MUA or HPSA.  Denominator includes all responses to survey administered to all trainees of residency program. Non responses were excluded from denominator value.","Rate of 58.7% shows the percentage of trainees in the residency/fellowship programs that have life experience of living in an MUA or HPSA.","Percent of trainees who have spent at least 5 years living in a health‐ professional shortage area (HPSA) or medically underserved area ","na",null,"Number of trainees who have spent at least 5 years living in an HPSA or MUA","Total number of trainees ",null,null,null,null,null,null,null,null,null,null,null,"PFP baseline under review",null,"1.9.1 ","","Percent of trainees who have spent at least 5 years living in a health‐ professional shortage area (HPSA) or medically underserved area ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 15_138951211.1.1","RHP 15_138951211.3.1","RHP 15_138951211.1.1_138951211.3.1",{"$f":"COUNTIFS($FI$4:$FI721,FI721)","v":1},"RHP 15_138951211.1.1_1",null,2,1,1,"RHP 15_138951211",{"$f":"COUNTIFS($FR$4:$FR721,FR721)","v":1},"RHP 15_138951211_1"]
["RHP 15","138951211","University Medical Center of El Paso","138951211.1.5","138951211.3.5","IT-6.1.b.iv","CG-CAHPS 12-month: Overall Provider Rating","Baseline Approved","Eligible to Report in October DY4","This project will expand access to primary and urgent care in the RHP Region, and more specifically El Paso County. UMC will expand primary and urgent care staffing, services and hours at two existing Neighborhood Health Centers at Ysleta and Fabens helping them to become minor hub sites which provide lab in addition to primary care.","CG-CAHPS 12-month: Overall Provider Rating","In DY4 and DY5 provider will improve (increase) the top-box score on the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS 12 month) survey for the subdomain Overall Provider Rating for patients at UMC's Neighborhood Healthcare Center located at Ysleta/Fabens.","Facility ","UMC Neighborhood Healthcare Center Ysleta & Fabens","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",125101.54,"Yes/No","RHP 15_138951211.3.5_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",125101.54,"Yes/No","RHP 15_138951211.3.5_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",199954.02,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",199954.02,"Numeric",0.8145,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",954254.44,"Numeric",0.82399999999999995,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.80500000000000005,319.58499999999998,397,"CY 2014 (1): January 1, 2014 - June 30, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.8145,null,0.82399999999999995,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator is the number of patients who ansered 9 or 10 in the top box.  The denominaotr is the total number of completed surveys.","80% of our patients believe that our physicians and midlevels rate a 9 or 10.","CG-CAHPS 12-month: Overall Provider Rating","Ambulatory",null,"Patient-mix and survey mode adjusted percent \"top box\" score for a given subdomain as provided by your survey administrator, multiplied by the number of completed CG-CAHPS surveys represented in the \"top box\" score.","The number of CG-CAHPS surveys completed during the measurement period as reported by your survey administrator. The denominator should be the same as the multiplier used in the numerator.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","CG-CAHPS 12-month: Overall Provider Rating",null,null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2014-01-01","2014-06-30",null,null,"RHP 15_138951211.1.5","RHP 15_138951211.3.5","RHP 15_138951211.1.5_138951211.3.5",{"$f":"COUNTIFS($FI$4:$FI729,FI729)","v":1},"RHP 15_138951211.1.5_1",null,2,1,1,"RHP 15_138951211",{"$f":"COUNTIFS($FR$4:$FR729,FR729)","v":9},"RHP 15_138951211_9"]
["RHP 15","138951211","University Medical Center of El Paso","138951211.2.100","138951211.3.100","IT-9.9","Transition Record with Specified Elements Received by Inpatient Discharge Patients","Baseline Approved","Eligible to Report in October DY4","This project will establish a Patient Care Navigation Program within the High Risk Clinic, a neonatal follow-up program at Texas Tech University Health Sciences Center (TTUHSC) El Paso - Department of Pediatrics. ","Transition Record with Specified Elements Received by Discharged Patients (Inpatient Discharges to Home/Self Care or Any Other Site of Care)","In DY4 and DY5 provider will improve (increase) the percentage of patients discharged from an inpatient facility ( EPCH NICU) to home or any other site of care, or their caregiver(s), who received a transition record (and with whom a review of all included information was documented) at the time of discharge including, at a minimum, all of the specified elements","Facility ","Patients discharged from the EPCH NICU","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",7960.165,"Yes/No","RHP 15_138951211.3.100_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",7960.165,"Yes/No","RHP 15_138951211.3.100_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",12723,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",12723,"Numeric",0.34747474699999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",60718.86,"Numeric",0.38181799999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.31313099999999999,31,99,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.34747474699999997,null,0.38181799999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator and Denominators were determined by counting the total number of patients who received a discharge record and the total number of patients discharged for the relevant period of time.","Baseline rate shows that only 31.31% of patients received the discharge record during the measurement period.  IOS will be measured for DY4 and DY5.","Transition Record with Specified Elements Received by Inpatient Discharge Patients","Inpatient/Ambulatory",null,"Patients or their caregiver(s) who received a transition record (and with whom a review of all included information was documented) at the time of discharge including, at a minimum, all of the following elements:\n \nInpatient Care\n•Reason for inpatient admission, AND \n•Major procedures and tests performed during inpatient stay and summary of results, AND \n•Principal diagnosis at discharge \n\nPost-Discharge/Patient Self-Management\n•Current medication list, AND \n•Studies pending at discharge (e.g., laboratory, radiological), AND \n•Patient instructions \n\nAdvance Care Plan\n•Advance directives or surrogate decision maker documented, OR\n•Documented reason for not providing advance care plan \n\nContact Information/Plan for Follow-up Care\n•24-hour/7-day contact information including physician for emergencies related to inpatient stay, AND \n•Contact information for obtaining results of studies pending at discharge, AND \n•Plan for follow-up care, AND \n•Primary physician, other health care professional, or site designated for follow-up care\n","All patients, regardless of age, discharged from an inpatient facility (e.g., hospital inpatient or observation, skilled nursing facility, or rehabilitation facility) to home/self-care or any other site of care",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1","","Transition Record with Specified Elements Received by Inpatient Discharge Patients",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 15_138951211.2.100","RHP 15_138951211.3.100","RHP 15_138951211.2.100_138951211.3.100",{"$f":"COUNTIFS($FI$4:$FI738,FI738)","v":1},"RHP 15_138951211.2.100_1",null,2,1,1,"RHP 15_138951211",{"$f":"COUNTIFS($FR$4:$FR738,FR738)","v":18},"RHP 15_138951211_18"]
["RHP 15","138951211","University Medical Center of El Paso","138951211.2.3","138951211.3.11","IT-3.22","Risk Adjusted All-Cause Readmission","Baseline Approved","Eligible to Report in April DY4","This project will create specific case management positions to discharge our Medicaid and Unfunded patients with chronic conditions to appropriate medical homes for follow-up healthcare treatment utilizing other UMC projects that will provide for clinic growth and expansion, as well as appropriate home health care services, and finally coordinating homeless and transient patients to our partner homeless residential facilities.","Risk Adjusted All-Cause Readmission","In DY4 and DY5 provider will improve the ratio of observed to expected readmissions that occur within 30 days following discharge for an index admission for any reason for Medicaid/Uninsured adults.  ","Payer ","Denominator narrowed to Medicaid and Uninsured as this project serves high proportion of low-income/uninsured population.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",208502.565,"Yes/No","RHP 15_138951211.3.11_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",208502.565,"Yes/No","RHP 15_138951211.3.11_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",333256.70500000002,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",333256.70500000002,"Numeric",0.95,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1590424.06,"Numeric",0.9,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",1,8.6999999999999994E-2,8.6999999999999994E-2,"10/1/2012 - 9/30/2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.95,null,0.9,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," The observed and expected rates are determined by dividing the total eligible discharges by the actual discharges and the system calculated expected discharges  with exclusionary criteria."," This rate indicates a better than expected result, and we will continue to improve due to DSRIP.  Data reflective of 1.0 or greater is worse than the norm.  We are striving for below 1.0 indexes which we are already moving in an improved direction.","Risk Adjusted All-Cause Readmission","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk admissions during the measurement period.","Expected (risk-adjusted) rate of readmissions for all-causes during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1 ","","Risk Adjusted All-Cause Readmission",null,null,null,null,"Care Discovery Risk Adjusting Software / Truven using MS-DRGs","2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 15_138951211.2.3","RHP 15_138951211.3.11","RHP 15_138951211.2.3_138951211.3.11",{"$f":"COUNTIFS($FI$4:$FI743,FI743)","v":1},"RHP 15_138951211.2.3_1",null,2,1,1,"RHP 15_138951211",{"$f":"COUNTIFS($FR$4:$FR743,FR743)","v":23},"RHP 15_138951211_23"]
["RHP 15","138951211","University Medical Center of El Paso","138951211.2.9","138951211.3.17","IT-9.10.a","Median Time from ED Arrival to ED Departure for Discharged ED Patients","Baseline Approved","Eligible to Report in April DY4","UMC will utilize LEAN principles throughout the hospital to improve hospital throughput, improve early discharge times, improve the admission process from the Emergency Department and reduce errors.","Median Time from ED Arrival to ED Departure for Discharged ED Patients","In DY4 and DY5 provider will improve (decrease) the median time from emergency department arrival to time of departure from the emergency room for patients discharged from the emergency department",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",32433.73,"Yes/No","RHP 15_138951211.3.17_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",32433.73,"Yes/No","RHP 15_138951211.3.17_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",51839.93,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",51839.93,"Numeric",298.3,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",247399.3,"Numeric",282.60000000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"time (minutes)",314,314,1,"September 1, 2012 -August 31, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,298.3,null,282.60000000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator and denominator values appear to be the same, and include the median minutes for ED discharges for 9/1/12 - 8/31/13.  The total number of ED patient arrivals during this time period is 55,928.  The total number of patients discharged from the ED (home, other, jail, shelter) = 29,748 for this time period. ","What we expect to do with this measure is improve upon the amount of time it takes during an ED visit to dicharge the patient by 5% in DY4 and another 5% in DY5.  The current median time is 314 minutes for the baseline measurement. ","Median Time from ED Arrival to ED Departure for Discharged ED Patients","ED",null,"Median Time from ED Arrival to ED Departure for Discharged ED Patients: Continuous Variable Statement: Time (in minutes) from ED arrival to ED departure for patients discharged from the emergency department. ",1,null,null,null,null,null,null,null,null,null,null,null,null,null,"2.8.1 ","","Median Time from ED Arrival to ED Departure for Discharged ED Patients",null,null,null,null,null,"2013-09-01","2014-08-31","2014-09-01","2015-08-31","2012-09-01","2013-08-31",null,null,"RHP 15_138951211.2.9","RHP 15_138951211.3.17","RHP 15_138951211.2.9_138951211.3.17",{"$f":"COUNTIFS($FI$4:$FI751,FI751)","v":1},"RHP 15_138951211.2.9_1",null,2,1,1,"RHP 15_138951211",{"$f":"COUNTIFS($FR$4:$FR751,FR751)","v":31},"RHP 15_138951211_31"]
["RHP 16","081771001","Central Counties Center for MHMR Services","081771001.2.101","081771001.3.102","IT-9.1","Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons","Baseline not yet reported","Eligible to Report in October DY4","This project would recruit, hire and train 3 full-time trained mental health case managers to assess the behavioral health acuity of county jail inmates who are being considered for early release under the Coryell County Indigent Defense Court Project, and to work with the inmates to put together a community-based mental health and social services community plan that supports the person’s re-entry into the community and the avoidance of re-arrests.  ","Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons","In DY4 and DY5 provider will improve (decrease) the percentage of individuals receiving Coryell County Indigent Mental Health Defense Program services who had a potentially preventable admission/readmission to a criminal justice setting (e.g. jail, prison, etc.) within the measurement period","Facility ","All persons served in the Coryell County Indigent Mental Health Defense Project","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",59264.75,"Yes/No","RHP 16_081771001.3.102_PM-8","Metric Carried Forward in October DY3","PM-9","Validation and submission of baseline performance",3331.8500000000058,"Yes/No","RHP 16_081771001.3.102_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",52386.897999999986,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",52386.897999999986,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",172484.40000000002,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons","ambulatory",null,"The number of individuals receiving project intervention(s) who had a potentially preventable admission/readmission to a criminal justice setting (e.g. jail, prison, etc.) within the measurement period.","Number of individuals receiving project intervention(s)",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.13.2","","Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 16_081771001.2.101","RHP 16_081771001.3.102","RHP 16_081771001.2.101_081771001.3.102",{"$f":"COUNTIFS($FI$4:$FI763,FI763)","v":1},"RHP 16_081771001.2.101_1",null,2,1,1,"RHP 16_081771001",{"$f":"COUNTIFS($FR$4:$FR763,FR763)","v":5},"RHP 16_081771001_5"]
["RHP 16","084859002","Heart of Texas Region MHMR Center","084859002.1.1","084859002.3.200","IT-11.26.d","Children and Adolescent Needs and Strengths Assessment\n(CANS-MH)\n","Baseline Approved","Eligible to Report in October DY4","Expand the hours of operation, locations of service and types of supports offered in the five rural counties in the catchment area. The expansion is specifically for child and adolescent services. It is anticipated that an additional 375 individuals will be served in the project","Children and Adolescent Needs and Strengths Assessment\n(CANS-MH)\n","in DY4 and DY5, the provider will report the  average score on the Children and Adolescent Needs and Strengths Assessment (CANS-MH) out of all surveys completed during the measurement period. In DY5, the provider will demonstrate improvement by increasing performance on CMHC.1 Follow-up after hospitalization for mental illness (7-day follow-up).",null,null,"P4R","CMHC.1","PM-8","Submission of Category 3 DY3 Status Report",19944.5625,"Yes/No","RHP 16_084859002.3.200_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",20210.020833333328,"Yes/No","RHP 16_084859002.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",46502.916666666664,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",48539.625000000007,"Yes/No","NA","AM-3.1","Achievement of DY5 performance goal for PFP measure",48539.625000000007,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Score",32.240409999999997,16378.13,508,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator was the total number of initial assessments completed during the DY. A few participants were in a pilot project and their initial CANS were prior to the DY and so they were excluded. The numerator was the total scores for all of the initial CANS completed on all active participants.","With 508 CANS completed the baseline data appears to be an adequate reflection of the functioning level. ","Children and Adolescent Needs and Strengths Assessment\n(CANS-MH)\n","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,"PFP baseline under review",null,"1.12.2","Scenario 2: Pre Test Only Baseline","Children and Adolescent Needs and Strengths Assessment\n(CANS-MH)\n",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 16_084859002.1.1","RHP 16_084859002.3.200","RHP 16_084859002.1.1_084859002.3.200",{"$f":"COUNTIFS($FI$4:$FI765,FI765)","v":2},"RHP 16_084859002.1.1_2",null,2,1,1,"RHP 16_084859002",{"$f":"COUNTIFS($FR$4:$FR765,FR765)","v":2},"RHP 16_084859002_2"]
["RHP 16","084859002","Heart of Texas Region MHMR Center","084859002.2.7","084859002.3.8","IT-11.24","Generalized Anxiety Disorder (GAD-7) ","Baseline Approved","Eligible to Report in October DY4","Establish a community clinic for outpatient services to work with individuals who do not qualify for traditional community center services based on not having a targeted qualifying diagnosis. The clinic would provide outpatient counseling, short-term psychiatric services, medications and case management designed to assist individual in learning more appropriate coping mechanisms. The clinic would employ licensed clinicians, a psychiatrist, RN, caseworkers and support and billing staff.  The clinic would have a strong orientation towards outpatient counseling while utilizing medications for short-term stabilization and to assist with other clinical interventions. ","Generalized Anxiety Disorder (GAD-7) ","In DY4 and DY5, the provider will report the average score on the Generalized Anxiety Disorder (GAD-7) among all instruments administered during the measurement period. In addition, in DY5 provider will complete Stretch Activity #3- Outcome Evaluation. ",null,null,"P4R","SA.3","PM-8","Submission of Category 3 DY3 Status Report",13296.375,"Yes/No","RHP 16_084859002.3.8_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",13473.347222222223,"Yes/No","RHP 16_084859002.3.8_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",31001.944444444445,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",32359.750000000007,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",32359.75,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",15.38636,677,44,"08012014 to 09302014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"For all those who entered services after the change in metric tools, a GAD-7 was administered. The total of 44 individuals were administered the tool. The total score of those 44 individuals was calculated and reported.","It is felt that 44 tests should be a large enough sampling to represent an accurate baseline.  ","Generalized Anxiety Disorder (GAD-7) ","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,"Stretch Activity baseline not reported in DY3",null,null,"2.13.1","Scenario 2: Pre Test Only Baseline","Generalized Anxiety Disorder (GAD-7) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-08-01","2014-09-30",null,null,"RHP 16_084859002.2.7","RHP 16_084859002.3.8","RHP 16_084859002.2.7_084859002.3.8",{"$f":"COUNTIFS($FI$4:$FI777,FI777)","v":1},"RHP 16_084859002.2.7_1",null,2,1,1,"RHP 16_084859002",{"$f":"COUNTIFS($FR$4:$FR777,FR777)","v":14},"RHP 16_084859002_14"]
["RHP 16","121792903","Hamilton General Hospital","121792903.1.3","121792903.3.200","IT-6.1.d.ii","CG-CAHPS Visit Survey 2.0: Provider Communication","Baseline Approved","Eligible to Report in October DY4","Expand our primary care capacity to provide improved access to primary care services. The project will add three additional providers and increase the clinic hours.","CG-CAHPS Visit Survey 2.0: Provider Communication","In DY4 and DY5 provider will improve (increase) top-box scores on the CG-CAHPS Visit Survey 2.0:  Provider Communication for all surveys completed during the measurement year at Family Practice Rural Health Clinic in Hamilton, Texas and Hico Clinic in Hico, Texas.","Facility ","Family Practice Rural Health Clinic in Hamilton, Texas and Hico Clinic in Hico, Texas","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",26379.75,"Yes/No","RHP 16_121792903.3.200_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",26379.75,"Yes/No","RHP 16_121792903.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",42510.6,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",42510.6,"Numeric",0.94904255299999996,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",203771.85,"Numeric",0.94914893600000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.948936,223,235,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.94904255299999996,null,0.94914893600000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The Provider Communication domain consists of 6 questions in the CG-CAHPS survey.  The report provided by the Press Ganey database includes the information needed to calculate the baseline rate.  The numerator is the  number of survey respondents that rated us with the \"Top Box\" score for each of the 6 questions, divided by 6 to come up with the average \"Top Box\" response across all 6 questions.  The denominator is the total number of survey responses recorded by our survey administrator for those 6 questions, divided by 6 to come up with the average number of completed surveys.  According to the compendium document you should multiply the \"Top Box\" score provided by the survey administrator and this should also be the denominator.  This does not make mathematic sense because those two numbers just cancel each other out and you are left with the reported \"Top Box\" score.  When those instructions are followed in this template, the baseline rate ends up being over 100%.  We reviewed the information with our Press Ganey representatives and we are confident that what we are reporting is correct.","94.89% of survey respondents chose the most positive response for the Provider Communication domain.","CG-CAHPS Visit Survey 2.0: Provider Communication","Ambulatory",null,"Patient-mix and survey mode adjusted percent \"top box\" score for a given subdomain as provided by your survey administrator, multiplied by the number of completed CG-CAHPS surveys represented in the \"top box\" score.","The number of CG-CAHPS surveys completed during the measurement period as reported by your survey administrator. The denominator should be the same as the multiplier used in the numerator. The denominator should be the same as the multiplier used in the numerator. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2","","CG-CAHPS Visit Survey 2.0: Provider Communication",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 16_121792903.1.3","RHP 16_121792903.3.200","RHP 16_121792903.1.3_121792903.3.200",{"$f":"COUNTIFS($FI$4:$FI780,FI780)","v":2},"RHP 16_121792903.1.3_2",null,2,1,1,"RHP 16_121792903",{"$f":"COUNTIFS($FR$4:$FR780,FR780)","v":2},"RHP 16_121792903_2"]
["RHP 16","121792903","Hamilton General Hospital","121792903.2.7","121792903.3.17","IT-2.9","Chronic Obstructive Pulmonary Disease (COPD) Admission Rate","Baseline Approved","Eligible to Report in April DY4","This project will introduce a chronic disease management program to address major chronic health issues such as diabetes, respiratory disease, and obesity. Case Managers will be assigned to apply the Chronic Care Management model to patients identified as having high-risk health care needs to prevent unnecessary utilization of the acute care setting. The project will be focused around the required core project components for development of the management methodology. Case Managers will follow chronic care patients, implement various care management activities, and track healthcare utilization of chronic care patients.","Chronic Obstructive Pulmonary Disease (COPD) Admission Rate","In DY4 and DY5 provider will report on all non-maternal discharges of age 18 years and older with principal diagnosis code for COPD out of all patients ages 18 and older at Hamilton General Hospital.  In addition, in DY5 provider will  demonstrate improvement in risk adjusted Asthma/COPD PPA (PPA.4).  ","Facility ","Hamilton General Hospital","P4R","PPA.4","PM-8","Submission of Category 3 DY3 Status Report",29897.05,"Yes/No","RHP 16_121792903.3.17_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",29897.05,"Yes/No","RHP 16_121792903.3.17_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",96357.36,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",115470.71500000001,"Yes/No","NA","AM-3.1","Achievement of DY5 performance goal for PFP measure",115470.71500000001,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",9114.1396933560482,107,1174,"September 1, 2012 -August 31, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator is the total number of discharges from Hamilton General Hospital with a primary diagnosis of COPD in the measurement year.  Denominator is the total number of discharges from Hamilton General Hospital in the measurement year.","9.11% of our admissions are for a primary diagnosis of COPD.","Chronic Obstructive Pulmonary Disease (COPD) Admission Rate","inpatient",null,"Discharges, for patients ages 18 years and older, with a principal ICD-9-CM diagnosis code for COPD (excluding acute bronchitis) x 100,000*","Population ages 18 years and older in metropolitan area  or county. Discharges in the numerator are assigned to the denominator based on the metropolitan area or county of the patient residence, not the metropolitan area or county of the hospital where the discharge occurred.",null,null,null,null,null,null,null,null,null,null,null,"PFP baseline under review",null,"2.2.1","","Chronic Obstructive Pulmonary Disease (COPD) Admission Rate",null,null,null,null,null,"2013-09-01","2014-08-31","2014-09-01","2015-08-31","2012-09-01","2013-08-31",null,null,"RHP 16_121792903.2.7","RHP 16_121792903.3.17","RHP 16_121792903.2.7_121792903.3.17",{"$f":"COUNTIFS($FI$4:$FI787,FI787)","v":1},"RHP 16_121792903.2.7_1",null,2,1,1,"RHP 16_121792903",{"$f":"COUNTIFS($FR$4:$FR787,FR787)","v":9},"RHP 16_121792903_9"]
["RHP 16","134772611","Coryell Memorial Hospital","134772611.2.4","134772611.3.11","IT-13.2","Hospice and Palliative Care – Treatment Preferences ","Baseline not yet reported","Eligible to Report in October DY4","Palliative Care Program including: outpatient office visits, inpatient consults, care planning including DNR preferences, referrals for post discharge support such as home health, and coordination of services with the patient’s primary care provider and specialists. We will work with the Palliative Care team at Hillcrest Baptist Medical Center. They act as a central hub for Region 16 for all knowledge and resources related to Palliative Care. The Hillcrest team will provide training to our facility as well as access to their trained staff. The highly trained and specialized providers can help to train and guide our primary care providers to offer the best care for our patients.","Hospice and Palliative Care – Treatment Preferences ","In DY4 and DY5 provider will increase percentage of patients whose medical record includes documentation of life sustaining preferences out of all seriously ill patients enrolled in hospice OR receiving specialty palliative care in an acute hospital setting.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",41217.040000000001,"Yes/No","RHP 16_134772611.3.11_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",41217.040000000001,"Yes/No","RHP 16_134772611.3.11_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",66363.64,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",66363.64,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",317963.61,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Hospice and Palliative Care – Treatment Preferences ","Ambulatory/Inpatient",null,"Patients whose medical record includes documentation of life sustaining preferences","Seriously ill patients enrolled in hospice OR receiving palliative care in an acute hospital setting",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.10.1","","Hospice and Palliative Care – Treatment Preferences ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 16_134772611.2.4","RHP 16_134772611.3.11","RHP 16_134772611.2.4_134772611.3.11",{"$f":"COUNTIFS($FI$4:$FI799,FI799)","v":2},"RHP 16_134772611.2.4_2",null,2,1,1,"RHP 16_134772611",{"$f":"COUNTIFS($FR$4:$FR799,FR799)","v":6},"RHP 16_134772611_6"]
["RHP 16","134772611","Coryell Memorial Hospital","134772611.2.6","134772611.3.501","IT-12.10","Adults (18+ years) Immunization status","Baseline not yet reported","Eligible to Report in October DY4","This project will implement a health literacy program utilizing trained community health workers in coordination with local healthcare providers to increase health literacy in the Medicaid, Uninsured, and Indigent Populations.  This project will serve all 7 counties and include interaction with and support of healthcare providers in all counties in RHP 16. CMHS will delegate oversight of the health literacy program to Texas A&M Agri-Life Extension (TAMU) who will provide leadership to a RHP 16 Task Force for Health Literacy.  TAMU is a state-wide system with more than 250 offices and 900 professional educators.  ","Adults (18+ years) Immunization status","In DY4 and DY5 provider will improve the percentage of adult patients 18 years and older who are up-to-date with the following immunizations:• One tetanus and diphtheria toxoids (Td) vaccine in the last 10 years;  • Varicella – two doses or history of disease up to year 1995; • Pneumococcal polysaccharide vaccine (PPSV23) for patients 65 and older\n• One influenza within last year; • Herpes zoster/shingles (patients 60 years and older)",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",0,"Yes/No","RHP 16_134772611.3.501_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",40144.58,"Yes/No","RHP 16_134772611.3.501_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",64636.872499999998,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",64636.875,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",309690.26,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"short","TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Adults (18+ years) Immunization status","ambulatory",null,"Number of patients who are up-to-date with following immunizations:\n• One tetanus and diphtheria toxoids (Td) vaccine in the last 10 years\n• Varicella – two doses or history of disease up to year 1995\n• Pneumococcal polysaccharide vaccine (PPSV23) for patients 65 and older\n• One influenza dose within the last year\n• Herpes zoster/shingles (patients 60 years and older)\n","Number of patients 18 years and older during the specified measurement period*",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.6.3","","Adults (18+ years) Immunization status",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 16_134772611.2.6","RHP 16_134772611.3.501","RHP 16_134772611.2.6_134772611.3.501",{"$f":"COUNTIFS($FI$4:$FI805,FI805)","v":2},"RHP 16_134772611.2.6_2",null,2,1,1,"RHP 16_134772611",{"$f":"COUNTIFS($FR$4:$FR805,FR805)","v":12},"RHP 16_134772611_12"]
["RHP 16","138962907","Hillcrest Baptist Medical Center","138962907.2.1","138962907.3.3","IT-13.5","Hospice and Palliative Care – documentation of spiritual/religions concerns ","Baseline Approved","Eligible to Report in April DY4","This project will implement a Palliative Care program, which provides a more\nappropriate level and place of care for a large portion of the chronically ill.  Hillcrest \nPalliative Care will be based in this facility but plans to serve as a regional project which acts as a  resource and referral destination for the partners in RHP 16.\n","Hospice and Palliative Care – Percentage of patients receiving hospice or palliative care services with documentation in the clinical record of a discussion of spiritual/religions concerns or documentation that the patient/caregiver did not want to discuss ","In DY4 and DY5 provider will improve the number of patients with clinical record documentation of spiritual or religious concerns or documentation that the patient/family did not want to discuss out of the total number of patients discharged from hospice care during measurement period.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",40116.71,"Yes/No","RHP 16_138962907.3.3_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",40116.71,"Yes/No","RHP 16_138962907.3.3_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",61695.51,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",61695.51,"Numeric",0.77068965599999995,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",279645,"Numeric",0.78275899999999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.75862099999999999,44,58,"07/01/13 - 12/31/13",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"proxy",0.77068965599999995,null,0.78275899999999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator includes patient charts that had life sustaining preferences documented in the medical record in the acute care phase prior to Hospice admission.  The denominator represents all seriously ill ICU patients that later were admitted to Hospice.","76% of seriously ill patients admitted to the ICU and later Hospice had documentation of their life-sustaining preferences prior to their referral for Hospice care.","Hospice and Palliative Care – documentation of spiritual/religions concerns ","Ambulatory/Inpatient",null,"Number of patient with clinical record documentation of spiritual/religious concerns or documentation that the patient/family did not want to discuss","Total number of patient’s discharged from hospice care and/or palliative care during the designated reporting period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.10.1","","Hospice and Palliative Care – documentation of spiritual/religions concerns ",null,null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-07-01","2013-12-31",null,null,"RHP 16_138962907.2.1","RHP 16_138962907.3.3","RHP 16_138962907.2.1_138962907.3.3",{"$f":"COUNTIFS($FI$4:$FI813,FI813)","v":3},"RHP 16_138962907.2.1_3",null,2,1,1,"RHP 16_138962907",{"$f":"COUNTIFS($FR$4:$FR813,FR813)","v":4},"RHP 16_138962907_4"]
["RHP 17","127267603","St. Joseph Regional Health Center","127267603.2.1","127267603.3.1","IT-8.19","Post-Partum Follow-Up and Care Coordination","Baseline Approved","Eligible to Report in October DY4","Establishment and implementation of a prenatal care navigation program to address the needs and provide services to prenatal patients with co-occurring chronic disease conditions that can cause high-risk pregnancies, in an effort to decrease the percentage of high-risk deliveries, provide referral to a primary obstetrician to reduce inappropriate ED use during pregnancy, provide health education, and connect both mother and baby to primary care providers postpartum. ","Post-Partum Follow-Up and Care Coordination","In DY4 and DY5 provider will increase the percentage of women receiving services from SJPA (St. Joseph Physician Associates) and affiliated providers, giving birth during the measurement period that were seen for post-partum care within 8 weeks of giving birth who received a breast feeding evaluation and education, post-partum depression screening, post-partum glucose screening for gestational diabetes patients, and resources or referral for family and contraceptive planning. ","Facility ","denominator subset will be post-partum education provided to all women of SJPA (St. Joseph Physician Associates) and affiliated providers who gave birth in a 12-month period, because data on post-partum education of SJPA patients is available to the SJRHC.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",11194,"Yes/No","RHP 17_127267603.3.1_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",11194,"Yes/No","RHP 17_127267603.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",16791,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",16791,"Numeric",0.27703604799999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",73881,"Numeric",0.31508700000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.238985,179,749,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.27703604799999998,null,0.31508700000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"With over 1,500 births annually at St. Joseph Regional Health Center delivered by a wide variety of providers (independent practitioners), we did not have access to the post-discharge clinical records of all women delivering at St. Joseph, so the team identified two large practices that, when combined, deliver almost 50% of the babies born at St. Joseph annually. The numerator/denominator values were derived from pulling clinical records from the two practices and determining which patients had met the required IT 8.19 required postpartum education elements.","The 23.9% baseline rate reflects that, as anticipated, postpartum education in both SJPA practices and for The Prenatal Clinic were not delivering all of the essential components for post-partum education withing the 8-week required time frame. Improved educational processes, especially for all of the navigation enrollees, is an essential part of this Improvement Project.","Post-Partum Follow-Up and Care Coordination","ambulatory",null,"Patients receiving the following at a post-partum visit:\n• Breast feeding evaluation and education, including patient-reported breast feeding\n• Post-partum depression screening\n• Post-partum glucose screening for gestational diabetes patients \n• Family and contraceptive planning\n","All patients, regardless of age, who gave birth during a 12-month period seen for post-partum care visit before or at 8 weeks of giving birth.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1","","Post-Partum Follow-Up and Care Coordination",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 17_127267603.2.1","RHP 17_127267603.3.1","RHP 17_127267603.2.1_127267603.3.1",{"$f":"COUNTIFS($FI$4:$FI821,FI821)","v":1},"RHP 17_127267603.2.1_1",null,2,1,1,"RHP 17_127267603",{"$f":"COUNTIFS($FR$4:$FR821,FR821)","v":1},"RHP 17_127267603_1"]
["RHP 17","136366507","MHMR Authority of Brazos Valley","136366507.2.2","136366507.3.2","IT-9.1","Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons","Baseline Approved","Eligible to Report in October DY4","Development and implementation of an Assertive Community Treatment (ACT) program to provide high-intensity, evidence-based community treatment and support services to individuals with a history of multiple hospitalizations in an effort to prevent avoidable inpatient admissions, provide jail diversion, and to promote wellness, adherence to treatment and recovery in the community.","Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons","In DY4&DY5, provider will decrease the number of individuals receiving ACT interventions who have a potentially preventable admission/readmission to a criminal justice setting within the measurement period, out of all individuals receiving ACT interventions. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",13487.5,"Yes/No","RHP 17_136366507.3.2_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",6743.75,"Yes/No","RHP 17_136366507.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",13829.875,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",13829.88,"Numeric",0.174166666,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",54987.5,"Numeric",0.16500000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.183333,11,60,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.174166666,null,0.16500000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator was determined by number of individuals who received  ACT services (target population) during the reporting period).  The denominator deterimned by how many of those individuals also had a criminal justice involvement during the same reporting period.","18.33% of all individuals who received ACT services had a potentiallly preventable admission/re-admission to a criminal justice setting.  The goal will be to decrease rate through project intevention.","Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons","ambulatory",null,"The number of individuals receiving project intervention(s) who had a potentially preventable admission/readmission to a criminal justice setting (e.g. jail, prison, etc.) within the measurement period.","Number of individuals receiving project intervention(s)",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.13.1","","Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 17_136366507.2.2","RHP 17_136366507.3.2","RHP 17_136366507.2.2_136366507.3.2",{"$f":"COUNTIFS($FI$4:$FI830,FI830)","v":1},"RHP 17_136366507.2.2_1",null,2,1,1,"RHP 17_136366507",{"$f":"COUNTIFS($FR$4:$FR830,FR830)","v":2},"RHP 17_136366507_2"]
["RHP 17","189791001","Huntsville Memorial Hospital","189791001.1.100","189791001.3.100","IT-1.13","Diabetes care:  Foot exam ","Baseline Approved","Eligible to Report in October DY4","This project will implement non-traditional clinics in small rural communities throughout the hospital's primary and secondary service areas in an effort to improve services available in these rural areas and increase the frequency of primary care visits. ","Diabetes care:  Foot exam ","In DY4 and DY5 provider will improve the number of  patients who received a diabetic foot exam out of all patients 18-75 years with diabetes. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",25666.33,"Yes/No","RHP 17_189791001.3.100_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",25666.33,"Yes/No","RHP 17_189791001.3.100_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",37251.195,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",37251.195,"Numeric",0.82060569999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",158434.99,"Numeric",0.83004800000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.811164,683,842,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.82060569999999999,null,0.83004800000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator equals total number of encounters during the selected timeframe. The numerator is the total number of encounters that received a comphrensive exam.","81% of our diabetics have received a foot exam. ","Diabetes care:  Foot exam ","ambulatory",null,"Patients who received a comprehensive foot exam (visual inspection with either a sensory exam or a pulse exam) during the measurement year","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1","","Diabetes care:  Foot exam ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 17_189791001.1.100","RHP 17_189791001.3.100",{"$f":"A835&\"_\"&D835&\"_\"&E835","v":"RHP 17_189791001.1.100_189791001.3.100"},{"$f":"COUNTIFS($FI$4:$FI835,FI835)","v":1},{"$f":"FI835&\"_\"&FL835","v":"RHP 17_189791001.1.100_1"},null,2,1,1,{"$f":"A835&\"_\"&RIGHT(\"000000000\"&B835,9)","v":"RHP 17_189791001"},{"$f":"COUNTIFS($FR$4:$FR835,FR835)","v":2},"RHP 17_189791001_2"]
["RHP 17","198523601","Texas A&M Physicians Group","198523601.1.2","198523601.3.2","IT-1.10","Diabetes care: HbA1c poor control (>9.0%) ","Baseline not yet reported","Eligible to Report in October DY4","Expand primary care training and retention, thereby increasing capacity to provide primary care in rural and underserved areas, through the development and delivery of a rural family medicine fellowship program","Diabetes care: HbA1c poor control (>9.0%) ","In DY4 and DY5, the provider will improve the percentage of patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year over all patients seen at the Rural Health Clinic, 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year","Facility ","Patients seen specifically at the Rural Site location (the service setting/delivery location).","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",26412.244999999999,"Yes/No","RHP 17_198523601.3.2_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",26412.244999999999,"Yes/No","RHP 17_198523601.3.2_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",52824.49,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",105648.97,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"dy4","TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Diabetes care: HbA1c poor control (>9.0%) ","ambulatory",null,"Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.2.4","","Diabetes care: HbA1c poor control (>9.0%) ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 17_198523601.1.2","RHP 17_198523601.3.2","RHP 17_198523601.1.2_198523601.3.2",{"$f":"COUNTIFS($FI$4:$FI843,FI843)","v":1},"RHP 17_198523601.1.2_1",null,1,1,0,"RHP 17_198523601",{"$f":"COUNTIFS($FR$4:$FR843,FR843)","v":2},"RHP 17_198523601_2"]
["RHP 17","198523601","Texas A&M Physicians Group","198523601.2.3","198523601.3.8","IT-6.2.c","Health Center Patient Satisfaction Survey","Baseline Approved","Eligible to Report in October DY4","Develop and implement a post-discharge care coordination program that provides patient navigation services to targeted frequent ED users at high risk of disconnect from institutionalized health care.","Health Center Patient Satisfaction Survey","In DY4 and DY5, the provider will report the overall score on the Health Center Patient Satisfaction Survey over all completed surveys. In DY5, the provider will demonstrate improved by completing stretch activity 4 via implementation of the Care Coordination program is a ER diversion program that seeks to connect individuals without a source of primary care with a source of primary care within the community.",null,null,"P4R","SA4","PM-8","Submission of Category 3 DY3 Status Report",26412.244999999999,"Yes/No","RHP 17_198523601.3.8_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",26412.244999999999,"Yes/No","RHP 17_198523601.3.8_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",52824.49,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",52824.485000000001,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",52824.485000000001,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",0.68,55.76,82,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator is the number of Patient Satisfaction Surveys completed during the measurement period (April 1, 2014-September 30, 2014).  The total number is calculated by the spreadsheet. A mean  of the highest responses [\"Very Good\" or \"Yes\"] on non-administrative items is used to calculate the \"Overall Score.\"  The numerator  is calculated by multiplying  the  \"Overall Score\"  by the number of surveys completed. ","The Brazos Valley Post Discharge Care Coordination program (Care Coordination program) refers clients to multiple providers in the Bryan-College Station area.  Referral sources include free clinics, low-cost clinics [FQHC}, an academic provider group, hospital/healthplan provider groups, and private physicians. Although the facility specific scores are reported directly to facilities, the score reported in this report is more reflective of the health care community as a whole. The score reported reflects an overall satisfaction rate of 68% for referral sources (medical) used by the program.   Once reported, these scores can be used to direct community wide efforts to improve access and the quality of care for patients in the Brazos Valley. ","Health Center Patient Satisfaction Survey","Ambulatory",null,"Overall Score, multiplied by the number of Patient Satisfaction Surveys completed during the measurement period. ","The number of Patient Satisfaction Surveys completed during the measurement period. The denominator should be the same as the multiplier used in the numerator. ",null,null,null,null,null,null,null,null,null,null,"SA4 is to participate in a regional initiative to promote ER diversion. Our project is one that seeks to promote right care in the right setting by connecting individuals without a source of primary care to  a source of primary care within the community.  The program works to identify clients with a history of 3 or more ED visits for the treatment of chronic conditions or conditions which could be treated in the primary care setting. Once identified, the program will track referral and scheduling rates.  The program has identified shared learning opportunities with other similar projects in the region with similar initiatives.  Five projects have been identified which share a goal of appropriate utilization of emergency department and emergency medical services.  Three of these programs are using community health workers or patient navigators.  To date, one meeting has been held to discuss best practices, barriers, and lessons learned.  More meeting have been planned to continue these efforts.  By DY5 the program goal is produce a report to demonstrate regional activities focused on improving and facilitating appropriate utilization of ED services  and hopefully a decline in the ED utilization rate for individuals enrolled in the program when compared to the year prior to enrollment. ",null,null,"2.9.1","","Health Center Patient Satisfaction Survey",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 17_198523601.2.3","RHP 17_198523601.3.8","RHP 17_198523601.2.3_198523601.3.8",{"$f":"COUNTIFS($FI$4:$FI847,FI847)","v":1},"RHP 17_198523601.2.3_1",null,2,1,1,"RHP 17_198523601",{"$f":"COUNTIFS($FR$4:$FR847,FR847)","v":6},"RHP 17_198523601_6"]
["RHP 18","084434201","Texoma Community Center","084434201.1.4","084434201.3.4","IT-1.18","Follow-Up After Hospitalization for Mental Illness ","Baseline Approved","Eligible to Report in October DY4","This project expands quality improvement capacity through people, processes and technology so that the resources are in place to conduct, report, drive and measure quality improvement by implementing an expanded Quality Improvement Department at TCC. The interventions will include process improvement methodologies by developing protocols and tools designed to identify and track project impacts, expand the patient population and services by increasing efficiencies and solving key challenges through focused and frequent (weekly) evaluation of intervention barriers and progress in all service areas, and through focused attention on special populations for further treatment expansion.","Follow-Up After Hospitalization for Mental Illness ","In DY4 and DY5 provider will improve (increase) the percentage of discharges for Medicaid/uninsured patients 6 years of age and older who were hospitalized for treatment of selected mental illness diagnoses and who had an outpatient visit, an intensive outpatient encounter or partial hospitalization with a mental health practitioner. Two rates are reported: - The percentage of discharges for which the patient received follow-up within 30 days of discharge - The percentage of discharges for which the patient received follow-up within 7 days of discharge.","Payer ","Individuals who are indigent/uninsured or have Medicaid.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",20668.5,"Yes/No","RHP 18_084434201.3.4_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",20668.5,"Yes/No","RHP 18_084434201.3.4_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",22110.15,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- 7 day follow-up",11055.075000000001,"Numeric",0.46440870899999998,"AM-1.2","Achievement of DY4 performance goal- 30 day follow-up",11055.075000000001,"Numeric",0.57289999999999996,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- 7 day follow-up",48064.95,"Numeric",0.49010774200000001,"AM-2.2","Achievement of DY5 performance goal- 30 day follow-up",48064.95,"Numeric",0.59989000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"%",0.43870999999999999,68,155,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",0.458065,71,155,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0.46440870899999998,null,0.49010774200000001,null,0.57289999999999996,null,0.59989000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"State Hospital Report HC029135 – “Admissions to State Mental Health Facility my MHA” which records hospital admission dates and discharge dates by county (via county codes assigned to this MHA for each county served) for Texoma Community Center (MHA).\n Secondly, data on this report was cross-referenced with the State Facility Action Form initiated by the LMHA which records the date, type of admit and discharge, and the encounter date for both admit screening and discharge follow-up.\n Both of these were  cross-referenced with encounter data from TCC’s data base.\n For local hospitalizations, data was gathered from encounter data using specific codes for hospital discharge encounters as well as the referring hospitals referred Discharge Papers which are faxed to TCC when an individual is referred from a local hospital.  These discharge papers are placed in the patient’s chart when an encounter occurs, or are kept is a separate secured file when no follow up occurs.\n The encounter data run from the data base was cross-referenced with the faxed paperwork to discern individuals who had been referred but not seen for a follow up within 7 or 30 days.\n The records were tallied together to determine both the state and local hospital referrals upon discharge, and then divided into those seen within 7 days after discharge, those seen within 30 days after discharge and those not seen at all after hospital discharge.  These percentages were used to establish the baseline for this outcome measure.","The baseline rate is the number of individuals we saw either 7 or 30 days after discharge from either the state facilities or local hospitals that were referred to us, divided by the total number of referrals.","Follow-Up After Hospitalization for Mental Illness ","ambulatory",null,"Rate #1: 7-Day Follow-Up: An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 7 days after discharge. ","Patients 6 years and older as of the date of discharge who were discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal diagnosis of mental illness during the first 11 months of the measurement year. ","Rate #2: 30-Day Follow-Up: An outpatient visit, intensive outpatient visit or partial hospitalization with a mental health practitioner within 30 days after discharge. ","Patients 6 years and older as of the date of discharge who were discharged alive from an acute inpatient setting (including acute care psychiatric facilities) with a principal diagnosis of mental illness during the first 11 months of the measurement year. ",null,null,null,null,null,null,null,null,null,null,null,"1.10.3","","7 day follow-up","30 day follow-up",null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 18_084434201.1.4","RHP 18_084434201.3.4","RHP 18_084434201.1.4_084434201.3.4",{"$f":"COUNTIFS($FI$4:$FI857,FI857)","v":1},"RHP 18_084434201.1.4_1",null,3,2,1,"RHP 18_084434201",{"$f":"COUNTIFS($FR$4:$FR857,FR857)","v":4},"RHP 18_084434201_4"]
["RHP 18","121988304","Lakes Regional MHMR Center","121988304.2.2","121988304.3.201","IT-10.4.b","Vineland Adaptive Behavior Scales, 2nd Edition (VABS II)","Baseline Approved","Eligible to Report in October DY4","The proposed project will house a day treatment center for children and adults with autism spectrum disorders and related behavioral, intellectual or developmental disabilities (IDD). Additionally, a community based Behavioral Support Outreach Team will provide community-based services to families and individuals referred in Rockwall County not requiring site-based treatment.","Vineland Adaptive Behavior Scales, 2nd Edition (VABS II)","In DY4 and DY5 provider will report average score on the Vineland Adaptive Behavior Scales, 2nd Edition (VABS II) 90 out of all surveys administered during the measurement period to individuals receiving services through the Lakes Regional ASD Day Treatment/Outreach Program - Rockwall.  In addition, in DY5, to demonstrate improvement the provider will submit a report detailing collaborative participation, including:  how the collaboration was formed, shared goals, provider activities related to the collaboration, findings from the process of normalizing and validating data/benchmarks, benchmark utility and/or limitations, and a discussion of how this activity has changed internal capacity (of the provider) around data infrastructure.   ","Facility ","Lakes Regional ASD Day Treatment/Outreach Program - Rockwall","P4R","SA1","PM-8","Submission of Category 3 DY3 Status Report",17006.474999999999,"Yes/No","RHP 18_121988304.3.201_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",17006.474999999999,"Yes/No","RHP 18_121988304.3.201_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",36544.800000000003,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",39861.599999999999,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",39861.599999999999,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",1.424242,47,33,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator was determined by the total amount of individuals assessed during the DY3 measurement period.  The denominator was calculated in five specifics domains with each domain individually averaged as per Scenerio 2.","The baseline rates represent the initial enrollment scores for individuals prior to receiving ABA interventions.  Individuals will be re-assessed on the same identified domain upon completion of  services or no later than 6 months from enrollment to determine if measurable improvements occur as a result of 1:1 ABA interventions.  The data collected with be used to meet criteria for selected stretch activities.","Vineland Adaptive Behavior Scales, 2nd Edition (VABS II)","Multiple",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,"This project is collaborating with other ABA providers that have selected SA-1 as a stretch activity.  The project is collecting data to identified benchmarks, shared goals and collaboration on how  improve treatment and the functioal outcomes of those served.  This stretch activity focus on individuals diagnosed with ASD/IDD that exhibit challenging behaviors.  ",null,null,"2.13.1","Scenario 2: Pre Test Only Baseline","Vineland Adaptive Behavior Scales, 2nd Edition (VABS II)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 18_121988304.2.2","RHP 18_121988304.3.201","RHP 18_121988304.2.2_121988304.3.201",{"$f":"COUNTIFS($FI$4:$FI865,FI865)","v":2},"RHP 18_121988304.2.2_2",null,2,1,1,"RHP 18_121988304",{"$f":"COUNTIFS($FR$4:$FR865,FR865)","v":5},"RHP 18_121988304_5"]
["RHP 18","138910807","Children's Medical Center of Dallas","138910807.1.4","138910807.3.4","IT-11.6","Follow-up Care for Children Prescribed ADHD Medication (ADD)","Baseline Approved","Eligible to Report in April DY4","The purpose of this project is to bring behavioral health services into the primary care setting through the MyChildren’s offices in Region 18.","Follow-up Care for Children Prescribed ADHD Medication (ADD)","In DY4 and DY5 provider will improve (increase) the percentage of MyChildren's practice patients newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication who had at least three follow-up care visits within a 10-month period, one of which was within 30 days of when the first ADHD medication was dispensed. Two rates are reported. 1) Initiation Phase. The percentage of members 6–12 years of age as of the IPSD with an ambulatory prescription dispensed for ADHD medication, who had one follow-up visit with practitioner with prescribing authority during the 30-day Initiation Phase. 2) Continuation and Maintenance (C&M) Phase. The percentage of members 6–12 years of age as of  the IPSD with an ambulatory prescription dispensed for ADHD medication, who remained on the medication for at least 210 days and who, in addition to the visit in the Initiation Phase, had at least two follow-up visits with a practitioner within 270 days (9 months) after the Initiation Phase ended.","Facility ","Patients seen at participating MyChildren's practices","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",68451.360000000001,"Yes/No","RHP 18_138910807.3.4_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",68451.360000000001,"Yes/No","RHP 18_138910807.3.4_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",109840.545,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- Initiation Phase",54920.272499999999,"Numeric",0.38275522899999997,"AM-1.2","Achievement of DY4 performance goal- C&M Phase",54920.272499999999,"Numeric",0.3836,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- Initiation Phase",262662.14500000002,"Numeric",0.39853798200000001,"AM-2.2","Achievement of DY5 performance goal- C&M Phase",262662.14500000002,"Numeric",0.40834999999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"%",0.36697200000000002,40,109,"CY 2013: Jan 1st, 2013 - Dec 31st, 2013",0.3669724770642202,40,109,"CY 2013: Jan 1st, 2013 - Dec 31st, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0.38275522899999997,null,0.39853798200000001,null,0.3836,null,0.40834999999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator:   Patients ages 6 to 12 with ambulatory prescription for ADHD medication during the measurement year \nNumerator1: Patients in Denominator who had a follow-up visit with a practitioner with prescribing authority during the 0-30day initiation phase\nNumerator2:  Patients in Denominator who satisfy Numerator1 condition AND who had at least 2 follow-up visits during the 31-300day continuation and maintenance phase","91.74% is the percentage of children ages 6 to 12 with ambulatory prescription for ADHD medication during the measurement year who had at least 3 follow-up visits within a 10-month period, one of which was within 30 days of when the first ADHD medication was prescribed/ordered.","Follow-up Care for Children Prescribed ADHD Medication (ADD)","ambulatory",null,"Initiation Phase: Patients from the denominator with one face-to-face outpatient, intensive outpatient or partial hospitalization follow-up visit with a practitioner with prescribing authority, within 30 days after the Index Prescription Start Date \n","Initiation Phase: Patients 6 years as of March 1 of the year prior to the measurement year to 12 years as of February 28 of the measurement year who were dispensed an attention deficit/hyperactivity disorder (ADHD) medication during the 12-month Intake Period \n","Continuation Phase: All patients who meet the following criteria:\n• An Initiation Phase visit in the first 30 days\n• At least two follow-up visits from 31-300 days (10 months) after the IPSD (one of the two visits may be a telephone visit with practitioner). \n","Continuation Phase: Patients 6 years as of March 1 of the year prior to the measurement year to 12 years as of February 28 of the measurement year who had continuous treatment for at least 210 days out of the 300-day period ",null,null,null,null,null,null,null,null,null,null,null,"1.12.2","","Initiation Phase","Continuation Phase",null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 18_138910807.1.4","RHP 18_138910807.3.4","RHP 18_138910807.1.4_138910807.3.4",{"$f":"COUNTIFS($FI$4:$FI872,FI872)","v":1},"RHP 18_138910807.1.4_1",null,3,2,1,"RHP 18_138910807",{"$f":"COUNTIFS($FR$4:$FR872,FR872)","v":4},"RHP 18_138910807_4"]
["RHP 19","084434201","Texoma Community Center","084434201.1.2","084434201.3.2","IT-10.1.a.iv","Assessment of Quality of Life (AQoL-8D) ","Baseline Approved","Eligible to Report in October DY4","Enhance behavioral health service availability, specifically substance abuse (SA) treatment services, and increase the number of substance abuse providers in Cooke County. A stand‐alone (SA) treatment center will be initiated and a SAMHSA‐based LCDC internship program will increase the provider pool.","Assessment of Quality of Life (AQoL-8D) ","In DY4 and DY5 provider will improve reported scores on the Assessment of Quality of Life  (AQoL-8D) out of all surveys administered during the measurement period to individuals receiving treatment at the identified substance abuse facility","Facility ","Individuals receiving treatment at the identified substance abuse facility","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",7352.375,"Yes/No","RHP 19_084434201.3.2_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",7352.375,"Yes/No","RHP 19_084434201.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",7868,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",7868,"Numeric",63.585000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",34194.75,"Numeric",63.943680000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",63.226300000000002,1201.3,19,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,63.585000000000001,null,63.943680000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"As approved by HHSC, Texoma Community Center serves individuals from three adjacent counties, each of which falls into a different RHP. As a result, TCC has three projects providing the same type of services in each county. For the purpose of establishing a baseline, we strongly believe that it makes more sense from a statistical perspective, as well as for practicality, to use the data from all of the individuals served. Our baseline subset is defined as those individuals receiving services at the Substance Abuse center, which is in one location but serves and supports individuals from all three regions. The following rationale was applied:\n• It’s the same staff providing the same services at the same location for all individuals regardless of their county of residence. Establishing different baselines arbitrarily based on the individual’s county of residence, solely for the purpose of reporting, does not seem to provide any meaningful distinction.\n• Including all of the individuals served by these projects provides the largest number of surveys from which to establish a statistically meaningful baseline, and would allow us to use the more appropriate and accurate scenario 1 for reporting, as opposed to having to use scenario 2.\nWe believe that scenario 1 is the better measure and would much prefer to use it, but we do not have sufficient follow-up surveys. We have a sufficient number of initial surveys for scenario 2, but far fewer follow-up surveys. By combining the surveys from all the counties, this provides more than enough to use scenario 1.\n• Having a consistent goal across all three projects will help us keep the different projects “in-line” with each other, prevent confusion, and allow us to better concentrate on improving the services rather than having to focus on multiple measurements.\nGoing forward for DY4 and DY5, the population will be narrowed to those individuals residing in the specific region only. ","The denominator value was selected by taking all of the AQoL surveys and filtering out only those that had an initial survey (survey type \"I\"), had a follow-up survey administered during the baseline period (survey type \"F\" and date between 4/1/214 and 9/30/2014), and received an intervention through the project (project ID \"202\").  The numerator was determined by adding up the scores for the last follow-up survey for each person from the group selected by the denominator.","The baseline rate is the average of the AQoL scores for the last follow-up survey to fall within the second half of DY3 (April 1st, 2014 thru September 30th, 2014)  for individuals who received an intervention through the waiver Substance Abuse project.","Assessment of Quality of Life (AQoL-8D) ","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.12.2","Scenario 1: Pre/Posttest Baseline","Assessment of Quality of Life (AQoL-8D) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 19_084434201.1.2","RHP 19_084434201.3.2","RHP 19_084434201.1.2_084434201.3.2",{"$f":"COUNTIFS($FI$4:$FI879,FI879)","v":1},"RHP 19_084434201.1.2_1",null,2,1,1,"RHP 19_084434201",{"$f":"COUNTIFS($FR$4:$FR879,FR879)","v":2},"RHP 19_084434201_2"]
["RHP 19","094138703","Clay County Memorial Hospital","094138703.2.2","094138703.3.500","IT-6.1.d.iii","CG-CAHPS Visit Survey 2.0: Office Staff","Baseline not yet reported","Eligible to Report in October DY4","This project will redesign our Primary Care model to improve patient experience and reduce no‐show rates","CG-CAHPS Visit Survey 2.0: Office Staff","In DY4 and DY5 provider will improve the percentage of top box scores on the CG-CAHPS Visit Survey 2.0: Office Staff out of all surveys administered during the measurement period. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",0,"Yes/No","RHP 19_094138703.3.500_PM-8","Metric Carried Forward in October DY3","PM-9","Validation and submission of baseline performance",4578.375,"Yes/No","RHP 19_094138703.3.500_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",7346.625,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",7346.625,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",35136.5,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"CG-CAHPS Visit Survey 2.0: Office Staff","Ambulatory",null,"Patient-mix and survey mode adjusted percent \"top box\" score for a given subdomain as provided by your survey administrator, multiplied by the number of completed CG-CAHPS surveys represented in the \"top box\" score.","The number of CG-CAHPS surveys completed during the measurement period as reported by your survey administrator. The denominator should be the same as the multiplier used in the numerator. The denominator should be the same as the multiplier used in the numerator. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.3.1","","CG-CAHPS Visit Survey 2.0: Office Staff",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 19_094138703.2.2","RHP 19_094138703.3.500","RHP 19_094138703.2.2_094138703.3.500",{"$f":"COUNTIFS($FI$4:$FI887,FI887)","v":2},"RHP 19_094138703.2.2_2",null,2,1,1,"RHP 19_094138703",{"$f":"COUNTIFS($FR$4:$FR887,FR887)","v":3},"RHP 19_094138703_3"]
["RHP 19","110856504","Hamilton Hospital","110856504.2.2","110856504.3.3","IT-2.17","Uncontrolled Diabetes Admissions Rate","Pending Approval","Eligible to Report in October DY4","Offer a Wellness program to teach self-management programs.  Provide fitness classes, including nutrition, to improve and or prevent complications from obesity in teens and adults in rural America.  ","Uncontrolled Diabetes Admissions Rate","In DY4 and DY5 provider will report the all non-maternal discharges of age 18 years and older with ICD-9-CM principal diagnosis code for uncontrolled diabetes.  In addition, in DY5 provider will demonstrate improvement in Alternative Approaches to Program and Outcome Linkages (SA.3). \n",null,null,"P4R","SA3","PM-8","Submission of Category 3 DY3 Status Report",30508.75,"Yes/No","RHP 19_110856504.3.3_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",30508.75,"Yes/No","RHP 19_110856504.3.3_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",81615.5,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",76272.75,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",76272.75,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Ran an Inpatient and Observation admission report for DY3 (October 1, 2013-September 30, 2014)out of our operating software system.  I first sorted and deleted all patients under 18.  This gave me my denominator.  I then sorted and deleted all remaining patients that did not have the required diabetes diagnosis as their primary diagnosis.","Out of all Inpatient and Observation admissions during DY3 2.82% of them were admitted for the required diabetic diagnosis that we are monitoring to show improvement due to our 1108504.2.2 project.","Uncontrolled Diabetes Admissions Rate","inpatient",null,"Discharges, for patients ages 18 years and older, with a principal ICD-9-CM diagnosis code for uncontrolled diabetes without mention of a short-term or long-term complication x 100,000*. ","Population in Metro Area  or county, age 18 years and older. ",null,null,null,null,null,null,null,null,null,null,"Starting in May 2014 we have enrolled one of our RNs in the Diebetic Educator Certification program.  She started having Diabetic Education Classes in late July 2014.  She will provide me information for proper documention as necessary.",null,null,"2.6.2","","Uncontrolled Diabetes Admissions Rate",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 19_110856504.2.2","RHP 19_110856504.3.3","RHP 19_110856504.2.2_110856504.3.3",{"$f":"COUNTIFS($FI$4:$FI889,FI889)","v":1},"RHP 19_110856504.2.2_1",null,2,1,1,"RHP 19_110856504",{"$f":"COUNTIFS($FR$4:$FR889,FR889)","v":2},"RHP 19_110856504_2"]
["RHP 19","127305405","Bowie Memorial Hospital","127305405.1.1","127305405.3.1","IT-9.2.a","Emergency Department (ED) visits per 100,000\n\n","Baseline Approved","Eligible to Report in October DY4","Expand primary care space, practioners and hours.","Emergency Department (ED) visits per 100,000\n\n","In DY4 and DY5 provider will decrease the  total number of adult ED Visits during the measurement period  out of all individuals ages 18 years and older in the Metro Area or County.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",18551.75,"Yes/No","RHP 19_127305405.3.1_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",18551.75,"Yes/No","RHP 19_127305405.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",26792.25,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",26792.25,"Numeric",15922.460571022872,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",112468.5,"Numeric",15084.436330442721,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",16760.484811603023,3305,19719,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,15922.460571022872,null,15084.436330442721,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numberator value was obtained from the 2010 US Census Bureau for Montague Co., Texas.  The Deoominator values were collected from Bowie Memorial's EMR system, CPSI.","The numberator value was obtained from the 2010 US Census Bureau for Montague Co., Texas.  The Deoominator values were collected from Bowie Memorial's EMR system, CPSI.","Emergency Department (ED) visits per 100,000\n\n","ED",null,"Total number of ED Visits during the measurement period ","Population in Metro Area or county, age 18 years and older",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2","","Emergency Department (ED) visits per 100,000\n\n",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 19_127305405.1.1","RHP 19_127305405.3.1","RHP 19_127305405.1.1_127305405.3.1",{"$f":"COUNTIFS($FI$4:$FI901,FI901)","v":1},"RHP 19_127305405.1.1_1",null,{"$f":"MAX(IF(AC901=\"\",0,1)+IF(AH901=\"\",0,1)+IF(AM901=\"\",0,1)+IF(AR901=\"\",0,1)+IF(AW901=\"\",0,1)+IF(BB901=\"\",0,1),IF(BG901=\"\",0,1)+IF(BL901=\"\",0,1)+IF(BQ901=\"\",0,1)+IF(BV901=\"\",0,1)+IF(CA901=\"\",0,1))","v":2},1,{"$f":"FO901-FP901","v":1},"RHP 19_127305405",{"$f":"COUNTIFS($FR$4:$FR901,FR901)","v":1},"RHP 19_127305405_1"]
["RHP 19","135034009","Electra Hospital District","135034009.1.3","135034009.3.4","IT-2.19","Flu and pneumonia Admission Rate ","Baseline Approved","Eligible to Report in April DY4","This project will open a new clinic in Iowa Park, which is located in central Wichita County.","Flu and pneumonia Admission Rate ","In DY4 and DY5 provider will report all non-maternal discharges of age 18 years and older with principal diagnosis code for Flu or Pneumonia at Electra Memorial Hospital.  In addition, in DY5 provider will submit a report detailing collaborative participation regarding validation of the P4R measure, including:  how the collaboration was formed, shared goals, provider activities related to the collaboration, findings from the process of normalizing and validating data/benchmarks, benchmark utility and/or limitations, and a discussion of how this activity has changed internal capacity (of the provider) around data infrastructure (SA.1). ","Facility ","Electra Memorial Hospital discharges","P4R","SA1","PM-8","Submission of Category 3 DY3 Status Report",106346.375,"Yes/No","RHP 19_135034009.3.4_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",106346.375,"Yes/No","RHP 19_135034009.3.4_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",341321.75,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",408070.5,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",408070.5,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",21727,78,359,"DY2: Oct 1st, 2012 - Sept 30th, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator represents all discharges from Electra Memorial Hospital, ages 18 and older, with a final primary diagnosis of flu or pneumonia, as described in the Compendium for OD-2, IT-2.19.  The denominator represents all discharges from Electra Memorial Hospital ages 18 and older.","The percentage of patients discharges, ages 18 and older, from Electra Memorial Hospital with a primary diagnosis of flu or pneumonia, as described in the Compendium for OD-1, IT-2.19.","Flu and pneumonia Admission Rate ","inpatient",null,"Discharges, for patients ages 18 years and older, with a principal ICD-9-CM diagnosis code for bacterial pneumonia and influenza x 100,000*.","Population ages 18 years and older in metropolitan area  or county. ",null,null,null,null,null,null,null,null,null,null,"We are preparing to validate the information reported.",null,null,"1.1.1","","Flu and pneumonia Admission Rate ",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 19_135034009.1.3","RHP 19_135034009.3.4","RHP 19_135034009.1.3_135034009.3.4",{"$f":"COUNTIFS($FI$4:$FI909,FI909)","v":1},"RHP 19_135034009.1.3_1",null,2,1,1,"RHP 19_135034009",{"$f":"COUNTIFS($FR$4:$FR909,FR909)","v":1},"RHP 19_135034009_1"]
["RHP 19","135237906","United Regional Health Care System","135237906.1.1","135237906.3.200","IT-3.17","Risk Adjusted Chronic Obstructive Pulmonary Disease (COPD) 30-day Readmission Rate ","Pending Approval","Eligible to Report in October DY4","Expand our existing clinic space, expand the hours of the clinic, and employ primary care providers and staff so that patients have enhanced access to services, allowing them to receive the right care at the right time in the right setting.","Risk Adjusted Chronic Obstructive Pulmonary Disease (COPD) 30-day Readmission Rate ","In DY4 and DY5 provider will improve the ratio of observed to expected readmissions that occur within 30 days following discharge from an index admission for COPD for patients 18 years of age and older.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",56429.125,"Yes/No","RHP 19_135237906.3.200_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",56429.125,"Yes/No","RHP 19_135237906.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",75466.125,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",75466.125,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",282146.63,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The rate of risk-adjusted hospital admissions (stays) for COPD that had at least one readmission for any reason within 30 days of discharge, for patients 18 years of age or older, as described in the HHSC Compendium.","Per observations with Truven, we are higher than the national norms which our Quality Department along with other hospital departments are trying to improve in order to lower the readmission rate.  \nThe recruitment of Primary Care is one of the action plans associated with the COPD readmission rate.  Our Quality department will provide further initiatives that will improve.","Risk Adjusted Chronic Obstructive Pulmonary Disease (COPD) 30-day Readmission Rate ","inpatient",null,"Total number of admissions (index stay) with at least one subsequent readmission (hospital stay) for any reason within 30 days during the measurement year","Expected (risk-adjusted) rate of readmissions for COPD during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2","","Risk Adjusted Chronic Obstructive Pulmonary Disease (COPD) 30-day Readmission Rate ",null,null,null,null,"Truven","2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 19_135237906.1.1","RHP 19_135237906.3.200","RHP 19_135237906.1.1_135237906.3.200",{"$f":"COUNTIFS($FI$4:$FI914,FI914)","v":2},"RHP 19_135237906.1.1_2",null,2,1,1,"RHP 19_135237906",{"$f":"COUNTIFS($FR$4:$FR914,FR914)","v":2},"RHP 19_135237906_2"]
["RHP 2","019053001","Coastal Health & Wellness","019053001.1.1","019053001.3.1","IT-1.7","Controlling high blood pressure ","Baseline Approved","Eligible to Report in April DY4","Galveston County Health District (GCHD) will contract with the Coastal Health & Wellness (formerly the 4C’s Clinic), its federally-qualified health center (FQHC), to increase access to primary care.  Access will be increased by increasing capacity to see patients both in the clinic as well as in a mobile clinic site.","Controlling high blood pressure ","In DY4 and DY5, the provider will improve the percentage of patients in the denominator whose most recent BP is adequately controlled (BP <140/90) during the measurement year over all patients 18 to 85 years of age by the end of the measurement year who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",100000,"Yes/No","RHP 2_019053001.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",100000,"Yes/No","RHP 2_019053001.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",125000,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",125000,"Numeric",0.58119053691275169,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",350000,"Numeric",0.59340269947800151,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.56897837434750187,1526,2682,"CY 2013: Jan 1st, 2013 - Dec 31st, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.58119053691275169,null,0.59340269947800151,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Ran EMR report of all pateints with diagnosis of hypertension per HHSC criteria in first six months of 2013.  Excluded patients matching exclusion criteria.  Included only patients with at least one encounter in 2012 also.  Numerator:  ran EMR report of all blood pressures for patients and filtered for those in denominator.  Considered inclusion and exclusion instructions.  Reported those with most recent blood pressure less than 140 systolic AND less than 90 diastolic as controlled.","57% of patients included in the denominator had controlled blood presuure at the end of 2013.  Therefore 43% of patients in the denominator require additional interventions to lower and control hypertension.  This is a change from baseline data reported in the past that did not follow latest HHSC criteria for reporting.","Controlling high blood pressure ","ambulatory",null,"The number of patients in the denominator whose most recent BP is adequately controlled during the measurement year. For a patient’s BP to be controlled, both the systolic and diastolic BP must be <140/90 (adequate control). To determine if a patient’s BP is adequately controlled, the representative BP must be identified.\n","Patients 18 to 85 years of age by the end of the measurement year who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","Controlling high blood pressure ",null,null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 2_019053001.1.1","RHP 2_019053001.3.1","RHP 2_019053001.1.1_019053001.3.1",{"$f":"COUNTIFS($FI$4:$FI923,FI923)","v":1},"RHP 2_019053001.1.1_1",null,2,1,1,"RHP 2_019053001",{"$f":"COUNTIFS($FR$4:$FR923,FR923)","v":1},"RHP 2_019053001_1"]
["RHP 2","094092602","UT Medical Branch Hospital","094092602.1.12","094092602.3.502","IT-1.10","Diabetes care: HbA1c poor control (>9.0%) ","Baseline not yet reported","Eligible to Report in October DY4","The project seeks to provide additional Primary Care services by improving education and chronic disease management in the community.","Diabetes care: HbA1c poor control (>9.0%) ","In DY4 and DY5 provider will improve (decrease) the percentage of patients 18-75 years of age with diabetes (type 1 and type 2) whose most recent HbA1c level during the measurement year was greater than 9.0% (poor control) or was missing a result, or if an HbA1c test was not done during the measurement year.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",45817.625,"Yes/No","RHP 2_094092602.3.502_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",45817.625,"Yes/No","RHP 2_094092602.3.502_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",151322.75,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",322938.25,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"DY4","TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator was based on lab values for the patients in the active Diabetes roster.  The denominator (the active Diabetes roster) is made up of all patients who in the measurement period had a recorded diagnosis of diabetes AND a recorded HbA1c value).","The denominator will change between measurement periods as newly diagnosed patients are added and existing patients may roll off of the active roster, but for DY3 the program saw only 4.23% of its patients with HbA1c > 9.0%.","Diabetes care: HbA1c poor control (>9.0%) ","ambulatory",null,"Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2","","Diabetes care: HbA1c poor control (>9.0%) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 2_094092602.1.12","RHP 2_094092602.3.502","RHP 2_094092602.1.12_094092602.3.502",{"$f":"COUNTIFS($FI$4:$FI928,FI928)","v":1},"RHP 2_094092602.1.12_1",null,1,1,0,"RHP 2_094092602",{"$f":"COUNTIFS($FR$4:$FR928,FR928)","v":4},"RHP 2_094092602_4"]
["RHP 2","094092602","UT Medical Branch Hospital","094092602.2.1","094092602.3.201","IT-6.1.b.i","CG-CAHPS 12-month: Timeliness of Appointments, Care, & Information","Baseline Approved","Eligible to Report in April DY4","Expand and enhance the delivery of care provided through the  Patient‐Centered  Medical Home (PCMH) model throughout twelve UTMB  primary  care clinics by restructuring the clinic staffing model into multidisciplinary care teams that manage a panel  of  patients,  reducing system  costs  associated  with  readmissions  and  ED  visits,  and improving the patient experience through  improved access to a  care provider","CG-CAHPS 12-month: Timeliness of Appointments, Care, & Information","In DY4 and DY5, the provider will improve the topbox score on the CG-CAHPS 12-month: Timeliness of Appointments, Care, & Information among all completed surveys at the clinics to be PMCH certified. ","Facility ","all primary care clinics that have or will have NCQA-accreditation on or before 1/1/2016","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",15636.555,"Yes/No","RHP 2_094092602.3.201_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",15636.555,"Yes/No","RHP 2_094092602.3.201_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",23419.18,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",23419.18,"Numeric",0.62746000000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",116540.12,"Numeric",0.64551999999999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.60940000000000005,4259.7060000000001,6990,"DY3 (1): Oct 1st, 2013 - March 31st, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.62746000000000002,null,0.64551999999999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator was based on ALWAYS responses for the Access to Care domain questions, as per the compendium instructions for calculating baseline.  The denominator subset in the Press Ganey report takes the highest response N in the Access to Care domain for the PCMH current and future certified locations.  The overall denominator is the total number of patient surveys responding to the Access to Care domain questions(all locations).","This measures is intended to evaluate the Access to the Providers for this population; based on that 60.94% of our patients in the PCMH clinics (current and future certification) feel that they always have good access to their care.  CG-CAHPS surveys are sent to patients after their ambulatory visit; only those who return the survey and complete at least half of the key questions have been included.  Patients who refuse the survey or for whom the contact address is found to be invalid have been excluded from the denominator.","CG-CAHPS 12-month: Timeliness of Appointments, Care, & Information","Ambulatory",null,"Patient-mix and survey mode adjusted percent \"top box\" score for a given subdomain as provided by your survey administrator, multiplied by the number of completed CG-CAHPS surveys represented in the \"top box\" score.","The number of CG-CAHPS surveys completed during the measurement period as reported by your survey administrator. The denominator should be the same as the multiplier used in the numerator.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.1.1 ","","CG-CAHPS 12-month: Timeliness of Appointments, Care, & Information",null,null,null,null,null,"2014-04-01","2015-03-31","2015-04-01","2016-03-31","2013-10-01","2014-03-31",null,null,"RHP 2_094092602.2.1","RHP 2_094092602.3.201","RHP 2_094092602.2.1_094092602.3.201",{"$f":"COUNTIFS($FI$4:$FI939,FI939)","v":1},"RHP 2_094092602.2.1_1",null,2,1,1,"RHP 2_094092602",{"$f":"COUNTIFS($FR$4:$FR939,FR939)","v":15},"RHP 2_094092602_15"]
["RHP 2","094092602","UT Medical Branch Hospital","094092602.2.2","094092602.3.10","IT-6.1.d.i","CG-CAHPS Visit Survey 2.0: Timeliness of Appointments, Care, & Information","Baseline Approved","Eligible to Report in April DY4","This LEAN project aims to use systems engineering to improve efficiency of care, reduce costs and enhance capacity. Ultimately, because of better and standardized workflows, we will also improve staff satisfaction and patient experience.","CG-CAHPS Visit Survey 2.0: Timeliness of Appointments, Care, & Information","In DY4 and DY5, the provider will improve the topbox score on the CG-CAHPS Visit Survey 2.0: Timeliness of Appointments, Care, & Information among patients in the Family Medicine & Neurology Clinics.","Facility ","Family Medicine & Neurology Clinics","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",39091.39,"Yes/No","RHP 2_094092602.3.10_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",39091.39,"Yes/No","RHP 2_094092602.3.10_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",58547.945,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",58547.95,"Numeric",0.65785000000000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",291350.31,"Numeric",0.66920000000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.64649999999999996,737.01,1140,"DY3 (1): Oct 1st, 2013 - March 31st, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.65785000000000005,null,0.66920000000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator was based on top-box scores (9 or 10 on a 10-point Likert scale) for Timeliness of Appointment, as per the compendium instructions for calculating baseline.  The denominator subset in the Press Ganey report was run for the Family Medicine and Neurology clinics that UTMB offers; we have the data separated by specialty (location) as well.  When looking at the entire UTMB ambulatory response, our baseline is 85.43% for this question. The full denominator represents the total number of ambulatory surveys received in the 6-month span.","This measure is intended to evaluate the patient satisfaction with the Timeliness of the care process in the clinic setting; our baseline value for the combined Family Medicine and Neurology Clinics is 64.65%, so our patients in these clinics are giving Top Box scores on their timeliness to care approximately two-thirds of the time.  CG-CAHPS surveys are sent to patients after their ambulatory visit; only those who return the survey and complete at least half of the key questions have been included.  Patients who refuse the survey or for whom the contact address is found to be invalid have been excluded from the denominator.","CG-CAHPS Visit Survey 2.0: Timeliness of Appointments, Care, & Information","Ambulatory",null,"Patient-mix and survey mode adjusted percent \"top box\" score for a given subdomain as provided by your survey administrator, multiplied by the number of completed CG-CAHPS surveys represented in the \"top box\" score.","The number of CG-CAHPS surveys completed during the measurement period as reported by your survey administrator. The denominator should be the same as the multiplier used in the numerator. The denominator should be the same as the multiplier used in the numerator. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.8.8 ","","CG-CAHPS Visit Survey 2.0: Timeliness of Appointments, Care, & Information",null,null,null,null,null,"2014-04-01","2015-03-31","2015-04-01","2016-03-31","2013-10-01","2014-03-31",null,null,"RHP 2_094092602.2.2","RHP 2_094092602.3.10","RHP 2_094092602.2.2_094092602.3.10",{"$f":"COUNTIFS($FI$4:$FI945,FI945)","v":1},"RHP 2_094092602.2.2_1",null,2,1,1,"RHP 2_094092602",{"$f":"COUNTIFS($FR$4:$FR945,FR945)","v":21},"RHP 2_094092602_21"]
["RHP 2","094092602","UT Medical Branch Hospital","094092602.2.4","094092602.3.13","IT-3.22","Risk Adjusted All-Cause Readmission","Baseline Approved","Eligible to Report in April DY4","Enable improvements in care transitions and coordination of care for patients  65+ transitioning from  a hospital setting to  a nursing home/rehabilitation facility, to home health care through centralized care coordination.  ","Risk Adjusted All-Cause Readmission","In DY4 and DY5 provider will improve the observed to expected ratio of 30 day readmission rates following discharge for any reason at UTMB Galveston for patients ages 65 or older","Age, Facility ","UTMB Galveston patients aged 65 years or older","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",109455.88499999999,"Yes/No","RHP 2_094092602.3.13_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",109455.88499999999,"Yes/No","RHP 2_094092602.3.13_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",163934.24,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",163934.24,"Numeric",1.3942446040000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",815780.85,"Numeric",1.3208629999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",1.4676260000000001,16.32,11.12,"09/01/13 - 02/28/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,1.3942446040000001,null,1.3208629999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator is the actual readmission rate seen in the medical population in this 6 month span: 16.32% (167 readmits from 1023 index discharges).  The denominator is the sum of the Texas PPR rates for the 1023 index discharges (totals 113.71).","With our O/E ratio of 1.47, our Medical patients have a 47% higher expectation of readmission than what the state of Texas would anticipate based on APR DRG, mental health status, severity of illness and patient age.","Risk Adjusted All-Cause Readmission","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk admissions during the measurement period.","Expected (risk-adjusted) rate of readmissions for all-causes during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.12.1","","Risk Adjusted All-Cause Readmission",null,null,null,null,"Texas State Medicaid Norms","2014-03-01","2015-02-28","2015-03-01","2016-02-28","2013-09-01","2014-02-28",null,null,"RHP 2_094092602.2.4","RHP 2_094092602.3.13","RHP 2_094092602.2.4_094092602.3.13",{"$f":"COUNTIFS($FI$4:$FI948,FI948)","v":1},"RHP 2_094092602.2.4_1",null,2,1,1,"RHP 2_094092602",{"$f":"COUNTIFS($FR$4:$FR948,FR948)","v":24},"RHP 2_094092602_24"]
["RHP 2","096166602","Spindletop Center","096166602.1.7","096166602.3.16","IT-11.8","Initiation and Engagement of Alcohol and Other Drug Dependence Treatment ","Baseline Approved","Eligible to Report in April DY4","a 10-bed unit within the Behavioral Health Hospital for the express purpose of providing medical detox services for residents of southeast Texas. A separate detox program including protocols for various addictive substances and continuity of care systems for long-term addiction treatment will be developed.","Initiation and Engagement of Alcohol and Other Drug Dependence Treatment ","In DY4 and DY5, provider will increase the number of individuals with initiation of AOD treatment through qualifying encounters with 14 days of diagnosis, and who have two or  more qualifying encounters within 30 days after the initiation encounter, out of all individuals diagnosed with a new episode of AOD at Baptist Hospital in Beaumont during the intake period of the measurement year. ","Facility ","Patients diagnosed with new AOD episode at Baptist Hospital in Beaumont","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",102129.645,"Yes/No","RHP 2_096166602.3.16_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",102129.645,"Yes/No","RHP 2_096166602.3.16_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",110663.03999999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- Initiation of AOD treatment",55331.519999999997,"Numeric",0.45944000000000002,"AM-1.2","Achievement of DY4 performance goal- Engagement of AOD treatment",55331.519999999997,"Numeric",0.28222179999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- Initiation of AOD treatment",243349.32,"Numeric",0.46332444499999997,"AM-2.2","Achievement of DY5 performance goal- Engagement of AOD treatment",243349.32,"Numeric",0.3199996,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"%",0.45555600000000002,41,90,"DY3 (1): Oct 1st, 2013 - March 31st, 2014",0.24444399999999999,22,90,"DY3 (1): Oct 1st, 2013 - March 31st, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0.45944000000000002,null,0.46332444499999997,null,0.28222179999999997,null,0.3199996,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"We used a proxy population because there was not a detox unit prior to the DSRIP project.  However, we have been able to identify clients that received similar services in the hospital during the designated time frame.  The expectation is that these clients would have been admitted to the Detox unit if it had been open.","We used a proxy population to establish the baseline due to Detox Services being a new service.    All patients presenting to the ER from October 1, 2013 through March 31, 2014, with a substance abuse diagnosis were pulled for review.  It was determined through review of the EMR if the patient was seeking detox.  For those seeking detox the area that care was provided was recorded (medical inpatient, ER, Behavioral Health Unit, or referred to outpatient).  The 42 charts of patients receiving inpatient detox at Behavioral Health Center were reviewed for the date of diagnosis, an encounter within 14 days of diagnosis and then 2 more encounters within 30 days of initial diagnosis.  The financial class of each patient receiving inpatient care at Behavioral Health was also recorded.","During the review period, 90 patients received a substance abuse diagnosis.  Out of those 90, 42 consented for inpatient detox on a behavioral health unit. Only 45.56% of patients with a substance abuse diagnosis received an initial \nencounter within 14 days of diagnosis. 24.44% of  patients had documentation of receiving 2 more encounters within 30 days of initial diagnosis.  It is believed that a portion did have these encounters, but they were not documented by the professional providing the service.  All inpatient detox care was provided in an acute psychiatric setting where the focus is acute mental illness not detox and substance abuse treatment.","Initiation and Engagement of Alcohol and Other Drug Dependence Treatment ","Ambulatory/Inpatient",null,"Initiation of AOD Treatment: Initiation of AOD treatment through an inpatient admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of diagnosis.","Patients age 13 years of age and older who were diagnosed with a new episode of alcohol and drug dependency (AOD) during the first 10 and ½ months of the measurement year (e.g., January 1-November 15).","Engagement of AOD Treatment: Initiation of AOD treatment and two or more inpatient admissions, outpatient visits, intensive outpatient encounters or partial hospitalizations with any AOD diagnosis within 30 days after the date of the Initiation encounter (inclusive). ","Patients age 13 years of age and older who were diagnosed with a new episode of alcohol and drug dependency (AOD) during the first 10 and ½ months of the measurement year (e.g., January 1-November 15).",null,null,null,null,null,null,null,null,null,null,null,"1.12.2","","Initiation ","Engagement",null,null,null,null,"2014-04-01","2015-03-31","2015-04-01","2016-03-31","2013-10-01","2014-03-31",null,null,"RHP 2_096166602.1.7","RHP 2_096166602.3.16","RHP 2_096166602.1.7_096166602.3.16",{"$f":"COUNTIFS($FI$4:$FI959,FI959)","v":1},"RHP 2_096166602.1.7_1",null,3,2,1,"RHP 2_096166602",{"$f":"COUNTIFS($FR$4:$FR959,FR959)","v":4},"RHP 2_096166602_4"]
["RHP 2","096166602","Spindletop Center","096166602.2.11","096166602.3.200","IT-1.21","Adult Body Mass Index (BMI) Assessment ","Baseline not yet reported","Eligible to Report in October DY4","health and wellness program for individuals with Intellectual and Developmental Disabilities (IDD) or Autism Spectrum Disorders (ASDs), utilizing swimming, exercise equipment, and aerobics to decrease cardiovascular risk factors for the targeted population in Jefferson, Orange, Hardin, and Chambers counties.","Adult Body Mass Index (BMI) Assessment ","In DY4 and DY5, provider will increase the number of adult patients with BMI calculated within the past six months and a follow up plan documented if BMI is outside the normal parameters, out of all adult individuals who are in Spindletop's Home and Community-based Services and Texas Home Living programs as well as other IDD individuals in the IDD Wellness Program","Facility ","individuals who are in Spindletop's Home and Community-based Services and Texas Home Living programs as well as other IDD individuals in the IDD Wellness Program","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",7388.8149999999996,"Yes/No","RHP 2_096166602.3.200_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",7388.8149999999996,"Yes/No","RHP 2_096166602.3.200_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",8006.18,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",8006.18,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",35211.379999999997,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Adult Body Mass Index (BMI) Assessment ","both",null,"Patients with BMI calculated within the past six months or during the current visit and a follow-up plan is documented within the last six months or during the current visit if the BMI is outside of normal parameters.\n\nDefinitions:\n\nBMI – Body mass index (BMI) is expressed as weight/height (BMI; kg/m2) and is commonly used to classify weight categories.\n\nCalculated BMI – Requires an eligible professional or their staff to measure both the height and weight. Self-reported values cannot be used. BMI is calculated either as weight in pounds divided by height in inches squared multiplied by 703, or as weight in kilograms divided by height in meters squared.\n\nFollow-up Plan – Proposed outline of treatment to be conducted as a result of a BMI out of normal parameters. Such follow-up may include but is not limited to: documentation of a future appointment, education, referral (such as, a registered dietician, nutritionist, occupational therapist, physical therapist, primary care provider, exercise physiologist, mental health professional or surgeon), pharmacological interventions, dietary supplements, exercise counseling or nutrition counseling.\n","Patients age 18 years as of the first day of the 12-month period prior to the measurement period to 74 years as of last day of the measurement period who had an outpatient visit during the measurement period or the 12-month period prior to the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.13.1","","Adult Body Mass Index (BMI) Assessment ",null,null,null,null,null,null,null,null,null,"","",null,null,{"$f":"A964&\"_\"&D964","v":"RHP 2_096166602.2.11"},{"$f":"A964&\"_\"&E964","v":"RHP 2_096166602.3.200"},"RHP 2_096166602.2.11_096166602.3.200",{"$f":"COUNTIFS($FI$4:$FI964,FI964)","v":2},"RHP 2_096166602.2.11_2",null,2,{"$f":"IF(DC964=\"\",0,1)+IF(DG964=\"\",0,1)+IF(DK964=\"\",0,1)+IF(DO964=\"\",0,1)+IF(DS964=\"\",0,1)","v":1},1,"RHP 2_096166602",{"$f":"COUNTIFS($FR$4:$FR964,FR964)","v":9},{"$f":"FR964&\"_\"&FS964","v":"RHP 2_096166602_9"}]
["RHP 2","109372601","Physician Practice affiliated with UTMB","109372601.1.1","109372601.3.1","IT-6.1.b.iv","CG-CAHPS 12-month: Overall Provider Rating","Baseline Approved","Eligible to Report in April DY4","This project will expand specialty care capacity for Galveston and Brazoria Counties by increasing service availability by looking at opportunities for extended hours, increasing number of specialty clinic locations (based on needs identified in the specialty care gap assessment, which is part of the DY 2 process milestone) and implementing transparent, standardized referrals across the system. ","CG-CAHPS 12-month: Overall Provider Rating","In DY4 and DY5 provider will increase the percentage of top box scores for CG-CAHPS- Overall Provider Rating. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",42280.824999999997,"Yes/No","RHP 2_109372601.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",42280.824999999997,"Yes/No","RHP 2_109372601.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",49117.684999999998,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",49117.69,"Numeric",0.8397,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",213863.43,"Numeric",0.84640000000000004,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.83299999999999996,1018.759,1223,"DY3 (1): Oct 1st, 2013 - March 31st, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.8397,null,0.84640000000000004,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator was based on top-box scores (9 or 10 on a 10-point Likert scale) for Overall Physician Rating.  The denominator in the Press Ganey report was selected specialty clinics; we excluded Primary Care, Thoracic Surgery and Transplant surgery responses.  Our data is also available at the service-line level.","This measures is intended to evaluate the patient satisfaction with the Providers seen in the clinic; based on the data pulled, our baseline Top Box score for this measure tells us that 83.3% of our patients in our selected population are pleased wth their UTMB Provider.  CG-CAHPS surveys are sent to patients after their ambulatory visit; only those who return the survey and complete at least half of the key questions have been included.  Patients who refuse the survey or for whom the contact address is found to be invalid have been excluded from the denominator.","CG-CAHPS 12-month: Overall Provider Rating","Ambulatory",null,"Patient-mix and survey mode adjusted percent \"top box\" score for a given subdomain as provided by your survey administrator, multiplied by the number of completed CG-CAHPS surveys represented in the \"top box\" score.","The number of CG-CAHPS surveys completed during the measurement period as reported by your survey administrator. The denominator should be the same as the multiplier used in the numerator.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2 ","","CG-CAHPS 12-month: Overall Provider Rating",null,null,null,null,null,"2014-04-01","2015-03-31","2015-04-01","2016-03-31","2013-10-01","2014-03-31",null,null,"RHP 2_109372601.1.1","RHP 2_109372601.3.1","RHP 2_109372601.1.1_109372601.3.1",{"$f":"COUNTIFS($FI$4:$FI973,FI973)","v":1},"RHP 2_109372601.1.1_1",null,2,1,1,"RHP 2_109372601",{"$f":"COUNTIFS($FR$4:$FR973,FR973)","v":1},"RHP 2_109372601_1"]
["RHP 2","112671602","Brazosport Regional Health System","112671602.1.1","112671602.3.1","IT-6.2.b","Visit-Specific Satisfaction Instrument (VSQ-9)","Baseline Approved","Eligible to Report in October DY4","The project will use LJFMC as a base for expanding primary care capacity by expanding the hours to include evenings and weekends.  ","Visit-Specific Satisfaction Instrument (VSQ-9)","In DY4 and DY5 provider will improve (increase) the average overall score on the Visit-Specific Satisfaction Instrument (VSQ-9) which measures patient satisfaction with access to primary care, with the direct interaction with the physician, and with the visit overall. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",35829.75,"Yes/No","RHP 2_112671602.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",17914.875,"Yes/No","RHP 2_112671602.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",28747,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",28747,"Numeric",87.9255,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",137486,"Numeric",88.561000000000007,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",87.29,8729,100,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,87.9255,null,88.561000000000007,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator for this metris is defined as the sum of all the \"overall scores\" for the surveys. We calculate the overall score for each of the surveys by averaging the responses from each person, and then totaling the averages from all 100 surveys. The sum of all 100 average scores is 8,729, which is our numerator.  The denominator for this metric is described as \"The total number VSQ-9 surveys completed during the measurement period\" but the IT-6.2.b companion document states that we may use a sample because our denominator size was over 380, as long as it was more than 20% of all cases. We chose to use 100 surveys in our sample, which is 22% of our total amount of cases. Therefore our baseline rate should be 8729/100= 87.29","Our interpretation of this baseline rate is that on average, our patient's level of satisfaction with our services is 87.29 out of a possible total score of 100% ","Visit-Specific Satisfaction Instrument (VSQ-9)","Ambulatory",null,"Sum of all the \"overall score\" of all VSQ-9 surveys completed during the measurement period. ","The total number VSQ-9 surveys completed during the measurement period. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","Visit-Specific Satisfaction Instrument (VSQ-9)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 2_112671602.1.1","RHP 2_112671602.3.1","RHP 2_112671602.1.1_112671602.3.1",{"$f":"COUNTIFS($FI$4:$FI981,FI981)","v":1},"RHP 2_112671602.1.1_1",null,2,1,1,"RHP 2_112671602",{"$f":"COUNTIFS($FR$4:$FR981,FR981)","v":1},"RHP 2_112671602_1"]
["RHP 2","131030203","Nacogdoches Memorial Hospital","131030203.1.2","131030203.3.2","IT-8.1","Timeliness of Prenatal/Postnatal Care","Baseline not yet reported","Eligible to Report in October DY4","This project will expand the capacity of primary care adding a certified nurse midwife and additional support staff to increase service capacity to the indigent and underserved populations of Nacogdoches County at the Nacogdoches Regional Maternal Child Health Program (RMCHP) clinic.","Timeliness of Prenatal/Postnatal Care","In DY4 and DY5 provider will improve (increase) the percentage of deliveries of live births between November 6 of the year prior to the measurement year and November 5 of the measurement year. For these women seen at the Maternal Care Clinic, the measure assesses the following: • Rate 1: Timeliness of Prenatal Care. The percentage of deliveries that received a prenatal care visit as a patient of the organization in the first trimester or within 42 days of enrollment in the organization. • Rate 2: Postpartum Care. The percentage of deliveries that had a postpartum visit on or between 21 and 56 days after delivery ","Facility ","Population would be limited to individuals receiving services at the Maternal Care Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",23000.575000000001,"Yes/No","RHP 2_131030203.3.2_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",23000.575000000001,"Yes/No","RHP 2_131030203.3.2_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",31384.74,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- Prenatal Care",15692.37,"Numeric","TBD","AM-1.2","Achievement of DY4 performance goal- Postnatal Care",15692.37,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- Prenatal Care",73960.914999999994,"Numeric","TBD","AM-2.2","Achievement of DY5 performance goal- Postnatal Care",73960.914999999994,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Timeliness of Prenatal/Postnatal Care","ambulatory",null,"Received a prenatal care visit as a patient of the organization in the first trimester \n","Deliveries of live births between the sixth day of Month 11of the year prior to the measurement year and the fifth day of Month 11 of the measurement year.","Had a postpartum visit for a pelvic exam or postpartum care on or between 21 and 56 days after delivery.","Deliveries of live births between the sixth day of Month 11of the year prior to the measurement year and the fifth day of Month 11 of the measurement year.",null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","Prenatal Care","Postnatal Care",null,null,null,null,null,null,null,null,"","",null,null,"RHP 2_131030203.1.2","RHP 2_131030203.3.2","RHP 2_131030203.1.2_131030203.3.2",{"$f":"COUNTIFS($FI$4:$FI986,FI986)","v":1},"RHP 2_131030203.1.2_1",null,3,2,1,"RHP 2_131030203",{"$f":"COUNTIFS($FR$4:$FR986,FR986)","v":3},"RHP 2_131030203_3"]
["RHP 2","135222109","Gulf Coast Center","135222109.2.1","135222109.3.200","IT-1.7","Controlling high blood pressure ","Pending Approval","Eligible to Report in October DY4","Co-locate outpatient physical health services in its adult mental health facilities so as to integrate primary care and behavioral health care services in order to improve access to needed services. ","Controlling high blood pressure ","In DY4 and DY5, the provider will improve the percentage of patients 18 to 85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90) during the measurement year over all patients 18 to 85 years of age by the end of the measurement year who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year",null,null,"P4P","","PM-8","Submission of Category 3 DY3 Status Report",28200.775000000001,"Yes/No","RHP 2_135222109.3.200_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",28576.224999999999,"Yes/No","RHP 2_135222109.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",41709.125000000007,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",41709.125000000007,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",168130.80000000005,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"","","","Controlling high blood pressure ","ambulatory",null,"The number of patients in the denominator whose most recent BP is adequately controlled during the measurement year. For a patient’s BP to be controlled, both the systolic and diastolic BP must be <140/90 (adequate control). To determine if a patient’s BP is adequately controlled, the representative BP must be identified.\n","Patients 18 to 85 years of age by the end of the measurement year who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.15.1",null,"Controlling high blood pressure ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 2_135222109.2.1","RHP 2_135222109.3.200","RHP 2_135222109.2.1_135222109.3.200",{"$f":"COUNTIFS($FI$4:$FI998,FI998)","v":1},"RHP 2_135222109.2.1_1",null,2,1,1,"RHP 2_135222109",{"$f":"COUNTIFS($FR$4:$FR998,FR998)","v":7},"RHP 2_135222109_7"]
["RHP 2","135222109","Gulf Coast Center","135222109.2.102","135222109.3.501","IT-1.23","Tobacco Use: Screening & Cessation ","Baseline not yet reported","Eligible to Report in October DY4","The Gulf Coast Center will offer smoking cessation interventions with proven, evidence based strategies for adults. This will be available to the general community, with a sub-population of individuals in substance abuse treatment. The project will also provide training for medical and behavioral health providers with screening and referral strategies. ","Tobacco Use: Screening & Cessation ","In DY4 and DY5 provider will improve the percentage of patients aged 18 years and older who were screened for tobacco use at least once during the two-year measurement period AND who received cessation counseling intervention if identified as a tobacco user",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",11280.31,"Yes/No","RHP 2_135222109.3.501_PM-8","Metric Carried Forward in October DY3","PM-9","Validation and submission of baseline performance",11430.49,"Yes/No","RHP 2_135222109.3.501_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",33367.300000000003,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",67252.320000000007,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"DY4","TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Tobacco Use: Screening & Cessation ","Multiple",null,"Patients who were screened for tobacco use* at least once during the two-year measurement period AND who received tobacco cessation counseling intervention** if identified as a tobacco user.","All patients aged 18 years and older who were seen twice for any visits or who had at least one preventive care visit during the two year measurement period.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.7.2","","Tobacco Use: Screening & Cessation ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 2_135222109.2.102","RHP 2_135222109.3.501","RHP 2_135222109.2.102_135222109.3.501",{"$f":"COUNTIFS($FI$4:$FI1003,FI1003)","v":2},"RHP 2_135222109.2.102_2",null,1,1,0,"RHP 2_135222109",{"$f":"COUNTIFS($FR$4:$FR1003,FR1003)","v":12},"RHP 2_135222109_12"]
["RHP 2","136367307","Burke Center","136367307.1.1","136367307.3.1","IT-11.5","Adherence to Antipsychotic Medications for Individuals with Schizophrenia ","Baseline Approved","Eligible to Report in October DY4","Expand the capacity of the Burke Center to serve more children and adults with mental illness. We will provide outpatient psychiatric care, therapy, medication services and patient education as needed.","Adherence to Antipsychotic Medications for Individuals with Schizophrenia ","In DY4 and DY5, provider will reduce the number of individuals with schizophrenia or schizoaffective disorder who filled at least two prescriptions for any antipsychotic and have a PDC for antipsychotic medication of at least .8, out of all adults with schizophrenia/schizoaffective disorder with at least two claims for any antipsychotic medication during the measurement period. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",92133.95,"Yes/No","RHP 2_136367307.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",98712.673950000011,"Yes/No","RHP 2_136367307.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",96906.434999999998,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",96906.44,"Numeric",0.91312684300000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",418153.32,"Numeric",0.91769911500000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.908555,308,339,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.91312684300000002,null,0.91769911500000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Data for the denominator was extracted from the EMR to include those that had a diagnosis of schizophrenia and other related psychotic disorders and were receiving antipsychotic medication during the timeline identified.  Data for the numerator was collected by contacting the pharmacy of record to determine if the individual picked up their prescribed medication during the timeline indicated. ","91% of individuals were consistent with picking up medications throughout the measurement period.  This baseline calculation allows us to identify individuals that could benefit from more clinical attention in order to improve medication compliance. ","Adherence to Antipsychotic Medications for Individuals with Schizophrenia ","ambulatory",null,"Individuals with schizophrenia or schizoaffective disorder who filled at least two prescriptions for any antipsychotic medication and have a Proportion of Days Covered (PDC) for antipsychotic medications of at least 0.8","Individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder with at least two claims for any antipsychotic medication during the measurement period (12 consecutive months)",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.12.2","","Adherence to Antipsychotic Medications for Individuals with Schizophrenia ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 2_136367307.1.1","RHP 2_136367307.3.1","RHP 2_136367307.1.1_136367307.3.1",{"$f":"COUNTIFS($FI$4:$FI1008,FI1008)","v":1},"RHP 2_136367307.1.1_1",null,2,1,1,"RHP 2_136367307",{"$f":"COUNTIFS($FR$4:$FR1008,FR1008)","v":1},"RHP 2_136367307_1"]
["RHP 2","136367307","Burke Center","136367307.2.4","136367307.3.6","IT-1.8","Screening and Treatment Plan for Clinical Depression ","Baseline Approved","Eligible to Report in October DY4","Integrate primary care with behavioral health care services the Center\nprovides in order to improve access to needed health services and improve overall health and\nwellbeing. Burke Center will partner with Angelina County/Cities Health District to create an\nintegrated health home for Burke Center clients with one or more comorbid chronic conditions\nand expand access to behavioral health services for clients of the Health District Clinic.","Depression management: Screening and Treatment Plan for Clinical Depression ","In DY4 and DY5, provider will increase the number of patients screened for clinical depression using a standardized tool and with a documented follow up plan, out of all adult patients seen at ACCHD (Angelina Cities and Counties Health District).","Facility ","Patients seen at ACCHD (Angelina Cities and Counties Health District) only","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",30711.316666666666,"Yes/No","RHP 2_136367307.3.6_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",32904.224650000004,"Yes/No","RHP 2_136367307.3.6_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",32302.145,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",32302.15,"Numeric",0.10145248599999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",139384.44,"Numeric",0.14874446099999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",5.4161000000000001E-2,110,2031,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.10145248599999999,null,0.14874446099999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Data was collected for all individuals receiving a service during the reporting period for the denominator.  The numerator is those individuals who received an irregular score on the depression screening and had a follow-up visit with the behavior specialist. ","5% of individuals that received a medical service received a screening with an outlying score and received a follow-up plan. ","Screening and Treatment Plan for Clinical Depression ","Multiple",null,"Patient’s screening for clinical depression using a standardized tool AND follow-up plan is documented","All patients aged 18 years and older",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.15.1","","Screening and Treatment Plan for Clinical Depression ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 2_136367307.2.4","RHP 2_136367307.3.6","RHP 2_136367307.2.4_136367307.3.6",{"$f":"COUNTIFS($FI$4:$FI1015,FI1015)","v":3},"RHP 2_136367307.2.4_3",null,2,1,1,"RHP 2_136367307",{"$f":"COUNTIFS($FR$4:$FR1015,FR1015)","v":8},"RHP 2_136367307_8"]
["RHP 2","138296208","CHRISTUS Hospital - St. Elizabeth","138296208.2.1","138296208.3.2","IT-9.4.a","Reduce Emergency Department visits for Congestive Heart Failure","Baseline Approved","Eligible to Report in April DY4","CHRISTUS will establish team-based clinics to address complex chronic diseases such as congestive heart failure, diabetes, COPD and asthma.  These clinics will offer intensive care management.","Reduce Emergency Department visits for Congestive Heart Failure","In DY4 and DY5 provider will improve (decrease) the percentage of ED Visits with a primary or secondary diagnosis of CHF for any individual 18 years and older out of the total number of ED visits to CHRISTUS Hospital's acute care facilities during the measurement period","Facility ","Total number of ED Visits at CHRISTUS Hospital's facilities with a primary or secondary diagnosis of CHF for any individual 18 years and older during the measurement period ","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",81691.5,"Yes/No","RHP 2_138296208.3.2_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",81691.5,"Yes/No","RHP 2_138296208.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",131086.5,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",131086.5,"Numeric",2.4545482E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",626936,"Numeric",2.3254E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",2.5836999999999999E-2,1721,66609,"September 1, 2012 -August 31, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,2.4545482E-2,null,2.3254E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denomiator was determined by accounting all emergency department visits for adults aged 18+ during the measurement time period.  The numnerator was determined by querying the hospital's administrative database for all adult patients with a primary or secondary diagnosis of CHF (as per specificaion sheet) during the measurement time period.","The baseline rate reflects the rate of ED utilization for preventable CHF conditions and complications, which was 2.58%","Reduce Emergency Department visits for Congestive Heart Failure","ED",null,"Total number of ED Visits with a primary or secondary diagnosis of CHF for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.2 ","","Reduce Emergency Department visits for Congestive Heart Failure",null,null,null,null,null,"2013-09-01","2014-08-31","2014-09-01","2015-08-31","2012-09-01","2013-08-31",null,null,"RHP 2_138296208.2.1","RHP 2_138296208.3.2","RHP 2_138296208.2.1_138296208.3.2",{"$f":"COUNTIFS($FI$4:$FI1022,FI1022)","v":1},"RHP 2_138296208.2.1_1",null,2,1,1,"RHP 2_138296208",{"$f":"COUNTIFS($FR$4:$FR1022,FR1022)","v":2},"RHP 2_138296208_2"]
["RHP 20","094186602","Laredo Regional Medical Center, LP","094186602.2.100","094186602.3.102","IT-9.2","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","Baseline Approved","Eligible to Report in October DY4","This project establishes a patient navigator program to track, follow-up on and help manage care for chronically ill patients who have a history of frequently visiting the ED. ","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","In DY4 and DY5 provider will improve (decrease) the percentage of adult ED visits for ACSC (primary or secondary diagnosis) out of the total number of adult ED visits to the facility during the measurement period. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",250000,"Yes/No","RHP 20_094186602.3.102_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",250000,"Yes/No","RHP 20_094186602.3.102_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",250000,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",250000,"Numeric",0.26170466599999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",666666.67000000004,"Numeric",0.24793100000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.27547899999999997,5425,19693,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.26170466599999997,null,0.24793100000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numberator value was determnined using queries from our Helathcare Query system, a Siemens product/system. Denominator value was determined using our Decision Support System, Invision.","Baseline rate seem to be in line with historical percentage of patients seen thru our ED with ambulatory care sensitive conditions.","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","ED",null,"Total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1","","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 20_094186602.2.100","RHP 20_094186602.3.102","RHP 20_094186602.2.100_094186602.3.102",{"$f":"COUNTIFS($FI$4:$FI1030,FI1030)","v":1},"RHP 20_094186602.2.100_1",null,2,1,1,"RHP 20_094186602",{"$f":"COUNTIFS($FR$4:$FR1030,FR1030)","v":3},"RHP 20_094186602_3"]
["RHP 20","121989102","Border Region Behavioral Health Center","121989102.2.2","121989102.3.204","IT-11.9","Care Planning for Dual Diagnosis","Baseline not yet reported","Eligible to Report in October DY4","Crisis prevention for outpatient services such as to address factors affecting inpatient admission rates such chronic homeless services, physical illness, lack of monitoring of medication compliance and decrease in functional status.","Care Planning for Dual Diagnosis","In DY4 and DY5, provider will increase the number of individuals from the denominator for whom a case manager has documented a plan of care that addresses the consumer's need for treatment of both conditions, out of the number of individuals participating in a case management program who are dually diagnosed with a mental disorder and a substance abuse disorder.      \n         \n",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",16415.599999999999,"Yes/No","RHP 20_121989102.3.204_PM-8","Metric Carried Forward in October DY3","PM-9","Validation and submission of baseline performance",16415.599999999999,"Yes/No","RHP 20_121989102.3.204_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",17155.900000000001,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",17155.900000000001,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",72571.8,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Care Planning for Dual Diagnosis","Ambulatory/Inpatient",null,"Those individuals from the denominator for whom a case manager has documented a plan of care that addresses the consumer's need for treatment of both conditions.","The number of individuals participating in a case management program who are dually diagnosed with a mental disorder and a substance abuse disorder ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.13.1","","Care Planning for Dual Diagnosis",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 20_121989102.2.2","RHP 20_121989102.3.204","RHP 20_121989102.2.2_121989102.3.204",{"$f":"COUNTIFS($FI$4:$FI1040,FI1040)","v":2},"RHP 20_121989102.2.2_2",null,2,1,1,"RHP 20_121989102",{"$f":"COUNTIFS($FR$4:$FR1040,FR1040)","v":10},"RHP 20_121989102_10"]
["RHP 20","121990904","Camino Real Community Services","121990904.2.1","121990904.3.200","IT-11.26.e.i","Patient Health Questionnaire 9 (PHQ-9)","Baseline Approved","Eligible to Report in October DY4","Project will integrate psychiatric and primary health care services","Patient Health Questionnaire 9 (PHQ-9)","In DY4 and DY5 provider will improve reported scores on the Patient Health Questionnaire  9 (PHQ-9)  out of all completed questionnaires during the measurement period. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",41297.230000000003,"Yes/No","RHP 20_121990904.3.200_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",41297.230000000003,"Yes/No","RHP 20_121990904.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",58583,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",58583,"Numeric",7.6928571430000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",195771.51999999999,"Numeric",6.3428570000000004,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",9.0428999999999995,633,70,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,7.6928571430000003,null,6.3428570000000004,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator is the total number of PHQ 9 collected.  The numerator is the sum of all scores.","The baseline rate of 9.04 will guide our DY4 and DY5 practices to ensure that those individuals identified as having a high severity score are appropriately referred for treatment.","Patient Health Questionnaire 9 (PHQ-9)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.15.1","Scenario 2: Pre Test Only Baseline","Patient Health Questionnaire 9 (PHQ-9)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 20_121990904.2.1","RHP 20_121990904.3.200","RHP 20_121990904.2.1_121990904.3.200",{"$f":"COUNTIFS($FI$4:$FI1044,FI1044)","v":1},"RHP 20_121990904.2.1_1",null,2,1,1,"RHP 20_121990904",{"$f":"COUNTIFS($FR$4:$FR1044,FR1044)","v":3},"RHP 20_121990904_3"]
["RHP 20","132812205","Driscoll Children's Hospital","132812205.1.100","132812205.3.101","IT-7.16","Preventive Services for Children at Elevated Caries Risk","Baseline Approved","Eligible to Report in April DY4","This project will improve access to oral health services for children by significantly expanding a successful Oral Health project that provides pediatric preventive dental care and education to patients in a primary care provider’s (PCP’s) office. ","Preventive Services for Children at Elevated Caries Risk","In DY4 and DY5 provider will improve (increase) the percentage of (a) all children (b) children who received at least one dental service who are at “elevated” risk (i.e., “moderate” or “high”) who received a topical fluoride application and/or sealants within the measurement period out of the total number of Driscoll Healthplan members aged 6-35 months. ","Age, Payer ","Ages: 6 through 35 months & Payer of Medicaid (Driscoll Healthplan Members)","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",37666.665000000001,"Yes/No","RHP 20_132812205.3.101_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",37666.665000000001,"Yes/No","RHP 20_132812205.3.101_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",59781.25,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- % of all children",29890.625,"Numeric",0.22488744399999999,"AM-1.2","Achievement of DY4 performance goal- % of all children with at least one dental service",29890.63,"Numeric",0.27192870769999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- % of all children",134260.42000000001,"Numeric",0.265683,"AM-2.2","Achievement of DY5 performance goal- % of all children with at least one dental service",134260.42000000001,"Numeric",0.31024824940000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"%",0.18409200000000001,368,1999,"07/01/13 - 12/31/13",0.23360916600000001,367,1571,"07/01/13 - 12/31/13",null,0,0,null,null,0,0,null,null,0,0,null,null,0.22488744399999999,null,0.265683,null,0.27192870769999999,null,0.31024824940000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator and denominators were determined using health plan data (we do not have access to or receive dental data) and documented specifications that suit health plan data and can be run consistently to measure performance.","Out of the 1999 Driscoll health plan members at elevated caries risk ages 6-35 months as of the end of 7/1/2013 - 12/31/2013 with no more than one gap in enrollment, 368 received topical fluoride applications and/or sealants as a dental service for a baseline rate of 18.41%. Out of the 1571 Driscoll health plan members ages 6-35 months as of the end of 7/1/2013 - 12/31/2013 with no more than one gap in enrollment who had a well child (Texas Healthy Steps) visit in the same time frame, 367 received topical fluoride applications and/or sealants as a dental service for a baseline rate of23.36%.","Preventive Services for Children at Elevated Caries Risk","ambulatory",null,"Unduplicated number of children at “elevated” risk (i.e., “moderate” or “high”) who received a topical fluoride application and/or sealants as a dental service.","Unduplicated number of all children at “elevated” risk (i.e., “moderate” or “high”) with at least 1 dental visit in the prior or current year. ","Unduplicated number of children at “elevated” risk (i.e., “moderate” or “high”) who received a topical fluoride application and/or sealants as a dental service.","Unduplicated number of all children at “elevated” risk (i.e., “moderate” or “high”) who received at least one dental service with at least 1 dental visit in the prior or current year.",null,null,null,null,null,null,null,null,null,null,null,"1.8.9","","all children","children receiving dental services",null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-07-01","2013-12-31",null,null,"RHP 20_132812205.1.100","RHP 20_132812205.3.101","RHP 20_132812205.1.100_132812205.3.101",{"$f":"COUNTIFS($FI$4:$FI1052,FI1052)","v":2},"RHP 20_132812205.1.100_2",null,3,2,1,"RHP 20_132812205",{"$f":"COUNTIFS($FR$4:$FR1052,FR1052)","v":3},"RHP 20_132812205_3"]
["RHP 3","020817501","Bayshore Medical Center","020817501.1.2","020817501.3.2","IT-3.15","Risk Adjusted Behavioral Health /Substance Abuse 30-day Readmission Rate ","Pending Approval","Eligible to Report in October DY4","HCA intends to expand its existing telemedicine program to include a 24/7 tele-psychiatry program in its Bayshore Emergency Department (ED), as well as implementing telemedicine capabilities in the EDs at its other local hospitals. Specifically, HCA will identify the necessary technology to establish the program, reach out to behavioral health providers to participate, train the ED staff at each hospital to effectively use the new capabilities, and will implement protocols for obtaining tele-psychiatry consults and referrals to and from Bayshore.","Risk Adjusted Behavioral Health /Substance Abuse 30-day Readmission Rate ","In DY4 & DY5 the provider will improve the ratio of the observed to expected rate of readmission within 30 days following discharge from an index admission related to BH/SA from Bayshore Medical Center.","Facility ","Bayshore Medical Center","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",261511.1,"Yes/No","RHP 3_020817501.3.2_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",261511.1,"Yes/No","RHP 3_020817501.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",419633.99,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",419633.99,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",2006945.56,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"For the numerator we took all index admissions.  For the denominator we took all the inpatient cases for the facility.","According to our historical data we expected a readmission rate of 9.1%.  Our observed rate of readmission was 9.2%.","Risk Adjusted Behavioral Health /Substance Abuse 30-day Readmission Rate ","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission for BH/SA during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk BH/SA admissions during the measurement period.\n","Expected (risk-adjusted) rate of readmissions for BH/SA during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.7.1 ","","Risk Adjusted Behavioral Health /Substance Abuse 30-day Readmission Rate ",null,null,null,null,"Internal Data Historical Norms","2013-07-01","2014-06-30","2014-07-01","2015-06-30","2013-01-01","2013-06-30",null,null,"RHP 3_020817501.1.2","RHP 3_020817501.3.2","RHP 3_020817501.1.2_020817501.3.2",{"$f":"COUNTIFS($FI$4:$FI1065,FI1065)","v":1},"RHP 3_020817501.1.2_1",null,2,1,1,"RHP 3_020817501",{"$f":"COUNTIFS($FR$4:$FR1065,FR1065)","v":2},"RHP 3_020817501_2"]
["RHP 3","020834001","Memorial Hermann Northwest Hospital","020834001.1.1","020834001.3.1","IT-7.2","Cavities: Children","Baseline Approved","Eligible to Report in April DY4","Memorial Hermann intends to increase the number of school-based primary care sites in low income communities for people with limited access to health and dental care in the community. The project will expand the Memorial Hermann Health Centers for Schools program by 3 health centers and 1 mobile dental van.","Cavities: Children","In DY4 and DY5 provider will reduce the percent of children aged 5-19 years with Medicaid or Uninsured/Indigent that have received dental or primary care services with untreated dental caries. ","Age, Payer "," Provider requests two denominator subsets: \nDenominator subset #1: Payer - Both Medicaid and Uninsured/indigent.  \nDenominator subset # 2: Age Group - lower bound = 5; upper bound = 19","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",234248.48,"Yes/No","RHP 3_020834001.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",117124.24,"Yes/No","RHP 3_020834001.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",187943.535,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",187943.54,"Numeric",0.38169642799999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",898860.45,"Numeric",0.36160700000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.40178599999999998,90,224,"DY2: Oct 1st, 2012 - Sept 30th, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.38169642799999998,null,0.36160700000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator was determined by reviewing XLS-based data that indicated that the number of unique patients had dental caries during the baseline period.  The denominator was determined by reviewing paper records that indicated the number of unique patients (ages 5-19 and Medicaid/Unisured) that had seen a dental provider.","40.19% of unique patients aged 5-19 with Medicaid/Uninsured or Indigent received dental services and had untreated dental caries during stated baseline period.","Cavities: Children","ambulatory",null,"Number of children with untreated dental caries","Total number of children that have seen a dental provider within the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1 ","","Cavities: Children",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 3_020834001.1.1","RHP 3_020834001.3.1","RHP 3_020834001.1.1_020834001.3.1",{"$f":"COUNTIFS($FI$4:$FI1066,FI1066)","v":1},"RHP 3_020834001.1.1_1",null,2,1,1,"RHP 3_020834001",{"$f":"COUNTIFS($FR$4:$FR1066,FR1066)","v":1},"RHP 3_020834001_1"]
["RHP 3","020993401","Bayside Community Hospital","020993401.1.100","020993401.3.100","IT-1.10","Diabetes care: HbA1c poor control (>9.0%) ","Baseline not yet reported","Eligible to Report in October DY4","Chambers County Public Hospital District proposes to provide additional primary care services for the growing population in West Chambers County as well as operate a new clinic in the heart of Winnie, Texas, which will accept all payer types and which will provide full primary care services in cooperation with Bayside Community Hospital and other local providers in the greater surrounding area.  This new clinic will allow residents local access to quality primary health care services.","Diabetes care: HbA1c poor control (>9.0%) ",0,null,null,"P4P","","PM-8","Submission of Category 3 DY3 Status Report",100000,"Yes/No","RHP 3_020993401.3.100_PM-8","Not Approved","PM-9","Validation and submission of baseline performance",100000,"Yes/No","RHP 3_020993401.3.100_PM-9","Not Approved","PM-10","Successful reporting to approved measure specifications",290750,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",290750,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",773080,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"","","","Diabetes care: HbA1c poor control (>9.0%) ","ambulatory",null,"Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1",null,"Diabetes care: HbA1c poor control (>9.0%) ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 3_020993401.1.100","RHP 3_020993401.3.100","RHP 3_020993401.1.100_020993401.3.100",{"$f":"COUNTIFS($FI$4:$FI1074,FI1074)","v":1},"RHP 3_020993401.1.100_1",null,2,1,1,"RHP 3_020993401",{"$f":"COUNTIFS($FR$4:$FR1074,FR1074)","v":1},"RHP 3_020993401_1"]
["RHP 3","082006001","Baylor College of Medicine","082006001.1.1","082006001.3.2","IT-8.9","Youth Pregnancy Rate ","Baseline Approved","Eligible to Report in October DY4","This project will expand the Baylor Teen Health Clinic service area by opening a new clinic at the Tejano Center for Community Concerns. The clinic will provide access to age-appropriate, comprehensive primary care services for 4,000 patients by DY5.","Youth Pregnancy Rate ","In DY4 and DY5 provider will report on the youth pregnancy rate (sum of births, abortions and miscarriages for women aged 15-19 when the pregnancy ended).  In addition, in DY5 provider will demonstrate improvement by doing a stretch activity SA3- Alternative Approaches to Program and Outcome Linkages.",null,null,"P4R","SA3","PM-8","Submission of Category 3 DY3 Status Report",10666.665000000001,"Yes/No","RHP 3_082006001.3.2_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",10666.665000000001,"Yes/No","RHP 3_082006001.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",34333.33,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",24833.334999999999,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",24833.334999999999,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"per 1K",75.268817204301072,7,93,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"A chart review was conducted of the paper medical records for all patients.  Included within the medical record is a patient encounter/flow sheet for each date of service.  The encounter/flow sheet lists the services provided to each patient at each visit, including the results of any urine pregnancy test (UPT) that was taken.   Based on this medical record data each patient was listed in an excel spreadsheet by chart number, date of birth, age and gender.  A column was inserted within the excel spreadsheet to list the date of service that each individual patient had a pregnancy outcome (positive pregnancy test results from a UPT).  The results of the UPT are also charted in the medical record in the progress notes by the medical provider and the social worker who follows up with the patient to determine if any additional support is needed.  The denominator was determined by highlighting all the rows and columns with the spreadsheet and performing a data sort to arrange the patients by age and gender.   After the patients were sorted by age, female patients between the ages of 15-19 where counted to arrive at the denominator total.  The numerator population was identified by counting all patients within the subset of the female patients between the ages of 15-19 that had a date of service listed in the column for pregnancy outcome within the excel spreadsheet.  ","A less than 10% pregnancy rate is not reflective of the East End community in which the school is located. Documented early sexual activity and high fertility among Latino youth, has led to targeted community efforts at preventing teen pregnancy and educating adolescents in this East End community. Greater efforts will be made to increase student access to the clinic and awareness of services offered,  to include pregnancy testing and referral for prenatal service. Advertising for the clinic should increase. A number of good opportunities for this will be the annual Open House and Health Fair, and fliers posted throughout the school and virtual bulletins that are presented to students during their lunch hour.  A robocall message via the school system to parents will be investigated.  New student enrollment at registration will be facilitated by including school clinic information/consent forms in the school packet sent out in the summer. Clinic staff will also continue to have a table at the school health fair in October to introduce families to the Baylor Teen Health Clinic.  We will continue to offer clinic tours to increase awareness of services offered to students.  However, it should be noted that the less than 10% pregnancy rate can be a direct reflection of the efforts of this community based charter school, which emphasizes family goals, parental involvement and preparing students for post-secondary education. ","Youth Pregnancy Rate ","Multiple",null,"Sum of births, abortions and miscarriages for women aged 15-19 when the pregnancy ended x 1000*.  ","All females  aged 15-19",null,null,null,null,null,null,null,null,null,null,"We are currently reviewing options for stretch activities and are discussing which options may be the best fit for the Baylor Teen Health Clinic.",null,null,"1.1.1 ","","Youth Pregnancy Rate ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 3_082006001.1.1","RHP 3_082006001.3.2","RHP 3_082006001.1.1_082006001.3.2",{"$f":"COUNTIFS($FI$4:$FI1082,FI1082)","v":2},"RHP 3_082006001.1.1_2",null,2,1,1,"RHP 3_082006001",{"$f":"COUNTIFS($FR$4:$FR1082,FR1082)","v":2},"RHP 3_082006001_2"]
["RHP 3","093774008","City of Houston Department of HHS","093774008.1.4","093774008.3.10","IT-9.1","Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons","Baseline Approved","Eligible to Report in October DY4","The new Sobering Center initiative provides a short term facility where individuals arrested for being under the influence of alcohol or other substances need a facility where they are under medical supervision but not utilizing valuable health care resources at other settings such as hospitals admissions or the ER.  \n","Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons","In DY4 and DY5, the provider will decrease the rate of admissions and readmissions to the criminal justice setting among individuals who receive program intervention. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",102000.21,"Yes/No","RHP 3_093774008.3.10_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",102000.21,"Yes/No","RHP 3_093774008.3.10_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",108058.06,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",108058.06,"Numeric",8.5074627E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",465014.35,"Numeric",8.0597014999999994E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",8.9552000000000007E-2,6,67,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,8.5074627E-2,null,8.0597014999999994E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator is the number of PART participants that have a behavioral health diagnosis AND history of criminal justice involvement at enrollment in PART. The numberator is the number of individuals in PART with history of behavioral health diagnosis and criminal justice history that had a potenially preventable admission/readmission to the criminal justice setting. ","In DY3, the percentage of  individuals within the intervention population whith a preventable admission/readmission into the crimal justice setting is 8.96%. ","Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons","ambulatory",null,"The number of individuals receiving project intervention(s) who had a potentially preventable admission/readmission to a criminal justice setting (e.g. jail, prison, etc.) within the measurement period.","Number of individuals receiving project intervention(s)",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.13.1","","Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 3_093774008.1.4","RHP 3_093774008.3.10","RHP 3_093774008.1.4_093774008.3.10",{"$f":"COUNTIFS($FI$4:$FI1088,FI1088)","v":1},"RHP 3_093774008.1.4_1",null,2,1,1,"RHP 3_093774008",{"$f":"COUNTIFS($FR$4:$FR1088,FR1088)","v":5},"RHP 3_093774008_5"]
["RHP 3","093774008","City of Houston Department of HHS","093774008.2.101","093774008.3.504","IT-12.6","Influenza Immunization -- Ambulatory","Baseline Approved","Eligible to Report in October DY4","Implement the CNRP- Integrated Health Services Project to provide care management services that integrate primary and behavioral health needs of released ex-offenders, parolees and probationers in Houston, Harris County","Influenza Immunization -- Ambulatory","In DY4 and DY5 provider will increase the percentage of patients aged 6 months and older seen for a visit between October 1 and March 31st who received an influenza immunization OR patient reported previous receipt of an influenza immunization",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",0,"Yes/No","RHP 3_093774008.3.504_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",27519.283333333336,"Yes/No","RHP 3_093774008.3.504_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",29153.67,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",29153.67,"Numeric",0.42795698900000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",125459.17,"Numeric",0.458065,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.39784900000000001,37,93,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.42795698900000001,null,0.458065,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator is number of patients who were enrolled in ReEntry during 06/30/14 to 09/30/14. Numerator is number of patients who received an influenza immunization between 10/01/13 to 03/31/14 or who reported previous receipt of influenza immunization between 08/01/13 and 03/31/14.","39.78% patients received an influenza immunization or reported previous receipt of influenza immunization in DY3. ","Influenza Immunization -- Ambulatory","ambulatory",null,"Patients who received an influenza immunization OR who reported previous receipt* of influenza immunization","All patients aged 6 months and older seen for a visit between October 1 and March 31.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.19.1","","Influenza Immunization -- Ambulatory",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 3_093774008.2.101","RHP 3_093774008.3.504","RHP 3_093774008.2.101_093774008.3.504",{"$f":"COUNTIFS($FI$4:$FI1096,FI1096)","v":2},"RHP 3_093774008.2.101_2",null,2,1,1,"RHP 3_093774008",{"$f":"COUNTIFS($FR$4:$FR1096,FR1096)","v":13},"RHP 3_093774008_13"]
["RHP 3","093774008","City of Houston Department of HHS","093774008.2.8","093774008.3.14","IT-10.1.b.iii","RAND Short Form 36[1] (SF-36) Health Survey","Baseline Approved","Eligible to Report in October DY4","This project will implement its comprehensive five step intervention for the homeless involving 1) permanent housing supportive model  2) program service linkages 3) physical and behavioral health needs 4) financial support 5) other services.   \n","RAND Short Form 36[1] (SF-36) Health Survey","In DY4 and DY5, the provider will improve reported scores on the SF-36 scores among all homeless individuals who receive the comprehensive service integration intervention. ","Facility ","All homeless individuals enrolled in the program locations","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",145189.92499999999,"Yes/No","RHP 3_093774008.3.14_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",72594.962499999994,"Yes/No","RHP 3_093774008.3.14_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",51270.945,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",51270.95,"Numeric",45.207792210000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",220638.11,"Numeric",50.207792210000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",40.207790000000003,6192,154,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,45.207792210000001,null,50.207792210000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"All clients (154) completed the SF36 during the enrollment process (denominator). The individual composite scores were calculated by program staff according to survey guidelines. The sum of all composite scores was calculated to achieve the numerator. ","The average socre of the RAND short form in DY3 for the targeted population is 40.21.","RAND Short Form 36[1] (SF-36) Health Survey","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.13.1","Scenario 2: Pre Test Only Baseline","RAND Short Form 36[1] (SF-36) Health Survey",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 3_093774008.2.8","RHP 3_093774008.3.14","RHP 3_093774008.2.8_093774008.3.14",{"$f":"COUNTIFS($FI$4:$FI1107,FI1107)","v":1},"RHP 3_093774008.2.8_1",null,2,1,1,"RHP 3_093774008",{"$f":"COUNTIFS($FR$4:$FR1107,FR1107)","v":24},"RHP 3_093774008_24"]
["RHP 3","093774008","City of Houston Department of HHS","093774008.2.9","093774008.3.200","IT-12.3","Colorectal Cancer Screening ","Baseline not yet reported","Eligible to Report in October DY4","Colorectal cancer (CRC) integrated awareness and screening (COCAS) project are to provide CRC FIT screening for 315 new individuals in DY4 and 330 new individuals in DY5. \n","Colorectal Cancer Screening ","In DY4 and DY5 provider will improve the percentage of patients 50–75 years of age who had appropriate screening for colorectal cancer",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",33181.595000000001,"Yes/No","RHP 3_093774008.3.200_PM-8","Metric Carried Forward in October DY3","PM-9","Validation and submission of baseline performance",33181.595000000001,"Yes/No","RHP 3_093774008.3.200_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",35152.269999999997,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",35152.269999999997,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",151273.4,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Colorectal Cancer Screening ","ambulatory",null,"One or more screenings for colorectal cancer. Any of the following meet the criteria: \n\n• Fecal occult blood test (FOBT) during the measurement year. For administrative data, assume the required number of samples were returned regardless of FOBT type.\n• Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year.\n• Colonoscopy during the measurement year or the nine years prior to the measurement year.\n","Patients 51–75 years of age as of the end of the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.7.1","","Colorectal Cancer Screening ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 3_093774008.2.9","RHP 3_093774008.3.200","RHP 3_093774008.2.9_093774008.3.200",{"$f":"COUNTIFS($FI$4:$FI1110,FI1110)","v":2},"RHP 3_093774008.2.9_2",null,2,1,1,"RHP 3_093774008",{"$f":"COUNTIFS($FR$4:$FR1110,FR1110)","v":27},"RHP 3_093774008_27"]
["RHP 3","111810101","UT Health Science Center Houston","111810101.1.101","111810101.3.102","IT-12.6","Influenza Immunization -- Ambulatory","Baseline Approved","Eligible to Report in October DY4","This project seeks to establish a prevention and wellness community health center (CHWC) in a low income areas in our region along with the provision of wellness services provided by ACPs. This center will operate using expanded hours that include evening and weekend hours.  The center will be well integrated with existing resources in the community.  Community leaders and stakeholders will be included in identifying gaps and priority services needed, as well as in the planning and implementation of support services ","Influenza Immunization -- Ambulatory","In DY4 and DY5 provider will improve the proportion of patients 6 months and older  receiving services at the  UT Physicians Community Health & Wellness Center located at Sharpstown between October 1st and March 31st that received an influenza immunization during the measurement year.  ","Facility ","UT Physicians Community Health & Wellness Center located at Sharpstown.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",56337.04,"Yes/No","RHP 3_111810101.3.102_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",56337.04,"Yes/No","RHP 3_111810101.3.102_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",58239.004999999997,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",58239.01,"Numeric",0.26746987999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",246483.16,"Numeric",0.30602400000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.22891600000000001,266,1162,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"proxy",0.26746987999999999,null,0.30602400000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Per HHSC, we received approval to establish the DY3 baseline using a proxy dataset since our CHWC is not yet open.  The HHSC approved proxy denominator included all UT Physicians patients who satisfied the following inclusion criteria: 1) aged 6 months and older at the time of their visit between October 1, 2013 and March 31, 2014; 2) had at least one outpatient encounter at any UT Physicians primary care clinic between October 1, 2013 and March 31, 2014.  This accounts for the 123,973 denominator cases.  Per HHSC, the approved subset specified an additional inclusion criterion: 3) race documented as “Asian” in clinical records. With this additional specification in place, the total number of cases in the denominator subset is 1,162.  The numerator for this measure included patients from the denominator subset (n= 1,162) who received an influenza immunization at a UT Physicians clinic between October 1, 2013 and March 31, 2014 or have a record of previous receipt of an influenza immunization between August 1, 2013 and September 30, 2013. The total number of numerator cases is 266.\n\n","Using the HHSC approved proxy, we established a baseline rate of 22.89%  which is low.  Improvement is needed in DY4.  This measure is improvement over self (IOS); therefore we will need to increase the baseline rate by at least 3.85% (i.e., 5%*performance gap) in DY 4.  ","Influenza Immunization -- Ambulatory","ambulatory",null,"Patients who received an influenza immunization OR who reported previous receipt* of influenza immunization","All patients aged 6 months and older seen for a visit between October 1 and March 31.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1","","Influenza Immunization -- Ambulatory",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 3_111810101.1.101","RHP 3_111810101.3.102","RHP 3_111810101.1.101_111810101.3.102",{"$f":"COUNTIFS($FI$4:$FI1122,FI1122)","v":2},"RHP 3_111810101.1.101_2",null,2,1,1,"RHP 3_111810101",{"$f":"COUNTIFS($FR$4:$FR1122,FR1122)","v":9},"RHP 3_111810101_9"]
["RHP 3","111810101","UT Health Science Center Houston","111810101.1.2","111810101.3.4","IT-14.6","Percent of trainees who have spent at least 5 years living in a health‐ professional shortage area (HPSA) or medically underserved area ","Baseline Approved","Eligible to Report in October DY4","This innovative program will train residents in the \"new primary care\" model that is capable of staffing \"enhanced medical homes.\" The training program for health care providers will be updated to lay emphasis on team-based practice, quality and cost control. Faculty staff at UT Health will  be trained to implement the new residency program.","Percent of trainees who have spent at least 5 years living in a health‐ professional shortage area (HPSA) or medically underserved area ","In DY4 and DY5 provider will report the percent of trainees who have spent 5 years living in a HPSA or MUA out of all trainees  In addition, in DY5 provider will complete Stretch Activity #7- Texas HIE Participation. ",null,null,"P4R","SA7","PM-8","Submission of Category 3 DY3 Status Report",28168.52,"Yes/No","RHP 3_111810101.3.4_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",28168.52,"Yes/No","RHP 3_111810101.3.4_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",58239.01,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",61620.789999999986,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",61620.789999999986,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.4,14,35,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator is simply the total number of trainees in the program.  The numerator was determined by asking each survey participant to list every zip code they've lived in throughout their lives, and the amount of time spent living in each of those zip codes.  We then analyzed the results and determined the number of trainees that had spent at least 5 years living in an HPSA or MUA.    ","40% of the trainees in this program have spent at least 5 years living in an HPSA or MUA. ","Percent of trainees who have spent at least 5 years living in a health‐ professional shortage area (HPSA) or medically underserved area ","na",null,"Number of trainees who have spent at least 5 years living in an HPSA or MUA","Total number of trainees ",null,null,null,null,null,null,null,null,null,null,"U.T Physicians is in the initial stage of this project with a signed contract and kickoff meeting(s) complete. The next step involves conducting subgroup meetings with resources from organizational leadership, legal and compliance, information technology, marketing and registration (front-desk). The goal of the subgroup meetings is to determine detailed project tasks, workflow decisions, and prepare updates for monthly leadership meetings.  The detailed project tasks developed from the subgroup meetings will be used to create an overall project plan that will drive the completion of this project. The preliminary plan is to have this health information exchange with GHH in place by the third or fourth quarter of 2015.  U.T. Physicians has contracted with Greater Houston Healthconnect (GHH), which provides a secure network of electronic health records to link all providers in Southeast Texas.  Our participation with GHH will allow authorized providers who are part of the exchange, access to patient medical information.  By implementing our DSRIP projects throughout our community-based clinics and partnering hospitals, we will be setting a stage for where providers can easily access records and important information for true continuity of care.  ",null,null,"1.2.1 ","","Percent of trainees who have spent at least 5 years living in a health‐ professional shortage area (HPSA) or medically underserved area ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 3_111810101.1.2","RHP 3_111810101.3.4","RHP 3_111810101.1.2_111810101.3.4",{"$f":"COUNTIFS($FI$4:$FI1124,FI1124)","v":1},"RHP 3_111810101.1.2_1",null,2,1,1,"RHP 3_111810101",{"$f":"COUNTIFS($FR$4:$FR1124,FR1124)","v":11},"RHP 3_111810101_11"]
["RHP 3","111810101","UT Health Science Center Houston","111810101.1.5","111810101.3.9","IT-1.34","Appropriate Testing for Children With Pharyngitis","Baseline Approved","Eligible to Report in April DY4","implementing a nurse-line medical triage call center that will be staffed 24/7/365.","Appropriate Testing for Children With Pharyngitis","In DY4 and DY5 provider will improve the proportion of all children within the UTP system with a diagnosis of Pharyngitis and receive antibiotics that also receive a group A strep test the three days prior or following the antibiotic initiation date. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",105631.95,"Yes/No","RHP 3_111810101.3.9_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",105631.95,"Yes/No","RHP 3_111810101.3.9_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",109198.14,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",109198.14,"Numeric",0.58499999999999996,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",462155.93,"Numeric",0.61014999999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.483871,60,124,"DY2: Oct 1st, 2012 - Sept 30th, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.58499999999999996,null,0.61014999999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"For the denominator, the following criteria were used for inclusion: Aged at least 2 years of age as of July 1, 2012 and not more than 18 years as of June 30, 2013; Had an outpatient encounter with any UT Physician provider with a diagnosis of pharyngitis; Had a negative medication history (see measure specification document for definition) as of the date of the diagnosis and had an antibiotic dispensed for that episode. Where a patient had more than one episode of pharyngitis, the earliest episode was selected for inclusion. The numerator included patients  from the denominator who had a group A streptococcus (strep) test in the seven-day period from three days prior to the Index Episode Start Date (IESD) through three days after the IESD","The baseline rate shows that 48.39% of children ages 2 to 18 years were diagnosed with pharyngitis, received a Group A streptococcus (strep) test, and were dispensed an antibiotic for that episode.","Appropriate Testing for Children With Pharyngitis","ambulatory",null,"Children from the denominator with a group A streptococcus (strep) test  in the seven-day period from three days prior to the Index Episode Start Date (IESD) through three days after the IESD ","Children 2 years of age as of July 1 of the year prior to the measurement year to 18 years of age as of June 30 of the measurement year, with a Negative Medication History, who had an outpatient or emergency department (ED) visit with only a diagnosis of pharyngitis and a dispensed antibiotic for that episode of care during the Intake Period ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.6.2 ","","Appropriate Testing for Children With Pharyngitis",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 3_111810101.1.5","RHP 3_111810101.3.9","RHP 3_111810101.1.5_111810101.3.9",{"$f":"COUNTIFS($FI$4:$FI1132,FI1132)","v":2},"RHP 3_111810101.1.5_2",null,2,1,1,"RHP 3_111810101",{"$f":"COUNTIFS($FR$4:$FR1132,FR1132)","v":19},"RHP 3_111810101_19"]
["RHP 3","111810101","UT Health Science Center Houston","111810101.2.101","111810101.3.106","IT-15.3","HIV Screening: Patients at High Risk of HIV ","Baseline not yet reported","Eligible to Report in October DY4","The UT medical homes for post-detention adolescents and at-risk youth will provide all medical and psycho-social services for this population. Our innovative program involves facilitating access to the medical home by assisting youths and their guardians in arranging clinic visits, transportation, overcoming language barriers, and other challenges that may interfere with clinic visits. ","HIV Screening: Patients at High Risk of HIV ","In DY4 and DY5 provider will improve the percent of individuals that receive services at UTP Bellaire-Dashwood Clinic and UTPB Pediatric Clinic - TMC that have been diagnosed with an STD, other than HIV, or diagnosed or screened for Hepatitis C that have also received HIV screening. ","Facility ","UTP Bellaire-Dashwood Clinic and UTPB Pediatric Clinic - TMC","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",28168.52,"Yes/No","RHP 3_111810101.3.106_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",28168.52,"Yes/No","RHP 3_111810101.3.106_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",58239.01,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",123241.57999999997,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"dy4","TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"HIV Screening: Patients at High Risk of HIV ","Ambulatory/Inpatient",null,"Patients care included in the numerator if any of the three conditions are met:\n(A) Patients who received HIV counseling, HIV-1 and HIV-2 screening tests, or an HIV-1 screening test 60 days prior to through 60 days after the index date; \n(B) Patients who had a CD4 count and an HIV RNA test 60 days prior through 60 days after the index date; \n(C) Patients who were diagnosed with HIV during the 1-60 days after the index date (exclusive of the index date).\n","Patients who have been screened for or diagnosed with an STD other than HIV and patients who are being diagnosed or screened for Hepatitis C. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.1.2","","HIV Screening: Patients at High Risk of HIV ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 3_111810101.2.101","RHP 3_111810101.3.106","RHP 3_111810101.2.101_111810101.3.106",{"$f":"COUNTIFS($FI$4:$FI1144,FI1144)","v":2},"RHP 3_111810101.2.101_2",null,1,1,0,"RHP 3_111810101",{"$f":"COUNTIFS($FR$4:$FR1144,FR1144)","v":31},"RHP 3_111810101_31"]
["RHP 3","111810101","UT Health Science Center Houston","111810101.2.5","111810101.3.23","IT-1.2","Annual monitoring for patients on persistent medications - ACE/ARBs","Baseline Approved","Eligible to Report in April DY4","implement a technologically driven patient-centered medication therapy management program. Allscripts analytics tool will enable staff to identify patients at high risk for developing complications and co-morbidities, and patients that have not refilled their medications. Patients will also have access to the patient portal, which will have detailed information on all their medications.","Annual monitoring for patients on persistent medications - Angiotensin Converting Enzyme (ACE) inhibitors or Angiotensin Receptor Blockers (ARBs) ","In DY4 and DY5 provider will improve the   percentage of adult patients at the Bellaire, Bayshore, Sienna Village and Cinco Ranch facilities with at least 180 treatment days of ACE/ARB that have at least one potassium and either BUN or creatinine test in the measurement year. ","Facility ","UT Physicians community-based clinics located at Bellaire, Sienna Village, Cinco Ranch and Bayshore.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",84505.56,"Yes/No","RHP 3_111810101.3.23_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",84505.56,"Yes/No","RHP 3_111810101.3.23_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",87358.51,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",87358.51,"Numeric",0.83699999999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",369724.74,"Numeric",0.84460000000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.76081699999999997,3429,4507,"DY2: Oct 1st, 2012 - Sept 30th, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.83699999999999997,null,0.84460000000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator values were determined by using the following criteria for inclusion: aged 18 years or older by the end of DY2 (i.e. September 30, 2013); received at least 180 treatment days of ambulatory angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) during the measurement year;  had an outpatient encounter at any of the four UT Physicians community clinic locations (i.e. Bayshore, Bellaire (Dashwood + Bellaire Multispecialty + Center for Healthy Aging), Cinco, and Sienna) during the measurement year (10/01/2012 - 09/30/2013). The numerator for the measure included patients from the denominator with at least one of the following criteria: had at least one serum potassium and a serum creatinine test in the measurement year; had at least one serum potassium and a blood urea nitrogen test in the measurement year.","The baseline shows that 76.1% of patients 18 years or older that received at least 180 treatment days of angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) in the measurement year and had at least one serum potassium and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test in the measurement year.","Annual monitoring for patients on persistent medications - ACE/ARBs","ambulatory",null,"Patients from the denominator with at least one serum potassium and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test in the measurement year ","Patients 18 years of age and older as of the last day of the measurement year on persistent angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) -- defined as patients who received at least 180 treatment days of ambulatory medication during the measurement year ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.11.1","","ACE/ARB",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 3_111810101.2.5","RHP 3_111810101.3.23","RHP 3_111810101.2.5_111810101.3.23",{"$f":"COUNTIFS($FI$4:$FI1149,FI1149)","v":1},"RHP 3_111810101.2.5_1",null,2,1,1,"RHP 3_111810101",{"$f":"COUNTIFS($FR$4:$FR1149,FR1149)","v":36},"RHP 3_111810101_36"]
["RHP 3","111810101","UT Health Science Center Houston","111810101.2.8","111810101.3.33","IT-10.1.a.v","Pediatric Quality of Life Inventory (PedsQL)","Baseline not yet reported","Eligible to Report in October DY4","UT Health will design, implement and evaluate a project that will integrate primary and behavioral healthcare services for children and adolescents within UT Physicians’ clinics to achieve a close collaboration in a partly integrated system of care (Level IV). A pediatric behavioral health provider will be placed in the primary care setting to children and adolescents with behavioral health services at their usual source of health care. ","Pediatric Quality of Life Inventory (PedsQL)","In DY4 and DY5 provider will improve the reported scores for the PedsQL survey out of all surveys completed during the measurement period at the Bellaire, Bayshore, Sienna Village and Cinco Ranch facilities.","Facility ","UT Physicians community-based clinics located at Bellaire-Dashwood, Sienna Village, Cinco Ranch and Bayshore.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",84505.56,"Yes/No","RHP 3_111810101.3.33_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",84505.56,"Yes/No","RHP 3_111810101.3.33_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",174717.02,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",369724.73999999993,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"dy4","TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Pediatric Quality of Life Inventory (PedsQL)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.15.1","","Pediatric Quality of Life Inventory (PedsQL)",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 3_111810101.2.8","RHP 3_111810101.3.33","RHP 3_111810101.2.8_111810101.3.33",{"$f":"COUNTIFS($FI$4:$FI1154,FI1154)","v":1},"RHP 3_111810101.2.8_1",null,1,1,0,"RHP 3_111810101",{"$f":"COUNTIFS($FR$4:$FR1154,FR1154)","v":41},"RHP 3_111810101_41"]
["RHP 3","113180703","MHMR Authority of Harris County","113180703.1.10","113180703.3.19","IT-6.1.b.ii","CG-CAHPS 12-month: Provider Communication","Pending Approval","Eligible to Report in October DY4","Establish a behavioral health clinic within the Lighthouse facility to provide and array of behavioral health care services and primary care services for individuals with visual impairments. ","CG-CAHPS 12-month: Provider Communication","In DY4 & DY5, the provider improve top box scores for the  CG-CAHPS (provider communication) for all patients receiving services.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",16292.424999999999,"Yes/No","RHP 3_113180703.3.19_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",16292.424999999999,"Yes/No","RHP 3_113180703.3.19_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",18751.080000000002,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",18751.080000000002,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",82729.005249999987,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Per the conpendium, the denominator were the total number of surveys completed from April 1, 2014 to Sept 30, 2014. The numerator was the number of surveys that reported an average score of 3. 00 or higher, indicating \"top-box\". ","Of the 27 patients who received intervention from the Lighthouse from  April 1, 2014 to Sept 30, 2014, 26 reported an a \"top-box\" score on the CAHPS Provider Communication subscale, indicating that most of this sample rated satisfaction with the communication with their clinician the receieved mental health services.  ","CG-CAHPS 12-month: Provider Communication","Ambulatory",null,"Patient-mix and survey mode adjusted percent \"top box\" score for a given subdomain as provided by your survey administrator, multiplied by the number of completed CG-CAHPS surveys represented in the \"top box\" score.","The number of CG-CAHPS surveys completed during the measurement period as reported by your survey administrator. The denominator should be the same as the multiplier used in the numerator.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2 ","","CG-CAHPS 12-month: Provider Communication",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 3_113180703.1.10","RHP 3_113180703.3.19","RHP 3_113180703.1.10_113180703.3.19",{"$f":"COUNTIFS($FI$4:$FI1166,FI1166)","v":1},"RHP 3_113180703.1.10_1",null,2,1,1,"RHP 3_113180703",{"$f":"COUNTIFS($FR$4:$FR1166,FR1166)","v":3},"RHP 3_113180703_3"]
["RHP 3","113180703","MHMR Authority of Harris County","113180703.1.12","113180703.3.40","IT-11.26.d","Children and Adolescent Needs and Strengths Assessment\n(CANS-MH)\n","Baseline Approved","Eligible to Report in October DY4","Increase outpatient capacity to treat an increase number of children, adolescents and their families.","Children and Adolescent Needs and Strengths Assessment\n(CANS-MH)\n","In DY4 and DY5 provider will report the average score on the  CANS-MH for all individuals completing the assessment.  In addition, in DY5 provider will demonstrate improvement by completing Stretch Activity #1- Validation of a P4R measure. ",null,null,"P4R","SA1","PM-8","Submission of Category 3 DY3 Status Report",123822.42,"Yes/No","RHP 3_113180703.3.40_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",123822.42,"Yes/No","RHP 3_113180703.3.40_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",285016.40000000002,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",314370.21994999994,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",314370.21994999994,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",2.1371829999999998,151.74,71,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator Description: Sum of the “overall scores”.\n\nDenominator Description: The total number of assessments administered. \n","The average CANS score for clients in the Children and Adolescent Clinic was 2.14 for this measurement period. The baseline was determined by using 10/01/2013 -09/30/2014 data. ","Children and Adolescent Needs and Strengths Assessment\n(CANS-MH)\n","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,"The stretch activity is validation of the measure. At this time, our plan is to use our own programs to pull ANSA data for validation since this data is collected agency-wide. ",null,null,"1.12.2","Scenario 3: Average Score","Children and Adolescent Needs and Strengths Assessment\n(CANS-MH)\n",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 3_113180703.1.12","RHP 3_113180703.3.40","RHP 3_113180703.1.12_113180703.3.40",{"$f":"COUNTIFS($FI$4:$FI1175,FI1175)","v":2},"RHP 3_113180703.1.12_2",null,2,1,1,"RHP 3_113180703",{"$f":"COUNTIFS($FR$4:$FR1175,FR1175)","v":12},"RHP 3_113180703_12"]
["RHP 3","113180703","MHMR Authority of Harris County","113180703.1.5","113180703.3.25","IT-11.26.c","Adult Needs and Strength Assessment (ANSA)","Baseline Approved","Eligible to Report in October DY4","Expand outpatient behavioral health services for adults","Adult Needs and Strength Assessment (ANSA)","In DY4 and DY5 provider will report the average score on the ANSA for all individuals completing the assessment.   In addition, in DY5 provider will demonstrate improvement by completing Stretch Activity #1- Validation of a P4R measure. ",null,null,"P4R","SA1","PM-8","Submission of Category 3 DY3 Status Report",86186.92,"Yes/No","RHP 3_113180703.3.25_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",86186.92,"Yes/No","RHP 3_113180703.3.25_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",198386.42,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",218818.21888624996,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",218818.21888624996,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",3.0189789999999999,8721.83,2889,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator Description: The sum of the “overall scores”.\n\nDenominator Description: The total number of assessments administered during the measurement period. \n","The average ANSA score for clients in the Southwest clinic is 3.02 for this measurement period.  The baseline was determined using 10.01.2013- 09.30.2014 data.","Adult Needs and Strength Assessment (ANSA)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,"The stretch activity is validation of the measure. At this time, our plan is to use our own programs to pull ANSA data for validation since this data is collected agency-wide. ",null,null,"1.12.2","Scenario 3: Average Score","Adult Needs and Strength Assessment (ANSA)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 3_113180703.1.5","RHP 3_113180703.3.25","RHP 3_113180703.1.5_113180703.3.25",{"$f":"COUNTIFS($FI$4:$FI1180,FI1180)","v":1},"RHP 3_113180703.1.5_1",null,2,1,1,"RHP 3_113180703",{"$f":"COUNTIFS($FR$4:$FR1180,FR1180)","v":17},"RHP 3_113180703_17"]
["RHP 3","113180703","MHMR Authority of Harris County","113180703.1.6","113180703.3.6","IT-11.26.e.i","Patient Health Questionnaire 9 (PHQ-9)","Baseline Approved","Eligible to Report in October DY4","Expand outpatient behavioral health services for adults","Patient Health Questionnaire 9 (PHQ-9)","In DY4 and DY5 provider will improve reported scores on the PHQ-9 out of all instruments administered during the measurement period to patients with a diagnosis of depression. ","Comorbid Condition ","Patients with depression","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",86186.92,"Yes/No","RHP 3_113180703.3.6_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",86186.92,"Yes/No","RHP 3_113180703.3.6_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",99193.21,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",99193.21,"Numeric",12.428000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",437636.44,"Numeric",12.336,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",12.52,701.12,56,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,12.428000000000001,null,12.336,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Per the compendium, the numerator is the sum of the overall scores. The denominator is the total number of assessments given.","The average PHQ post-test score in a Depressive Disorder subset during DY3 (October 1, 2013-September 30, 2014) is 12.52.","Patient Health Questionnaire 9 (PHQ-9)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.12.2","Scenario 1: Pre/Posttest Baseline","Patient Health Questionnaire 9 (PHQ-9)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 3_113180703.1.6","RHP 3_113180703.3.6","RHP 3_113180703.1.6_113180703.3.6",{"$f":"COUNTIFS($FI$4:$FI1183,FI1183)","v":2},"RHP 3_113180703.1.6_2",null,2,1,1,"RHP 3_113180703",{"$f":"COUNTIFS($FR$4:$FR1183,FR1183)","v":20},"RHP 3_113180703_20"]
["RHP 3","113180703","MHMR Authority of Harris County","113180703.2.102","113180703.3.107","IT-11.25","Daily Living Activities (DLA-20)","Baseline Approved","Eligible to Report in October DY4","CTI is a nine-month case management model emphasizing developing community linkages and enhancing treatment engagement for mentally ill individuals undergoing transition.  ","Daily Living Activities (DLA-20)","In DY4 and DY5 provider will report the average score on the DLA-20 for all individuals completing the assessment.   In addition, in DY5 provider will demonstrate improvement by completing Stretch Activity #1- Validation of a P4R measure. ",null,null,"P4R","SA1","PM-8","Submission of Category 3 DY3 Status Report",35517.485000000001,"Yes/No","RHP 3_113180703.3.107_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",35517.485000000001,"Yes/No","RHP 3_113180703.3.107_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",81754.710000000006,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",90174.615722499977,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",90174.615722499977,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",4.9800000000000004,149.4,30,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator = sum of total scores for all survery participants. These total scores are the average score across the 20 scale items.  Denominator is number of completed scales.","Surprisingly high rate.  Score of 4.98 is just into the clinical range (not within niormal limits).","Daily Living Activities (DLA-20)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,"The stretch activity is validation of the measure. At this time, our plan is to use our own programs to pull DLA-20 data for validation since this data is collected agency-wide. ",null,null,"2.13.1","Scenario 3: Average Score","Daily Living Activities (DLA-20)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 3_113180703.2.102","RHP 3_113180703.3.107","RHP 3_113180703.2.102_113180703.3.107",{"$f":"COUNTIFS($FI$4:$FI1197,FI1197)","v":2},"RHP 3_113180703.2.102_2",null,2,1,1,"RHP 3_113180703",{"$f":"COUNTIFS($FR$4:$FR1197,FR1197)","v":34},"RHP 3_113180703_34"]
["RHP 3","113180703","MHMR Authority of Harris County","113180703.2.104","113180703.3.204","IT-8.24","Adolescent Well-Care Visits (AWC)","Baseline not yet reported","Eligible to Report in October DY4","Treatment planning for children and youth with multi-agency systems involvement utilizing an HIE system for tracking.","Adolescent Well-Care Visits (AWC)","In DY4 & DY5 provider will improve on the number of adolescents (ages 12-21) who received at least one PCP and/or OBGYN visit with a practitioner during the measurement year over all youth 12-21 years old receive this service.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",21723.233333333334,"Yes/No","RHP 3_113180703.3.204_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",21723.233333333334,"Yes/No","RHP 3_113180703.3.204_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",50002.880000000005,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",110305.34033333331,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"DY4","TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Adolescent Well-Care Visits (AWC)","ambulatory",null,"At least one comprehensive well-care visit with a primary care practitioner (PCP) or an obstetrics and gynecology (OB/GYN) practitioner during the measurement year.","Patients age 12 to 21 years as of the end of the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.13.1","","Adolescent Well-Care Visits (AWC)",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 3_113180703.2.104","RHP 3_113180703.3.204","RHP 3_113180703.2.104_113180703.3.204",{"$f":"COUNTIFS($FI$4:$FI1202,FI1202)","v":3},"RHP 3_113180703.2.104_3",null,1,1,0,"RHP 3_113180703",{"$f":"COUNTIFS($FR$4:$FR1202,FR1202)","v":39},"RHP 3_113180703_39"]
["RHP 3","113180703","MHMR Authority of Harris County","113180703.2.3","113180703.3.32","IT-11.25","Daily Living Activities (DLA-20)","Baseline Approved","Eligible to Report in October DY4","Care transition services for adults being discharged from Harris County Psychiatric Center.","Daily Living Activities (DLA-20)","In DY4 and DY5 provider will report the average score on the DLA-20 for all individuals completing the assessment.   In addition, in DY5 provider will demonstrate improvement by completing Stretch Activity #1- Validation of a P4R measure. ",null,null,"P4R","SA1","PM-8","Submission of Category 3 DY3 Status Report",32584.85,"Yes/No","RHP 3_113180703.3.32_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",32584.85,"Yes/No","RHP 3_113180703.3.32_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",75004.320000000007,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",82729.005249999987,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",82729.005249999987,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",3.0089290000000002,674,224,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Per the compendium, the numerator is described as the sum of the “average DLA score” of all DLA-20 questionnaires completed during the measurement period. The denominator is described as the total number of DLA-20 questionnaires completed during the measurement period. ","DLA-20 questionnaires were collected between April 1, 2014 and September 30, 2014. We chose Scenario 3 for reporting due to the inability to complete post-testing with this population. The average DLA score is 3.01. ","Daily Living Activities (DLA-20)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,"The stretch activity is validation of the measure. At this time, our plan is to use our own programs to pull DLA-20 data for validation since this data is collected agency-wide. ",null,null,"2.17.1","Scenario 3: Average Score","Daily Living Activities (DLA-20)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 3_113180703.2.3","RHP 3_113180703.3.32","RHP 3_113180703.2.3_113180703.3.32",{"$f":"COUNTIFS($FI$4:$FI1208,FI1208)","v":2},"RHP 3_113180703.2.3_2",null,2,1,1,"RHP 3_113180703",{"$f":"COUNTIFS($FR$4:$FR1208,FR1208)","v":45},"RHP 3_113180703_45"]
["RHP 3","113180703","MHMR Authority of Harris County","113180703.2.9","113180703.3.17","IT-3.14","Behavioral Health /Substance Abuse 30-day Readmission Rate ","Pending Approval","Eligible to Report in October DY4","Inpatient Consultation and Liaison (C&L) team that provides consultation and services to patients suspected of Intellectual and Developmental Disabilities and Autism Spectrum Disorders (IDD and ASD)","Behavioral Health /Substance Abuse 30-day Readmission Rate ","For DY4 & DY5 the provider will report the number of individuals in the target population who were readmitted to an inpatient psychiatric facility out of all  adult individuals readmitted for any reason within 30-days of discharge (unplanned).   In addition, in DY5 provider will demonstrate improvement by completing Stretch Activity #1- Validation of a P4R measure. ",null,null,"P4R","SA1","PM-8","Submission of Category 3 DY3 Status Report",46759.254999999997,"Yes/No","RHP 3_113180703.3.17_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",46759.254999999997,"Yes/No","RHP 3_113180703.3.17_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",107631.2,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",118716.12253374998,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",118716.12253374998,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator: Total number of hospital stays for BH/SA during the measurement year for patients 18 years of age and older.\n\n\nNumerator: Total number of admissions (index stay) with at least one subsequent readmission (hospital stay) for any reason within 30 days during the measurement year\n","Data was avaliable for 122 individuals.  13 has hospitalization stays during the reporting period.  ","Behavioral Health /Substance Abuse 30-day Readmission Rate ","inpatient",null,"Total number of admissions (index stay) with at least one subsequent readmission (hospital stay) for any reason within 30 days during the measurement year","Total number of hospital stays for BH/SA during the measurement year for patients 18 years of age and older.",null,null,null,null,null,null,null,null,null,null,"We plan on creating norms for this population through internal and external collaborations among providers serving the same population. ",null,null,"2.17.1","","Behavioral Health /Substance Abuse 30-day Readmission Rate ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 3_113180703.2.9","RHP 3_113180703.3.17","RHP 3_113180703.2.9_113180703.3.17",{"$f":"COUNTIFS($FI$4:$FI1216,FI1216)","v":1},"RHP 3_113180703.2.9_1",null,2,1,1,"RHP 3_113180703",{"$f":"COUNTIFS($FR$4:$FR1216,FR1216)","v":53},"RHP 3_113180703_53"]
["RHP 3","127303903","OakBend Medical Center","127303903.2.100","127303903.3.101","IT-3.22","Risk Adjusted All-Cause Readmission","Baseline not yet reported","Eligible to Report in October DY4","OBMC will educate and train patients and staff on the health benefits of medication management, as well implement evidence-based strategies to enhance the quality of life and the appropriate management. In furtherance of this goal, OBMC will partner with Fort Bend Family Health Center (FBFHC) and OakBend medical group physicians to educate their staff and the community on the importance of medication management, and to assist patients in managing their chronic conditions. ","Risk Adjusted All-Cause Readmission","In DY4 and DY5 provider will improve the ratio of observed to expected readmissions within 30 days from discharge from an index admission at OakBend's hospital facilities for any cause","Facility ","Patient population receiving services at OakBend's hospital facilities","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",38419.35,"Yes/No","RHP 3_127303903.3.101_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",42419.3400000045,"Yes/No","RHP 3_127303903.3.101_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",58738.526156249391,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",58738.526156249391,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",250427.2204724981,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Risk Adjusted All-Cause Readmission","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk admissions during the measurement period.","Expected (risk-adjusted) rate of readmissions for all-causes during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.11.1","","Risk Adjusted All-Cause Readmission",null,null,null,null,"Risk adjustment method not yet reported",null,null,null,null,"","",null,null,"RHP 3_127303903.2.100","RHP 3_127303903.3.101","RHP 3_127303903.2.100_127303903.3.101",{"$f":"COUNTIFS($FI$4:$FI1224,FI1224)","v":1},"RHP 3_127303903.2.100_1",null,2,1,1,"RHP 3_127303903",{"$f":"COUNTIFS($FR$4:$FR1224,FR1224)","v":5},"RHP 3_127303903_5"]
["RHP 3","130959304","Matagorda Regional Medical Center","130959304.2.1","130959304.3.2","IT-9.2","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","Baseline not yet reported","Eligible to Report in October DY4","Expand patient navigation and education for high ED utilizers","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","In DY4 and DY5 provider will decrease the percent of (ED) utilization for ACSC relative to all ED admissions",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",23824.2,"Yes/No","RHP 3_130959304.3.2_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",23824.2,"Yes/No","RHP 3_130959304.3.2_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",38523.699999999997,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",38523.699999999997,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",183924.4,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","ED",null,"Total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1 ","","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 3_130959304.2.1","RHP 3_130959304.3.2","RHP 3_130959304.2.1_130959304.3.2",{"$f":"COUNTIFS($FI$4:$FI1233,FI1233)","v":1},"RHP 3_130959304.2.1_1",null,2,1,1,"RHP 3_130959304",{"$f":"COUNTIFS($FR$4:$FR1233,FR1233)","v":5},"RHP 3_130959304_5"]
["RHP 3","133355104","Ben Taub Hospital","133355104.1.1","133355104.3.1","IT-1.13","Diabetes care:  Foot exam ","Baseline Approved","Eligible to Report in October DY4","Harris Health System proposes to expand the capacity of primary care by establishing an adult-focused primary care same day access clinic near the Gulfgate Health Center that offers same day visits during extended hours to meet demand that saturated existing Harris Health System health centers cannot meet. \n","Diabetes care:  Foot exam ","In DY4 and DY5 provider will improve the percent of adult patients with diabetes receiving services at the GulfGate Same day clinic that receive a diabetic foot exam. ","Facility ","Diabetic patients for Gulfgate Same Day site (outpatient facility)","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",173922.33733333339,"Yes/No","RHP 3_133355104.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",175530.73165066668,"Yes/No","RHP 3_133355104.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",280998.29499999998,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",280998.3,"Numeric",0.76089887700000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1341273.82,"Numeric",0.77348300000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.74831499999999995,333,445,"5/19/14 - 9/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"short",0.76089887700000003,null,0.77348300000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Data specifications were submitted for report creation in accordance with specific guidelines from HHSC/CMS Category 3 Planning Protocol. These specifications and reports were reviewed and approved by all relevant stakeholders. Epic queries for specific ICD9 diagnosis codes used for patients with diabetes at project site only for denominator. CPT code 2028F used for numerator to capture patients receiving foot exam at specific project site. Exclude patients with a diagnosis of polycystic ovaries (ICD9 code 256.4) during the measurement year and prior or gestational or steroid-induced diabetes (ICD9 codes 249, 251.8, 962.0, 648.8) during the measurement year or prior measurement year. Data fields captured include: MRN, Age, Foot exam at Visit, Contact Date, Department.","74.83% of diabetic patients seen at Gulfgate Same Day clinic received a diabetic foot exam. ","Diabetes care:  Foot exam ","ambulatory",null,"Patients who received a comprehensive foot exam (visual inspection with either a sensory exam or a pulse exam) during the measurement year","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1 ","","Diabetes care:  Foot exam ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-05-19","2014-09-30",null,null,"RHP 3_133355104.1.1","RHP 3_133355104.3.1","RHP 3_133355104.1.1_133355104.3.1",{"$f":"COUNTIFS($FI$4:$FI1238,FI1238)","v":1},"RHP 3_133355104.1.1_1",null,2,1,1,"RHP 3_133355104",{"$f":"COUNTIFS($FR$4:$FR1238,FR1238)","v":1},"RHP 3_133355104_1"]
["RHP 3","133355104","Ben Taub Hospital","133355104.1.14","133355104.3.39","IT-12.4","Pneumonia vaccination status for older adults ","Baseline Approved","Eligible to Report in October DY4","This project will expand the capacity of primary care by establishing an adult-focused primary care clinic near the current Casa de Amigos Health Center that offers same day visits during extended hours to meet demand that saturated existing Harris Health System health centers cannot meet. \n","Pneumonia vaccination status for older adults ","In DY4 and DY5 provider will improve the percent of individuals 65 years and older and receive services at the Same Day clinics who have ever received a pneumococcal vaccine.","Facility ","All same day clinics","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",173922.33733333339,"Yes/No","RHP 3_133355104.3.39_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",175530.73165066668,"Yes/No","RHP 3_133355104.3.39_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",280998.29597400007,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",280998.29597400007,"Numeric",0.91258289999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1341273.8197079999,"Numeric",0.91718379999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.90798199999999996,819,902,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"short",0.91258289999999997,null,0.91718379999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Harris Health requests to change the denominator subset for this measure. We would like to denominator subset to be change from  site specific to all Same Day Clinics. This subset will be the same used for all Same Day Clinic projects (1.1, 1.2, 1.14, 1.6)","Data specifications were submitted for report creation in accordance with specific guidelines from HHSC/CMS Category 3 Planning Protocol. In creating report specifications for this measure, we referred to the GPRO PREV-8 (NQF 0043): Pneumonia Vaccination Status for Older Adults/2014 GPRO Preventive Care Measure Narrative Measure Specifications found in the measure steward section of the compendium specific to IT-12.4. Denominator includes patients 65 years of age and older with a visit during the measurement period. Numerator includes those patients who ever received a pneumococcal vaccination, including those that received one the day of their visit. These specifications and reports were reviewed and approved by all relevant stakeholders. Epic queries used for specific codes used for patients 65 years and older  that received pneumococcal vaccine or self-reported as documented in immunization. Specific to project site(s). ","90.80 % of patients 65 years of age and older seen across all Same Day Clinics  have ever received a pneumococcal vaccine.","Pneumonia vaccination status for older adults ","Ambulatory/Inpatient",null,"The number of patients in the denominator who responded “Yes” to the question “Have you ever had a pneumonia shot? This shot is usually given only once or twice in the person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.”","The number of patients who responded “Yes” or “No” to the question “Have you ever had a pneumonia shot? This shot is usually given only once or twice in a person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.” ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1 ","","Pneumonia vaccination status for older adults ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 3_133355104.1.14","RHP 3_133355104.3.39","RHP 3_133355104.1.14_133355104.3.39",{"$f":"COUNTIFS($FI$4:$FI1246,FI1246)","v":2},"RHP 3_133355104.1.14_2",null,2,1,1,"RHP 3_133355104",{"$f":"COUNTIFS($FR$4:$FR1246,FR1246)","v":9},"RHP 3_133355104_9"]
["RHP 3","133355104","Ben Taub Hospital","133355104.1.17","133355104.3.32","IT-7.6","Percentage of children with urgent dental care needs","Baseline Approved","Eligible to Report in October DY4","This project will address the growing need for pediatric oral health services by implementing these services across three facilities within our system. \n","Urgent Dental Care Needs in Children: Percentage of children with urgent dental care needs","In DY4 and DY5 provider will reduce the number of children with urgent dental care needs out of the total number of children receiving dental care services.  ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",105356.80050000004,"Yes/No","RHP 3_133355104.3.32_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",108197.85276799998,"Yes/No","RHP 3_133355104.3.32_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",171721.18,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",171721.18,"Numeric",2.6508759999999999E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",819667.33,"Numeric",2.5114000000000001E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",2.7904000000000002E-2,43,1541,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,2.6508759999999999E-2,null,2.5114000000000001E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Data specifications were submitted for report creation in accordance with specific guidelines from HHSC/CMS Category 3 Planning Protocol.  These specifications and reports were reviewed and approved by all relevant stakeholders. Specific queries from EPIC for count of MRN/children less than 18 at time of service accessing urgent dental services defined by having the following urgent visit charge  11300160  ECHG DENT EMERGENCY EVALUATION-PROBLEM FOCUSED. All pediatric dental sites included. Data fields captured include: MRN, Age, Location, Department.","2.79% of pediatric dental patients at Harris Health System were seen for urgent dental care needs. ","Percentage of children with urgent dental care needs","ambulatory",null,"Number of children with urgent dental care needs","Total number of children seen by a dental provider",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.8.6 ","","Percentage of children with urgent dental care needs",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 3_133355104.1.17","RHP 3_133355104.3.32","RHP 3_133355104.1.17_133355104.3.32",{"$f":"COUNTIFS($FI$4:$FI1250,FI1250)","v":2},"RHP 3_133355104.1.17_2",null,2,1,1,"RHP 3_133355104",{"$f":"COUNTIFS($FR$4:$FR1250,FR1250)","v":13},"RHP 3_133355104_13"]
["RHP 3","133355104","Ben Taub Hospital","133355104.1.8","133355104.3.10","IT-1.10","Diabetes care: HbA1c poor control (>9.0%) ","Baseline Approved","Eligible to Report in October DY4","Harris Health System proposes to develop a seamless referral process by which Harris Health can refer primary care patients to FQHCs, as necessary. The additional providers will result in an additional 24,500 visits by DY5. \n","Diabetes care: HbA1c poor control (>9.0%) ","In DY4 and DY5 provider will reduce the percentage of diabetic patients where the most recent HbA1c value is greater than 9 or not tested during the measurement period  out of all diabetics receiving services at Harris Health System ambulatory care services/outpatient services diabetes patients. Sites: Acres, Aldine, Baytown, Casa, El Franco Lee, Gulfgate, MLK, Northwest, Quentin Mease – Medicine Clinic, Settegast, Squatty Lyons, Strawberry, Vallbona","Facility ","Harris Health System ambulatory care services/outpatient services diabetes patients. Sites: Acres, Aldine, Baytown, Casa, El Franco Lee, Gulfgate, MLK, Northwest, Quentin Mease – Medicine Clinic, Settegast, Squatty Lyons, Strawberry, Vallbona\n","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",421427.20200000016,"Yes/No","RHP 3_133355104.3.10_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",432791.41107199993,"Yes/No","RHP 3_133355104.3.10_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",686884.72349200002,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",686884.72349200002,"Numeric",0.24987699999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",3278669.3370639998,"Numeric",0.23672499999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.26302799999999998,7157,27210,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.24987699999999999,null,0.23672499999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Data specifications were submitted for report creation in accordance with specific guidelines from HHSC/CMS Category 3 Planning Protocol. These specifications and reports were reviewed and approved by all relevant stakeholders. Specific ICD9 diagnosis codes used for patients with diabetes, completed 2 primary care visits, and have HbA1C of 9.0% or greater, missing a result, or no HbA1C test during measurement year at specific project site(s) only. Location defined by location of last visit. ","26.30% of patients age 18-75 with diabetes seen at Harris Health System ambulatory care services health clinics (from denominator subset) had an HbA1C greater than 9.0%","Diabetes care: HbA1c poor control (>9.0%) ","ambulatory",null,"Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","Diabetes care: HbA1c poor control (>9.0%) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 3_133355104.1.8","RHP 3_133355104.3.10","RHP 3_133355104.1.8_133355104.3.10",{"$f":"COUNTIFS($FI$4:$FI1260,FI1260)","v":1},"RHP 3_133355104.1.8_1",null,2,1,1,"RHP 3_133355104",{"$f":"COUNTIFS($FR$4:$FR1260,FR1260)","v":23},"RHP 3_133355104_23"]
["RHP 3","133355104","Ben Taub Hospital","133355104.2.5","133355104.3.25","IT-1.25","Adult tobacco use ","Baseline Approved","Eligible to Report in October DY4","This project will expand point-of-care services provided by clinical pharmacists for the chronic management of patients receiving anticoagulation therapy and create an educational website.","Adult tobacco use ","In DY4 and DY5 provider will report the number of adults receiving services in the Harris Health System that report tobacco use.   In addition, in DY5 provider will demonstrate improvement through the use of a PFP measure- PPR- 30 day all cause. ","Facility ","We will only measure population within Harris Health System","P4R","PPR.12","PM-8","Submission of Category 3 DY3 Status Report",210713.60100000008,"Yes/No","RHP 3_133355104.3.25_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",216395.70553599996,"Yes/No","RHP 3_133355104.3.25_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",686884.72349200002,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",819667.33426599996,"Yes/No","NA","AM-3.1","Achievement of DY5 performance goal for PFP measure",819667.33426599996,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"%",0.197269,54053,274006,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Data for patients gathered from Epic according to report specifications used to create report in accordance with specific guidelines from HHSC/CMS Category 3 Planning Protocol. Report includes data fields for MRN, HAR, Discharge Date, Tobacco Use within 30 days, Acct Base Class, Age 18+. Denominator includes all Harris Health System patients with a HAR and aged 18+. Numerator includes those from denominator that reported tobacco use within 30 days of last visit. These specifications and reports were reviewed and approved by all relevant stakeholders. ","19.73% of all Harris Health System patients 18+ years of age reported using tobacco within last 30 days of their visit. ","Adult tobacco use ","ambulatory",null,"Number of adults aged 18 years and older who report the use of cigarettes, chewing tobacco, snuff, or cigars in the past 30 days. ","Number of adults aged 18 years and older in the service area. ",null,null,null,null,null,null,null,null,null,null,null,"PFP baseline under review",null,"2.2.1 ","","Adult tobacco use ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 3_133355104.2.5","RHP 3_133355104.3.25","RHP 3_133355104.2.5_133355104.3.25",{"$f":"COUNTIFS($FI$4:$FI1268,FI1268)","v":1},"RHP 3_133355104.2.5_1",null,2,1,1,"RHP 3_133355104",{"$f":"COUNTIFS($FR$4:$FR1268,FR1268)","v":31},"RHP 3_133355104_31"]
["RHP 3","137805107","Memorial Hermann Hospital","137805107.1.1","137805107.3.1","IT-1.7","Controlling high blood pressure ","Baseline not yet reported","Eligible to Report in October DY4","Memorial will expand the capacity of primary care through more clinics\nand available health care professionals to better accommodate the regional patient\npopulation and community so that patients have enhanced access to services. Memorial\nwill aim to recruit 60+ new primary care providers and 18 new primary care locations are\nplanned.","Controlling high blood pressure ","In DY4 and DY5 provider will increase the percentage of patients 18 to 85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90) during the measurement year. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",287726.61499999999,"Yes/No","RHP 3_137805107.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",287726.61499999999,"Yes/No","RHP 3_137805107.3.1_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",461700.77500000002,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",461700.77500000002,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",2208134.2200000002,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Controlling high blood pressure ","ambulatory",null,"The number of patients in the denominator whose most recent BP is adequately controlled during the measurement year. For a patient’s BP to be controlled, both the systolic and diastolic BP must be <140/90 (adequate control). To determine if a patient’s BP is adequately controlled, the representative BP must be identified.\n","Patients 18 to 85 years of age by the end of the measurement year who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1 ","","Controlling high blood pressure ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 3_137805107.1.1","RHP 3_137805107.3.1","RHP 3_137805107.1.1_137805107.3.1",{"$f":"COUNTIFS($FI$4:$FI1275,FI1275)","v":1},"RHP 3_137805107.1.1_1",null,2,1,1,"RHP 3_137805107",{"$f":"COUNTIFS($FR$4:$FR1275,FR1275)","v":1},"RHP 3_137805107_1"]
["RHP 3","137909111","Memorial Medical Center","137909111.1.1","137909111.3.5","IT-9.5","Reduce low acuity ED visits ","Baseline Approved","Eligible to Report in April DY4","This project expands access to primary and specialty care services through the establishment of a hospital-based clinic. This initiative will provide critically needed services to a medically underserved area of rural Texas.  To ensure patients have access to services at times that are convenient for them, are able to secure appointments with appropriate providers, and to reduce the inappropriate use of the hospital emergency department for non-urgent and primary care services, the clinic will offer extended and non-traditional hours of care.\n","Reduce low acuity ED visits ","In DY4 and DY5, the provider will report the percentage of patients triaged as low acuity (ESI 3, 4 or 5) that receive treatment in the Emergency Department during the measurement period.  In addition, in DY5 provider will complete Stretch Activity #4. ",null,null,"P4R","SA4","PM-8","Submission of Category 3 DY3 Status Report",12350.395,"Yes/No","RHP 3_137909111.3.5_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",12350.395,"Yes/No","RHP 3_137909111.3.5_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",39932.949999999997,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",46809.5,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",46809.5,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",1,4849,4849,"07/01/13 - 12/31/13",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The Denominator is the total of the patients that presented themselve at our ER with a triage level of 3, 4 and 5, during the time period of July 1, 2013 to Dec. 31, 2013. The numerator was the total of patients who ere triaged at levels 3, 4 and 5 and received treatment, during the time frame of July 1, 2013 to Dec. 31, 2013.","We triaged and medically treated all of the patients who presented in our ER with triage levels of 3, 4 and 5.","Reduce low acuity ED visits ","ED",null,"Total number of patients triaged as low acuity (ESI 3, 4 or 5) and receives treatment in the Emergency Department during the measurement period","Total number of patients triaged as low acuity (ESI 3, 4 or 5) upon presentation to the Emergency Department during the measurement period",null,null,null,null,null,null,null,null,null,null,"Stretch Activity status not reported in DY3",null,null,"1.1.2","","Reduce low acuity ED visits ",null,null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-07-01","2013-12-31",null,null,"RHP 3_137909111.1.1","RHP 3_137909111.3.5","RHP 3_137909111.1.1_137909111.3.5",{"$f":"COUNTIFS($FI$4:$FI1282,FI1282)","v":2},"RHP 3_137909111.1.1_2",null,2,1,1,"RHP 3_137909111",{"$f":"COUNTIFS($FR$4:$FR1282,FR1282)","v":2},"RHP 3_137909111_2"]
["RHP 3","137909111","Memorial Medical Center","137909111.2.3","137909111.3.202","IT-6.1.a.x","HCAHPS Likelihood to Recommend","Baseline Approved","Eligible to Report in April DY4","Memorial Medical Center will research, design, and implement (if found to be effective) a hospitalist model to increase productivity and access to care for patients arriving in the ER and  require admission to the hospital. The increase in supply of regular providers is expected to reduce waiti times and improve health outcomes and patient satisfaction.  ","HCAHPS Likelihood to Recommend","In DY4 and DY5, the provider will improve top box scores of the HCAHPS Likelihood to Recommend",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",3293.44,"Yes/No","RHP 3_137909111.3.202_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",3293.44,"Yes/No","RHP 3_137909111.3.202_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",5324.3950000000004,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",5324.4,"Numeric",0.65,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",24965.07,"Numeric",0.66800000000000004,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.62984099999999998,39.68,63,"DY3 (1): Oct 1st, 2013 - March 31st, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.65,null,0.66800000000000004,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Based on our current inpatient volume - an average of 100 patients a month - per Healthstream the sample size should be at least 30 patients per quarter.","Based on the Top Box score of 62.98% - we can continue to work with our patients to improve the patient experience and help improve the scores.","HCAHPS Likelihood to Recommend","Inpatient",null,"Patient-mix and survey mode adjusted percent \"top box\" score for a given subdomain as provided by your survey administrator, multiplied by the number of completed surveys represented in the \"top box\" score.","The number of HCAHPS surveys completed during the measurement period as reported by your survey administrator. The denominator should be the same as the multiplier used in the numerator. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.4.3","","HCAHPS Likelihood to Recommend",null,null,null,null,null,"2014-04-01","2015-03-31","2015-04-01","2016-03-31","2013-10-01","2014-03-31",null,null,"RHP 3_137909111.2.3","RHP 3_137909111.3.202","RHP 3_137909111.2.3_137909111.3.202",{"$f":"COUNTIFS($FI$4:$FI1290,FI1290)","v":1},"RHP 3_137909111.2.3_1",null,2,1,1,"RHP 3_137909111",{"$f":"COUNTIFS($FR$4:$FR1290,FR1290)","v":10},"RHP 3_137909111_10"]
["RHP 3","139135109","Texas Children’s Hospital","139135109.1.12","139135109.3.30","IT-10.1.a.v","Pediatric Quality of Life Inventory (PedsQL)","Baseline not yet reported","Eligible to Report in October DY4","Increase outpatient access for Harris County and the surrounding communities to care for pediatric patients with hearing loss to sinus disease and swallowing abnormalities and those patients with disorders of the ear, nose and/or throat","Pediatric Quality of Life Inventory (PedsQL)","In DY4 and DY5, the provider will improve the reported scores on the PedsQL out of all instruments completed among children receiving services within the Otolaryngology clinic at TCH who are deaf or severely hearing impaired patients receiving a cochlear implant.","Facility, Comorbid Condition ","Otolaryngology clinic at TCH, patients who are deaf or severely hearing impaired patients receiving a cochlear implant.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",65169.48,"Yes/No","RHP 3_139135109.3.30_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",65169.48,"Yes/No","RHP 3_139135109.3.30_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",209148.75,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",514088.01,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"dy4","TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Pediatric Quality of Life Inventory (PedsQL)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2 ","","Pediatric Quality of Life Inventory (PedsQL)",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 3_139135109.1.12","RHP 3_139135109.3.30","RHP 3_139135109.1.12_139135109.3.30",{"$f":"COUNTIFS($FI$4:$FI1300,FI1300)","v":1},"RHP 3_139135109.1.12_1",null,1,1,0,"RHP 3_139135109",{"$f":"COUNTIFS($FR$4:$FR1300,FR1300)","v":7},"RHP 3_139135109_7"]
["RHP 3","139135109","Texas Children’s Hospital","139135109.1.16","139135109.3.42","IT-11.26.e.v","Edinburg Postpartum Depression Scale ","Baseline Approved","Eligible to Report in October DY4","Increase access for women with reproductive mental health issues.  American women are two times more likely to experience depression than men and depression is considered to be the leading cause of disease-related disability among women today. Approximately 13-15% of new mothers are diagnosed with Postpartum Depression (PPD). \n","Edinburg Postpartum Depression Scale ","In DY4 and DY5, the provider will report scores on the  Edinburg Postnatal Depression Scale out of all instruments completed at the Center for Reproductive Psychiatry. In addition, in DY5 provider will complete Stretch Activity #3- Outcome Evaluation. ","Facility ","The denominator subset selected is the facility-level. The Center for Reproductive Psychiatry will serve as the denominator sub-set. Denominator subset description: The Center for Reproductive Psychiatry will serve as the denominator subset that will capture the targeted population (women seeking perinatal mental health services). The target population will be further selected by measurement criteria of the Edinburgh Postnatal Depression Scale (EPDS).\n","P4R","SA3","PM-8","Submission of Category 3 DY3 Status Report",43446.32,"Yes/No","RHP 3_139135109.3.42_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",43446.32,"Yes/No","RHP 3_139135109.3.42_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",139432.5,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",171362.67,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",171362.67,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",11.52908,10111,877,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Since the reported baseline is an average, the numerator value is the sum of 877 EPDS questionnaires completed at The Women's Place from 4/1/2014-9/30/2014. The denominator value is the number of EPDS questionnaires completed at The Women's Place and entered into the EPDS Flowsheet from 4/1/2014-9/30/2014, which was 877.","Among 877 maternal depression patient visits completed at The Women's Place from 4/1/2014-9-30-2014, the average EPDS score was 11.5. ","Edinburg Postpartum Depression Scale ","Multiple",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,"For Stretch Activity #3, we have begun to develop the variables that will be reported. We are reporting Category 3 using scenario 3; however, for SA3, we plan to report data using analyses similar to those described in scenario 1, only without the limitation of DY1.",null,null,"1.9.2 ","Scenario 3: Average Score","Edinburg Postpartum Depression Scale ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 3_139135109.1.16","RHP 3_139135109.3.42","RHP 3_139135109.1.16_139135109.3.42",{"$f":"COUNTIFS($FI$4:$FI1304,FI1304)","v":1},"RHP 3_139135109.1.16_1",null,2,1,1,"RHP 3_139135109",{"$f":"COUNTIFS($FR$4:$FR1304,FR1304)","v":11},"RHP 3_139135109_11"]
["RHP 3","139135109","Texas Children’s Hospital","139135109.1.5","139135109.3.13","IT-1.22","Asthma Percent of Opportunity Achieved","Baseline Approved","Eligible to Report in October DY4","Increase outpatient access for Harris County, specifically North Houston, to care for pediatric patients with conditions affecting the lungs and respiratory tract.  ","Asthma Percent of Opportunity Achieved","In DY4 and DY5, the provider will improve the percentage of asthma opportunities completed/fulfilled (documentation of action/management plan, severity assessment, controller therapy for those who are eligible, and spirometry within last two years) among all eligible patients 6 years and older. ","Age ","Patients 6 years and older","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",73858.740000000005,"Yes/No","RHP 3_139135109.3.13_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",73858.740000000005,"Yes/No","RHP 3_139135109.3.13_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",118517.625,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",118517.63,"Numeric",0.84475609799999996,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",582633.07999999996,"Numeric",0.85292699999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.83658500000000002,686,820,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.84475609799999996,null,0.85292699999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The number of asthma opportunities possible for each episode of care may differ depending on the patient. However, the Pulmonary service has established that some minimum requirements exist for every asthma patient. For example,  asthma action plans and disease severity assessment should be performed with every asthma episode of care. These 2 metrics represent a total of 438 asthma opportunities for the sampled 219 patients. Of these 438 possible asthma opportunities, our service successfully achieved 305. Much of this gap was related to documentation of disease severity. Appropriate use of controller therapy was assessed based on labeling of the disease severity as persistent. For patients without a disease severity label, further chart review was performed including review of the patient's reported asthma control tests (ACTs). For ACTs less than 19, controller therapy should be considered. Based on these guidelines, 193 asthma opportunities were identified. The fourth asthma opportunity was spirometry assessment and chart audits were conducted to ensure patients had spirometry performed at least once in a two year period. Patients with development delay, however, were excluded from the denominator for this metric. The identified asthma opportunities for this metric totaled 189. Based on the above information, our denominator was established as 820 and chart audits provided the numerator of 686.","84% of asthma opportunities associated with the sampled episodes of care were successfully met. The asthma opportunity with the greatest opportunity for improvement is related to disease severity assessment.","Asthma Percent of Opportunity Achieved","ambulatory",null,"The number of times that each of the asthma opportunities (processes) listed below were completed/fulfilled at least once during the measurement year for all individuals with asthma (any age) :  \n1.) Documentation of Action/Management Plan, \n2.) Severity Assessment\n3.) Controller Therapy for those who are eligible, and \n4.) Documentation of spirometry assessment completed within last two years.\n","The total number of opportunities can be calculated in the following manner-\nFor each individual with an asthma diagnosis assign a count one for each of the four processes that should have been completed (should be 3-4 counts per patient) at least once during the measurement period. \n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2 ","","Asthma Percent of Opportunity Achieved",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 3_139135109.1.5","RHP 3_139135109.3.13","RHP 3_139135109.1.5_139135109.3.13",{"$f":"COUNTIFS($FI$4:$FI1309,FI1309)","v":1},"RHP 3_139135109.1.5_1",null,2,1,1,"RHP 3_139135109",{"$f":"COUNTIFS($FR$4:$FR1309,FR1309)","v":16},"RHP 3_139135109_16"]
["RHP 3","158771901","Harris County Public Health & Environmental Services","158771901.1.100","158771901.3.200","IT-7.15","Prevention: Topical Fluoride Intensity for Children at Elevated Caries Risk ","Pending Approval","Eligible to Report in October DY4","Provide preventive dental screenings and fluoride varnish applications, oral health education, and navigator-assisted referrals to community dental providers, including HCPHES dental services","Prevention: Topical Fluoride Intensity for Children at Elevated Caries Risk ","In DY4 and DY5, the provider will increase the number of children who receive at least one topical fluoride treatment as a dental service out of all eligible children identified as at \"elevated\" risk with at least one dental visit through school based services.","Facility ","school-based oral health program","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",138713.48499999999,"Yes/No","RHP 3_158771901.3.200_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",138713.48499999999,"Yes/No","RHP 3_158771901.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",122817.015,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- all children",61408.5075,"Numeric","TBD","AM-1.2","Achievment of DY4 performance goal- children with at least one dental visit",61408.5075,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- all children",154244.315,"Numeric","TBD","AM-2.2","Achievment of DY5 performance goal- children with at least one dental visit",154244.315,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"proxy","TBD",null,"TBD",null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The baseline denominator population was selected by choosing patients that received preventive dental services in our safety net clinics (all of the patients are either Medicaid, CHIP or uninsured) so they mirror our target population.  We chose the same age group.  The only difference is that the patients are in a clinic setting not school based.This proxy baseline was approved by Texas HHSC on 1/17/14","The numerator was determined by utilizing the  report (generated directly in EHR) to tabulate the number of total unduplicated patients in the target group and then to run another report which tabulated how many of those patients received fluoride varnish specifically.  All of the patients involved received fluoride varnish applications.  Some of the patients received more than one application during the reporting preriod.","Our interpretation of the baseline rate calculated above is that of all eligible children that presented to the clinic for services, we were able to successfully provide a the recommended fluoride varnish treatment.","Prevention: Topical Fluoride Intensity for Children at Elevated Caries Risk ","ambulatory",null,"Unduplicated number of children at “elevated” risk (i.e. “moderate” or “high”) who received (1, 2, 3, >4) topical fluoride applications as a dental service.\n\nNote: No more than one fluoride application can be counted for the same patient on the same date of service.\n","Unduplicated number of all  children at “elevated” risk (i.e. “moderate” or “high”) with at least 1 dental visit in the prior or current year.","Unduplicated number of children at “elevated” risk (i.e. “moderate” or “high”) who received (1, 2, 3, >4) topical fluoride applications as a dental service.\n\nNote: No more than one fluoride application can be counted for the same patient on the same date of service.\n","Unduplicated number of all children at “elevated” risk (i.e. “moderate” or “high”) who received at least one dental service with at least 1 dental visit in the prior or current year.",null,null,null,null,null,null,null,null,null,null,null,"1.8.9","","all children","children receiving dental services",null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 3_158771901.1.100","RHP 3_158771901.3.200","RHP 3_158771901.1.100_158771901.3.200",{"$f":"COUNTIFS($FI$4:$FI1317,FI1317)","v":2},"RHP 3_158771901.1.100_2",null,3,2,1,"RHP 3_158771901",{"$f":"COUNTIFS($FR$4:$FR1317,FR1317)","v":2},"RHP 3_158771901_2"]
["RHP 3","158771901","Harris County Public Health & Environmental Services","158771901.2.101","158771901.3.206","IT-1.24","Adolescent tobacco use ","Baseline Approved","Eligible to Report in October DY4","Expand its operations and leverage mobile clinic units alongside existing fixed clinics to meet the health needs of low income, indigent and special needs populations, that lack the resources and/or physical mobility to commute to fixed site locations to receive the vital and preventative services necessary to reduce tobacco use.","Adolescent tobacco use ","In DY4 and DY5, the provider will report prevalence of adolescents age 12 to 18 years who report the use of cigarettes, chewing tobacco, snuff, or cigars in the past 30 days. In addition, in DY5 provider will complete Stretch Activity # 1 (Validation of P4R measure) ","Age ","12 to 18","P4R","SA1","PM-8","Submission of Category 3 DY3 Status Report",208070.22500000001,"Yes/No","RHP 3_158771901.3.206_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",208070.22500000001,"Yes/No","RHP 3_158771901.3.206_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",368451.05,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",231366.47500000001,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",231366.47500000001,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.02,4,200,"08/01/14-09/30-2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"short","P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Self-declared intake form surveying specific information","Only 2.0% of patients who were screened,  in grades 9 through 12,  reported using cigarettes, spit tobacco, or cigars on 1 or more of the 30 days preceding the survey.","Adolescent tobacco use ","ambulatory",null,"Number of students in grades 9 through 12 who report using cigarettes, spit tobacco, or cigars on 1 or more of the 30 days preceding the survey.","Number of students in grades 9 through 12",null,null,null,null,null,null,null,null,null,null,"Stretch Activity status not reported in DY3",null,null,"2.7.2","","Adolescent tobacco use ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-08-01","2014-09-30",null,null,"RHP 3_158771901.2.101","RHP 3_158771901.3.206","RHP 3_158771901.2.101_158771901.3.206",{"$f":"COUNTIFS($FI$4:$FI1326,FI1326)","v":2},"RHP 3_158771901.2.101_2",null,2,1,1,"RHP 3_158771901",{"$f":"COUNTIFS($FR$4:$FR1326,FR1326)","v":11},"RHP 3_158771901_11"]
["RHP 3","212060201","Rice Medical Center","212060201.1.2","212060201.3.5","IT-9.10","ED throughput Measure bundle","Baseline Approved","Eligible to Report in April DY4","Rice intends to develop the use of telemedicine in its Colorado County \nfacilities and in schools to increase and improve access to specialty care services for\ncommunity stakeholders.","ED throughput Measure bundle","In DY4 and DY5 provider will improve (decrease) the following ED throughput measures. 1.) Median Time from ED Arrival to ED Departure for Discharged ED Patients: 2.)  Median time from admit decision time to time of departure from the ED for ED patients admitted to inpatient status: 3.) Median time from ED arrival to time of departure from the emergency room for patients admitted to the facility from the ED. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",21808.22,"Yes/No","RHP 3_212060201.3.5_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",21808.22,"Yes/No","RHP 3_212060201.3.5_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",32843.39,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- ED Arrival to ED Departure for Discharged ED Patients",10947.796666666667,"Numeric",76,"AM-1.2","Achievement of DY4 performance goal- admit decision to departure for ED patients admitted",10947.796666666667,"Numeric",40.85,"AM-1.3","Achievement of DY4 performance goal- arrival to departure for ED patients admitted",10947.796666666667,"Numeric",114.47499999999999,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- ED Arrival to ED Departure for Discharged ED Patients",48426.593333333331,"Numeric",72,"AM-2.2","Achievement of DY5 performance goal- admit decision to departure for ED patients admitted",48426.593333333331,"Numeric",38.700000000000003,"AM-2.3","Achievement of DY5 performance goal- arrival to departure for ED patients admitted",48426.593333333331,"Numeric",108.45,null,null,null,null,null,null,null,null,null,null,3,"time (minutes)",80,80,1,"DY2: Oct 1st, 2012 - Sept 30th, 2013",43,43,1,"DY2: Oct 1st, 2012 - Sept 30th, 2013",120.5,120.5,1,"DY2: Oct 1st, 2012 - Sept 30th, 2013",null,0,0,null,null,0,0,null,null,76,null,72,null,40.85,null,38.700000000000003,null,114.47499999999999,null,108.45,null,null,null,null,null,null,null,null,null,null,null,"Rice determined the rates as follows:\nRate #1: Median Time from ED Arrival to ED Departure for Discharged ED Patients: Median time from emergency department arrival to time of departure from the emergency room for patients discharged from the emergency department\nRate #2: Median time from admit decision time to time of departure from the ED for ED patients admitted to inpatient status: Median time from admit decision time to time of departure from the emergency department (ED) for ED patients admitted to inpatient status\nRate #3: Median time from ED arrival to time of departure from the emergency room for patients admitted to the facility from the ED: Median time from emergency department (ED) arrival to time of departure from the emergency room for patients admitted to the facility from the ED\n","The rates reported above are inaccurate due to the reporting template requiring a denominator.  Per guidance from Ms. Woodard at HHSC, Rice reported its denominator as \"1\". The numerators represent the accurate baseline rate.  These rates are the median times as determined above. ","ED throughput Measure bundle","ED",null,"Rate #1: Median Time from ED Arrival to ED Departure for Discharged ED Patients: Continuous Variable Statement: Time (in minutes) from ED arrival to ED departure for patients discharged from the emergency department. ",1,"Rate #2: Median time from admit decision time to time of departure from the ED for ED patients admitted to inpatient status: Continuous variable statement: Time (in minutes) from admit decision time to time of departure from the emergency department (ED) for ED patients admitted to inpatient status",1,"Rate #3: Median time from ED arrival to time of departure from the emergency room for patients admitted to the facility from the ED: Continuous variable statement: Time (in minutes) from emergency department (ED) arrival to ED departure for patients admitted to the facility from the ED",1,null,null,null,null,null,null,null,null,null,"1.7.1 ","","ED arrival to ED departure for ED discharge","admit decision time to ED departure for admitted patients","ED arrival to ED departure for admitted patients",null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 3_212060201.1.2","RHP 3_212060201.3.5","RHP 3_212060201.1.2_212060201.3.5",{"$f":"COUNTIFS($FI$4:$FI1331,FI1331)","v":1},"RHP 3_212060201.1.2_1",null,4,3,1,"RHP 3_212060201",{"$f":"COUNTIFS($FR$4:$FR1331,FR1331)","v":2},"RHP 3_212060201_2"]
["RHP 3","212060201","Rice Medical Center","212060201.2.3","212060201.3.4","IT-1.10","Diabetes care: HbA1c poor control (>9.0%) ","Baseline Approved","Eligible to Report in October DY4","Rice will develop a Certified Diabetes Teaching Center to educate and assist patients with managing their chronic disease. Rice will provide guidance to at-risk community members to accomplish the goal of prevention and management of diabetes for at-risk patients. ","Diabetes care: HbA1c poor control (>9.0%) ","In DY4 and DY5 provider will improve (decrease) the percentage of patients 18-75 years of age with diabetes (type 1 and type 2) treated in Rice's Outpatient Clinics whose most recent HbA1c level during the measurement year was greater than 9.0% (poor control) or was missing a result, or if an HbA1c test was not done during the measurement year.","Facility ","Patients eligible in the denominator who were  treated in Rice's  outpatient Clinics","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",21808.22,"Yes/No","RHP 3_212060201.3.4_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",21808.22,"Yes/No","RHP 3_212060201.3.4_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",32843.39,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",32843.39,"Numeric",0.451520017,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",145279.78,"Numeric",0.43351800000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.46952199999999999,285,607,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.451520017,null,0.43351800000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Rice determined its denominator by including patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year. Rice determined its numerator by patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year.","Rice understands its baseline rate is that 46.95% of patients 18-75 years of age with diabetes (type 1 and type 2) whose most recent HbA1c level during the measurement year was greater than 9.0% (poor control) or was missing a result, or if an HbA1c test was not done during the measurement year. Rice understands that it will need to decrease this percentage over DY4 and DY5. ","Diabetes care: HbA1c poor control (>9.0%) ","ambulatory",null,"Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.6.2 ","","Diabetes care: HbA1c poor control (>9.0%) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 3_212060201.2.3","RHP 3_212060201.3.4","RHP 3_212060201.2.3_212060201.3.4",{"$f":"COUNTIFS($FI$4:$FI1342,FI1342)","v":1},"RHP 3_212060201.2.3_1",null,2,1,1,"RHP 3_212060201",{"$f":"COUNTIFS($FR$4:$FR1342,FR1342)","v":13},"RHP 3_212060201_13"]
["RHP 3","296760601","Fort Bend County Clinical Health Services","296760601.2.101","296760601.3.103","IT-9.1","Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons","Baseline not yet reported","Eligible to Report in October DY4","Develop a continuum of care that is founded on evidence-based practices for this target group (persons with severe mental illness and / or mental illness and physical health conditions) identified as high risk for recidivism due to homelessness/ lack of stable housing, prior history of noncompliance, lack of access to services, complex trauma, lack of family supports and /or lack of integrated care to address complex needs.","Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons","In DY4 and DY5, the provider aims to reduce admissions and readmissions to the criminal justice setting among individuals age 18 or older  with a behavioral health diagnosis and history of criminal justice involvement in Fort Bend County jail","Facility ","Number of individuals age 18 or older  with a behavioral health diagnosis and history of criminal justice involvement in Fort Bend County jail","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",13096.05,"Yes/No","RHP 3_296760601.3.103_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",13096.05,"Yes/No","RHP 3_296760601.3.103_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",30184.799999999999,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",67799.759999999995,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"dy4","TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons","ambulatory",null,"The number of individuals receiving project intervention(s) who had a potentially preventable admission/readmission to a criminal justice setting (e.g. jail, prison, etc.) within the measurement period.","Number of individuals receiving project intervention(s)",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.13.1",null,"Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons",null,null,null,null,null,null,null,null,null,"","",null,null,{"$f":"A1348&\"_\"&D1348","v":"RHP 3_296760601.2.101"},{"$f":"A1348&\"_\"&E1348","v":"RHP 3_296760601.3.103"},"RHP 3_296760601.2.101_296760601.3.103",{"$f":"COUNTIFS($FI$4:$FI1348,FI1348)","v":1},"RHP 3_296760601.2.101_1",null,1,{"$f":"IF(DC1348=\"\",0,1)+IF(DG1348=\"\",0,1)+IF(DK1348=\"\",0,1)+IF(DO1348=\"\",0,1)+IF(DS1348=\"\",0,1)","v":1},0,"RHP 3_296760601",{"$f":"COUNTIFS($FR$4:$FR1348,FR1348)","v":6},{"$f":"FR1348&\"_\"&FS1348","v":"RHP 3_296760601_6"}]
["RHP 4","020811801","Christus Spohn- Beeville","020811801.1.2","020811801.3.2","IT-1.11","Diabetes care:  BP control (<140/90mm Hg) ","Pending Approval","Eligible to Report in October DY4","Spohn plans to implement a system for early detection and ongoing treatment and management of peripheral arterial disease (PAD) in Region 4, using a new telemedicine disease management system that allows specialist input at primary care provider (PCP) offices for both diagnostics and treatment plans. ","Diabetes care:  BP control (<140/90mm Hg) ","In DY4 and DY5 provider will improve the percentage of patients 18-75 years of age with diabetes (type 1 and type 2) receiving services at Beeville Family Health Center whose most recent blood pressure (BP) reading is <140/90 mm Hg during the measurement year.","Facility ","Beeville Family Health Center","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",15911.11,"Yes/No","RHP 4_020811801.3.2_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",15911.11,"Yes/No","RHP 4_020811801.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",25435.3,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",25435.3,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",123337.91,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator was determined by identifying diabetic clinic patients that had atleast two visits in the bsaeline time period or 12 months prior.  The numerator consists of denominator patients that had a blood pressure value of less than 140/90 in the baseline time period.","69.57% of diabetic clinic patients had a blood pressure reading under 140/90 during the baseline time period at their most recent reading.","Diabetes care:  BP control (<140/90mm Hg) ","ambulatory",null,"Patients whose most recent BP reading is <140/90 mm Hg during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.7.6","","Diabetes care:  BP control (<140/90mm Hg) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 4_020811801.1.2","RHP 4_020811801.3.2","RHP 4_020811801.1.2_020811801.3.2",{"$f":"COUNTIFS($FI$4:$FI1353,FI1353)","v":1},"RHP 4_020811801.1.2_1",null,2,1,1,"RHP 4_020811801",{"$f":"COUNTIFS($FR$4:$FR1353,FR1353)","v":2},"RHP 4_020811801_2"]
["RHP 4","020811801","Christus Spohn- Beeville","020811801.2.5","020811801.3.9","IT-9.4.b","Reduce Emergency Department visits for Diabetes","Baseline Approved","Eligible to Report in October DY4","Spohn will implement a screening and treatment protocol in its hospital EDs and Family Health Centers (FHCs) to identify patients with dual diagnoses (medical and behavioral health (BH)) and assign a case manager to coordinate their care. Two medical diagnoses, CHF and Diabetes, will be targeted for screening and identification of co-existing BH illness.","Reduce Emergency Department visits for Diabetes","In DY4 and DY5, the provider will improve the rate of ED Visits with a primary or secondary diagnosis of diabetes for any individual 18 years and older during the measurement period over all ED Visits at the Beeville ED facilities ","Facility ","Beeville ED facilities","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",15911.11,"Yes/No","RHP 4_020811801.3.9_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",15911.11,"Yes/No","RHP 4_020811801.3.9_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",25435.3,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",25435.3,"Numeric",6.8394444999999998E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",123337.91,"Numeric",6.4795000000000005E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",7.1994000000000002E-2,591,8209,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,6.8394444999999998E-2,null,6.4795000000000005E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator was calculated by identifying all Emergency Room visits to CHRISTUS Spohn Beeville between April 1, 2014 and September 30, 2014.  The visits were then narrowed down by age (18 and older).  The numerator was calculated by identifying the patients with the specified primary and secondary diagnosis, minus the exclusion criteria, from the denominator population.","Spohn interprets the baseline rate to mean that 7.2% of all Emergency Department visits for patients ages 18 and older were for patients with a primary or secondary diagnosis of  Diabetes.","Reduce Emergency Department visits for Diabetes","ED",null,"Total number of ED Visits with a primary or secondary diagnosis of diabetes for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.19.1","","Reduce Emergency Department visits for Diabetes",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 4_020811801.2.5","RHP 4_020811801.3.9","RHP 4_020811801.2.5_020811801.3.9",{"$f":"COUNTIFS($FI$4:$FI1359,FI1359)","v":1},"RHP 4_020811801.2.5_1",null,2,1,1,"RHP 4_020811801",{"$f":"COUNTIFS($FR$4:$FR1359,FR1359)","v":8},"RHP 4_020811801_8"]
["RHP 4","020973601","Corpus Christi Medical Center - Bay Area","020973601.2.2","020973601.3.11","IT-4.10","Sepsis bundle  (NQF 0500)","Baseline Approved","Eligible to Report in October DY4","This project will implement standardized evidence based identification and care management protocols for sepsis patients.  ","Sepsis bundle  (NQF 0500)","In DY4 and DY5 provider will improve (increase) the percentage of Corpus Christi Medical Center patients aged 18 years and older who present with symptoms of severe sepsis or septic shock and receive the 3 hour (severe sepsis) and/or 6 hour (septic shock) early management bundle.\n","Facility ","Corpus will limit this outcome to patients within its own facility.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",324111.69,"Yes/No","RHP 4_020973601.3.11_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",324111.69,"Yes/No","RHP 4_020973601.3.11_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",346630.06,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",346630.06,"Numeric",0.11089784999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",867837.46,"Numeric",0.157692,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",6.4102999999999993E-2,10,156,"CY 2014 (1): January 1, 2014 - June 30, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.11089784999999999,null,0.157692,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"During the measurement period of January through June 2014, there was a total of 156 patients coded as severe sepsis or septic shock, all of whom were eligible to receive the 3 hour bundle elements (results 20/156 received all 3 hour elements). 37 of the 156 patients also met criteria to receive the 6 hour bundle elements (results 0/37 patients received all 6 hour elements). The compliance rate itself was determined by identifying the total number of patients in the denominator who received all of the required bundle elements (3 hr AND/OR 6 hr). Since 10 of the 20 patients who received all of the 3 hour elements also required additional interventions that they did not receive in the 6 hour time frame, we conclude that 10/156 patients received all of the clinically indicated sepsis intervention for a rate of 6.41%.","6.41% of the severe sepsis or septic shock patients treated during the measurement period received all of the clinically indicated management (3 hour) or resuscitation (6 hour) interventions in a timely manner. ","Sepsis bundle  (NQF 0500)","inpatient",null,"Patients from the denominator who received all the following: A, B, C, and D within 3 hours of time of presentation†, \nAND, \nIF septic shock is present (as either defined as hypotension* or lactate >=4 mmol/L) who also received E, ,F and G within 6 hours of time of presentation\n\nTo be completed within 3 hours:\nA. measure lactate level\nB. obtain blood cultures prior to antibiotics\nC. administer broad spectrum antibiotics\nD. administer 30 ml/kg crystalloid (bolus) for hypotension or lactate >=4 mmol/L\n\nTo be completed within 6 hours (or if septic shock is present):\nE. apply vasopressors (for hypotension that does not respond to initial fluid resuscitation to maintain a mean arterial pressure >= 65)\nF. In the event of persistent arterial hypotension despite volume resuscitation (septic shock) or initial lactate >=4 mmol/L (36 mg/dl) the resuscitation is objectively monitored using a method such as lactate clearance, ScvO2 monitoring or CVP monitoring\nG. re-measure lactate if initial lactate is elevated\n","Number of patients presenting with severe sepsis or septic shock.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.8.11","","Sepsis bundle  (NQF 0500)",null,null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2014-01-01","2014-06-30",null,null,"RHP 4_020973601.2.2","RHP 4_020973601.3.11","RHP 4_020973601.2.2_020973601.3.11",{"$f":"COUNTIFS($FI$4:$FI1367,FI1367)","v":1},"RHP 4_020973601.2.2_1",null,2,1,1,"RHP 4_020973601",{"$f":"COUNTIFS($FR$4:$FR1367,FR1367)","v":8},"RHP 4_020973601_8"]
["RHP 4","094118902","DeTar Hospital Navarro","094118902.1.3","094118902.3.14","IT-14.8","Percent of trainees who report that they plan to serve Medicaid populations based on a systematic survey ","Baseline not yet reported","Eligible to Report in October DY4","Implement a family practice residency program. DeTar intends to establish this residency program, which should add six primary care residents per year and three additional faculty positions to serve DeTar’s medically underserved population.  Further, the resident selection process and rural‐focused curriculum is designed to encourage graduates to remain in medically underserved areas and to accept Medicaid patients","Percent of trainees who report that they plan to serve Medicaid populations based on a systematic survey ","In DY4 and DY5, the provider will report the percent of trainees who report that they plan to serve Medicaid populations based on a systematic survey. In DY5, the provider will demonstrate improvement by improving the rate of alternative improvement activity Physician Practice Group 3 (PP.3) 30-day all-cause readmission following health failure (HF) hospitalization.",null,null,"P4R","PP.3","PM-8","Submission of Category 3 DY3 Status Report",52198.25,"Yes/No","RHP 4_094118902.3.14_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",52198.25,"Yes/No","RHP 4_094118902.3.14_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",111137.17,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",91346.79,"Yes/No","NA","AM-3.1","Achievement of DY5 performance goal for PFP measure",91346.79,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Percent of trainees who report that they plan to serve Medicaid populations based on a systematic survey ","na",null,"Number of trainees who report that they plan to serve Medicaid populations based on a systematic survey ","Rate #1: Individuals in the HPSA ",null,null,null,null,null,null,null,null,null,null,null,"PFP baseline not yet reported",null,"1.2.3","","Percent of trainees who report that they plan to serve Medicaid populations based on a systematic survey ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 4_094118902.1.3","RHP 4_094118902.3.14","RHP 4_094118902.1.3_094118902.3.14",{"$f":"COUNTIFS($FI$4:$FI1375,FI1375)","v":3},"RHP 4_094118902.1.3_3",null,2,1,1,"RHP 4_094118902",{"$f":"COUNTIFS($FR$4:$FR1375,FR1375)","v":5},"RHP 4_094118902_5"]
["RHP 4","094222902","CHRISTUS Spohn Hospital Alice","094222902.1.3","094222902.3.3","IT-1.11","Diabetes care:  BP control (<140/90mm Hg) ","Baseline Approved","Eligible to Report in October DY4","Implement a system for early detection and ongoing treatment and management of peripheral arterial disease (PAD) in Region 4, using a new telemedicine disease management system that allows specialist input at primary care provider (PCP) offices for both diagnostics and treatment plans. PAD telemedicine systems provide patients that present at PCP offices with access to specialists to address issues with PAD.","Diabetes care:  BP control (<140/90mm Hg) ","In DY4 and DY5, the provider will improve the percentage of patients 18-75 years of age with diabetes (type 1 and type 2) whose most recent blood pressure (BP) reading is <140/90 mm Hg during the measurement year and receiving services at Freer Clinic (Alice's outpatient clinic serving the Jim Wells County community)\n","Facility ","Freer Clinic (Alice's outpatient clinic serving the Jim Wells County community)","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",16873.115000000002,"Yes/No","RHP 4_094222902.3.3_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",16873.115000000002,"Yes/No","RHP 4_094222902.3.3_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",27075.365000000002,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",27075.37,"Numeric",0.53790000000000004,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",129491.05,"Numeric",0.55954999999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.33333299999999999,75,225,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.53790000000000004,null,0.55954999999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator was determined by identifying diabetic clinic patients that had atleast two visits in the baseline time period or 12 months prior.  The numerator consists of denominator patients that had a blood pressure value of less than 140/90 in the baseline time period.","33.33% of diabetic clinic patients had a blood pressure reading under 140/90 during the baseline time period at their most recent reading.","Diabetes care:  BP control (<140/90mm Hg) ","ambulatory",null,"Patients whose most recent BP reading is <140/90 mm Hg during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.7.6","","Diabetes care:  BP control (<140/90mm Hg) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 4_094222902.1.3","RHP 4_094222902.3.3","RHP 4_094222902.1.3_094222902.3.3",{"$f":"COUNTIFS($FI$4:$FI1384,FI1384)","v":1},"RHP 4_094222902.1.3_1",null,2,1,1,"RHP 4_094222902",{"$f":"COUNTIFS($FR$4:$FR1384,FR1384)","v":3},"RHP 4_094222902_3"]
["RHP 4","094222902","CHRISTUS Spohn Hospital Alice","094222902.2.5","094222902.3.10","IT-3.3","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","Baseline Approved","Eligible to Report in October DY4","Expand Spohn’s Care Transitions program to focus on preventing readmissions for CHF and diabetes patients at Spohn’s Alice campus. Under the expansion, the RN Coach is the centerpiece of the program, and will function as a facilitator of an interdisciplinary collaboration to transition patients from hospital to home self-care. The RN Coach will facilitate the intervention over a 33 day period by identifying and meeting with the patient at bedside, and conducting a home visit within 48-72 hours post discharge. In addition to the home visit, the RN Coach will conduct 3 follow-up calls at intervals of 7, 14 and 31 days post discharge","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","In DY4 and DY5 provider will improve the ratio of observed to expected readmissions within 30 days following discharge from an index admission for Congestive Heart Failure (CHF) at Spohn's Alice Hospital Facilities.","Facility ","Alice Hospital Facilities","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",16873.115000000002,"Yes/No","RHP 4_094222902.3.10_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",16873.115000000002,"Yes/No","RHP 4_094222902.3.10_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",27075.365000000002,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",27075.37,"Numeric",1.215027978,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",129491.05,"Numeric",1.151079,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",1.278977,0.16,0.12509999999999999,"CY 2014 (1): January 1, 2014 - June 30, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,1.215027978,null,1.151079,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The Midas definition of CHF readmission rate includes patients of all ages and all payors who were discharged for CHF and readmitted within 30 days with a qualifying clinically related readmission.","After adjusting for patient risk-factors,16.00% of all CHF patients were readmitted within 30 days.","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission for CHF during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk CHF admissions during the measurement period.\n","Expected (risk-adjusted) rate of readmissions for CHF during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc. \n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.12.2","","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate",null,null,null,null,"Midas","2014-07-01","2015-06-30","2015-07-01","2016-06-30","2014-01-01","2014-06-30",null,null,"RHP 4_094222902.2.5","RHP 4_094222902.3.10","RHP 4_094222902.2.5_094222902.3.10",{"$f":"COUNTIFS($FI$4:$FI1389,FI1389)","v":1},"RHP 4_094222902.2.5_1",null,2,1,1,"RHP 4_094222902",{"$f":"COUNTIFS($FR$4:$FR1389,FR1389)","v":8},"RHP 4_094222902_8"]
["RHP 4","121775403","CHRISTUS Spohn Hospital Corpus Christi","121775403.2.10","121775403.3.18","IT-3.3","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","Baseline Approved","Eligible to Report in October DY4","Expand Spohn’s Care Transitions program to focus on preventing readmissions for CHF and diabetes patients at Spohn’s South,  Memorial and Shoreline campuses. Under the expansion, the RN Coach is the centerpiece of the program, and will function as a facilitator of an interdisciplinary collaboration to transition patients from hospital to home self-care. The RN Coach will facilitate the intervention over a 33 day period by identifying and meeting with the patient at bedside, and conducting a home visit within 48-72 hours post discharge. In addition to the home visit, the RN Coach will conduct 3 follow-up calls at intervals of 7, 14 and 31 days post discharge","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","In DY4 and DY5 provider will improve the ratio of observed to expected readmissions within 30 days following discharge from an index admission for Congestive Heart Failure (CHF) at Spohn's Corpus Christi Hospital Facilities. ","Facility ","Spohn's Corpus Christi hospital facilities (Memorial, Shoreline, and South)","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",117722.59,"Yes/No","RHP 4_121775403.3.18_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",117722.59,"Yes/No","RHP 4_121775403.3.18_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",188888.155,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",188888.16,"Numeric",1.0128787880000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",910862.12,"Numeric",0.95956900000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",1.0661879999999999,0.13370000000000001,0.12540000000000001,"CY 2014 (1): January 1, 2014 - June 30, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,1.0128787880000001,null,0.95956900000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The Midas definition of CHF readmission rate includes patients of all ages and all payors who were discharged for CHF and readmitted within 30 days with a qualifying clinically related readmission.","After adjusting for patient risk-factors, 13.37% of all CHF patients were readmitted within 30 days.","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission for CHF during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk CHF admissions during the measurement period.\n","Expected (risk-adjusted) rate of readmissions for CHF during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc. \n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.12.2","","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate",null,null,null,null,"Midas","2014-07-01","2015-06-30","2015-07-01","2016-06-30","2014-01-01","2014-06-30",null,null,"RHP 4_121775403.2.10","RHP 4_121775403.3.18","RHP 4_121775403.2.10_121775403.3.18",{"$f":"COUNTIFS($FI$4:$FI1401,FI1401)","v":1},"RHP 4_121775403.2.10_1",null,2,1,1,"RHP 4_121775403",{"$f":"COUNTIFS($FR$4:$FR1401,FR1401)","v":9},"RHP 4_121775403_9"]
["RHP 4","121775403","CHRISTUS Spohn Hospital Corpus Christi","121775403.2.6","121775403.3.12","IT-9.4.a","Reduce Emergency Department visits for Congestive Heart Failure","Baseline Approved","Eligible to Report in October DY4","Implement the Medical Home Model of care delivery in community clinics to improve accessibility to primary care and reducing the appointment wait time to impact the percentage of potentially preventable admissions (PPAs), which is currently higher than the statewide average for asthma, COPD, CHF, bacterial pneumonia, and diabetes long-term complications manageable through regular follow up with primary care providers","Reduce Emergency Department visits for Congestive Heart Failure","In DY4 and DY5, the provider will improve the rate of ED Visits with a primary or secondary diagnosis of Congestive Heart Failure (CHF) for any individual 18 years and older during the measurement period over all ED Visits at the Spohn's Corpus Christi Hospital Facilities","Facility ","Spohn's Corpus Christi hospital facilities (Memorial, Shoreline, and South)","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",117722.59,"Yes/No","RHP 4_121775403.3.12_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",117722.59,"Yes/No","RHP 4_121775403.3.12_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",188888.155,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",188888.155,"Numeric",1.4473273E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",910862.12,"Numeric",1.3712E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",1.5235E-2,926,60781,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,1.4473273E-2,null,1.3712E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator was calculated by identifying all Emergency Room visits to CHRISTUS Spohn Memorial, Shoreline and South between April 1, 2014 and September 30, 2014.  The visits were then narrowed down by age (18 and older).  The numerator was calculated by identifying the patients with the specified primary and secondary diagnosis, minus the exclusion criteria, from the denominator population.","Spohn interprets the baseline rate to mean that 1.52% of all Emergency Department visits for patients ages 18 and older were for patients with a primary or secondary diagnosis of  CHF.","Reduce Emergency Department visits for Congestive Heart Failure","ED",null,"Total number of ED Visits with a primary or secondary diagnosis of CHF for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.1.1","","Reduce Emergency Department visits for Congestive Heart Failure",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 4_121775403.2.6","RHP 4_121775403.3.12","RHP 4_121775403.2.6_121775403.3.12",{"$f":"COUNTIFS($FI$4:$FI1406,FI1406)","v":1},"RHP 4_121775403.2.6_1",null,2,1,1,"RHP 4_121775403",{"$f":"COUNTIFS($FR$4:$FR1406,FR1406)","v":14},"RHP 4_121775403_14"]
["RHP 4","121785303","Memorial Hospital","121785303.1.100","121785303.3.100","IT-1.10","Diabetes care: HbA1c poor control (>9.0%) ","Pending Approval","Eligible to Report in October DY4","The intent of this program is to implement a continuous glucose monitoring system that will allow providers to discover patterns or trends in diabetic patient glucose control that are not evident by patient self-testing or routine laboratory studies.","Diabetes care: HbA1c poor control (>9.0%) ","In DY4 and DY5, provider will decrease the number of patients age 18-75 years whose most recent HbA1c level is greater than 9%, is missing, or not conducted during the measurement year, out of all qualifying adult with a diagnosis of diabetes during the measurement year or the year prior. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",3863.2649999999999,"Yes/No","RHP 4_121785303.3.100_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",3479.8201999999997,"Yes/No","RHP 4_121785303.3.100_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",5896.33,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",5896.33,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",29396.111111111113,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"A report was run requesting a list of all patients treated in the clinic with a diagnosis of type I or type II diabetes.  A filter was applied looking for the most recent hemoglobin A1C level.  The resulting report was then downloaded into an Excel spreadsheet and sorted by results.  The number of patients with an A1C level of 9 or above (166) and the number of patients for whom no result was available (364) were added together.","The number of patients with an A1c of 9 or greater (13.0%) and the number of patients with no results (38.5%) during the baseline period result in 51.5% of the diabetic patients served by the clinic being eligible for the intervention.","Diabetes care: HbA1c poor control (>9.0%) ","ambulatory",null,"Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.7.2",null,"Diabetes care: HbA1c poor control (>9.0%) ",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 4_121785303.1.100","RHP 4_121785303.3.100",{"$f":"A1411&\"_\"&D1411&\"_\"&E1411","v":"RHP 4_121785303.1.100_121785303.3.100"},{"$f":"COUNTIFS($FI$4:$FI1411,FI1411)","v":1},{"$f":"FI1411&\"_\"&FL1411","v":"RHP 4_121785303.1.100_1"},null,2,1,1,{"$f":"A1411&\"_\"&RIGHT(\"000000000\"&B1411,9)","v":"RHP 4_121785303"},{"$f":"COUNTIFS($FR$4:$FR1411,FR1411)","v":2},"RHP 4_121785303_2"]
["RHP 4","126844305","Bluebonnet Trails Community MHMR Center","126844305.2.1","126844305.3.1","IT-9.2","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","Pending Approval","Eligible to Report in October DY4","Patient navigation project for frequent users of the ED due to chronic health conditions including behavioral health disorders. 2 RN’s will be located at the Hospital and provide assessment, triage, diversion and referral. Those without PCP’s will be referred to establish ongoing care and a medical home.","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","In DY4 and DY5, provider will reduce the total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period (See Adult ACSC diagnostic codes) out of the total number of ED visits at Gonzales Memorial Hospital","Facility ","Gonzales Memorial Hospital","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",16651,"Yes/No","RHP 4_126844305.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",16651,"Yes/No","RHP 4_126844305.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",17812.5,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",17812.5,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",77446,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The EMR was queried for the period 10/1/13 through 9/30/14 and for all admissions  for individuals 18 and over; results were used for the Denominator above.  The Denominator data was filtered for thse ASCS diagonses in the Outcome Description above and that number was used for the Numerator above.","The baseline rate above indicates that 4.56% of the individals 18 and over admitted to the ED of Gonzales Memorial Hospital during the reporting period were diagnosed with the ASCS codes listed in the Outcome Description.","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","ED",null,"Total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1","","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 4_126844305.2.1","RHP 4_126844305.3.1","RHP 4_126844305.2.1_126844305.3.1",{"$f":"COUNTIFS($FI$4:$FI1418,FI1418)","v":1},"RHP 4_126844305.2.1_1",null,2,1,1,"RHP 4_126844305",{"$f":"COUNTIFS($FR$4:$FR1418,FR1418)","v":1},"RHP 4_126844305_1"]
["RHP 4","132812205","Driscoll Children's Hospital","132812205.2.2","132812205.3.6","IT-8.12","Pre-term birth rate ","Baseline Approved","Eligible to Report in April DY4","The goal of this project is to educate and provide support to low income women with high risk pregnancies in order to foster healthy pregnancies and better health outcomes for baby and mother. This goal will be achieved by expanding access to the Cadena de Madres program. The Project has two major components—a set of “educational” baby showers, nutritional and lactation consultations, and a series of consultation visits after delivery.  ","Pre-term birth rate ","In DY4 and DY5 provider will reduce the percentage of Driscoll Healthplan members births delivered preterm, measuring percent of term singleton live births delivered with less than 37 completed weeks of gestation out of all births.","Payer ","Driscoll Healthplan members","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",77176.61,"Yes/No","RHP 4_132812205.3.6_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",77176.61,"Yes/No","RHP 4_132812205.3.6_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",123807.88,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",123807.88,"Numeric",9.8881598000000001E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",596692.73,"Numeric",9.3676999999999996E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.104086,349,3353,"CY2012: January 1, 2012 - December 31, 2012",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,9.8881598000000001E-2,null,9.3676999999999996E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator and denominator were determined by extracting medical claims and delivery data from databases using approved specifications.","Out of the 3353 live births in RHP4 during calendar year 2012, 349 were delivered prior 37 weeks for a preterm birth rate of 10.41%.","Pre-term birth rate ","Multiple",null,"Number of singleton livebirths delivered with less than 37 completed weeks of gestation. \n","All live births. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.6.2","","Pre-term birth rate ",null,null,null,null,null,"2013-01-01","2013-12-31","2014-01-01","2014-12-31","2012-01-01","2012-12-31",null,null,"RHP 4_132812205.2.2","RHP 4_132812205.3.6","RHP 4_132812205.2.2_132812205.3.6",{"$f":"COUNTIFS($FI$4:$FI1432,FI1432)","v":1},"RHP 4_132812205.2.2_1",null,2,1,1,"RHP 4_132812205",{"$f":"COUNTIFS($FR$4:$FR1432,FR1432)","v":10},"RHP 4_132812205_10"]
["RHP 4","132812205","Driscoll Children's Hospital","132812205.2.3","132812205.3.8","IT-10.5","Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III)","Baseline Approved","Eligible to Report in April DY4","The High Risk Infant Follow-up Program is designed to assist pediatricians and families in follow-up care for infants and young children who are at high risk for developmental and neurological problems following discharge from an intensive care unit (ICU) at Driscoll Children’s Hospital or other local Neonatal ICU’s.","Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III)","In DY4 and DY5 provider will report the average score for the Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III) out of all surveys administered during the measurement period.  In addition, in DY5 provider will submit a comprehensive report describing  outcome evaluation of the intervention (Stretch Activity 3) ",null,null,"P4R","SA3","PM-8","Submission of Category 3 DY3 Status Report",187428.91,"Yes/No","RHP 4_132812205.3.8_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",187428.91,"Yes/No","RHP 4_132812205.3.8_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",601352.56000000006,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",724555.46,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",724555.46,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",40.723080000000003,2647,65,"09/01/13 - 02/28/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator represents the number of individual patients tested during the baseline time period. The numerator represents the total (summation) of the 5 scaled scores for the individual patients receiving the Bayley Exam during the baseline time period. The survey administration scenerio was selected as \"Pre-Test\" since these were the first patients examed in the first six months of the program's service. An exam is adminstered upon each visit to the program for monitoring the 5-scale results. The overall 5 scaled-score should reduce as our patients are examed. ","The average 5 scaled score for a patient","Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III)","Multiple",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,"Weight loss or significant changes in patients’ percentile ranking exercises a serious cause for concern. For this reason, our team will engage in a number of activities to include: providing feeding schedules to parents for consistency and reference, increase the patients’ caloric density and/or volume designed to meet the individual patient needs, implement nutritional “visits” to measure weight, length, and head circumference prior to their next scheduled visit, assist families in identifying over-the-counter vitamins and supplements promoting growth and bone density, as well as periodic phone calls to ensure compliance and understanding of changes discussed. ",null,null,"2.12.2","Scenario 2: Pre Test Only Baseline","Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III)",null,null,null,null,null,"2014-03-01","2015-02-28","2015-03-01","2016-02-28","2013-09-01","2014-02-28",null,null,"RHP 4_132812205.2.3","RHP 4_132812205.3.8","RHP 4_132812205.2.3_132812205.3.8",{"$f":"COUNTIFS($FI$4:$FI1433,FI1433)","v":1},"RHP 4_132812205.2.3_1",null,2,1,1,"RHP 4_132812205",{"$f":"COUNTIFS($FR$4:$FR1433,FR1433)","v":11},"RHP 4_132812205_11"]
["RHP 4","136436606","CHRISTUS Spohn Hospital Kleberg","136436606.1.1","136436606.3.1","IT-3.3","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","Baseline Approved","Eligible to Report in October DY4","Implement a Chronic Disease registry to assist Spohn in tracking and managing patients with conditions, which will initially focus on patients with CHF and diabetes. The chronic disease database/repository will be created for Spohn by heartbase™ to support and sustain management of patients in our Care Transitions/Care Partners program, which focuses on using RN Coaches to coordinate the care for chronically ill patients","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","In DY4 and DY5 provider will improve the ratio of observed to expected readmissions within 30 days following discharge from an index admission for Congestive Heart Failure (CHF) at Spohn's Kleberg Hospital Facilities. ","Facility ","Kleberg Hospital facilities","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",13943.115,"Yes/No","RHP 4_136436606.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",13943.115,"Yes/No","RHP 4_136436606.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",22373.86,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",22373.86,"Numeric",1.251028807,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",107006.35,"Numeric",1.1851849999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",1.316872,0.16,0.1215,"CY 2014 (1): January 1, 2014 - June 30, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,1.251028807,null,1.1851849999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The Midas definition of CHF readmission rate includes patients of all ages and all payors who were discharged for CHF and readmitted within 30 days with a qualifying clinically related readmission.","After adjusting for patient risk-factors, 16.00% of all CHF patients were readmitted within 30 days.","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission for CHF during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk CHF admissions during the measurement period.\n","Expected (risk-adjusted) rate of readmissions for CHF during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc. \n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.3.1","","Risk Adjusted Congestive Heart Failure (CHF) 30-day Readmission Rate",null,null,null,null,"Midas","2014-07-01","2015-06-30","2015-07-01","2016-06-30","2014-01-01","2014-06-30",null,null,"RHP 4_136436606.1.1","RHP 4_136436606.3.1","RHP 4_136436606.1.1_136436606.3.1",{"$f":"COUNTIFS($FI$4:$FI1443,FI1443)","v":1},"RHP 4_136436606.1.1_1",null,2,1,1,"RHP 4_136436606",{"$f":"COUNTIFS($FR$4:$FR1443,FR1443)","v":1},"RHP 4_136436606_1"]
["RHP 4","137907508","Citizens Medical Center","137907508.1.100","137907508.3.100","IT-9.4.e","Reduce Emergency Department visits for Behavioral Health/Substance Abuse","Baseline Approved","Eligible to Report in April DY4","Implement an extended behavioral health observation unit in Victoria and the surrounding area of Region 4 to better accommodate the behavioral health and crisis stabilization needs of the regional patient population and community. The Medical Center’s collaborative effort with Gulf Bend Center, a Local Mental Health facility, also located in Victoria, TX, will provide a safe and secure environment for short-term stabilization of patients presenting in emergency rooms exhibiting behavioral health symptoms that may or may not require a continued stay in an inpatient care facility","Reduce Emergency Department visits for Behavioral Health/Substance Abuse","In DY4 and DY5, the provider will improve the rate of ED Visits with a primary or secondary diagnosis of COPD for any individual 18 years and older during the measurement period over all ED visits for individuals 18 years or older during the measurement period",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",95452,"Yes/No","RHP 4_137907508.3.100_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",95452,"Yes/No","RHP 4_137907508.3.100_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",147427.25,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",147427.25,"Numeric",0.28813349799999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",674254,"Numeric",0.27296857699999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.30329800000000001,4662,15371,"DY3 (1): Oct 1st, 2013 - March 31st, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.28813349799999999,null,0.27296857699999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator: Patients with a primary or secondary diagnosis of behavioral health and/or substance abuse, age 18 or older, who visited the ED\nDenominator: Total ED visits for patients 18 and older","Approximately 30% of ED patients ultimately receive a primary or secondary diagnosis of behavioral health and/or substance abuse. This suggests that a large proportion of patients visiting the ED may benefit from behavioral health services.","Reduce Emergency Department visits for Behavioral Health/Substance Abuse","ED",null,"Total number of ED Visits with a primary or secondary diagnosis of behavioral health and/or substance abuse for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.13.1","","Reduce Emergency Department visits for Behavioral Health/Substance Abuse",null,null,null,null,null,"2014-04-01","2015-03-31","2015-04-01","2016-03-31","2013-10-01","2014-03-31",null,null,"RHP 4_137907508.1.100","RHP 4_137907508.3.100","RHP 4_137907508.1.100_137907508.3.100",{"$f":"COUNTIFS($FI$4:$FI1454,FI1454)","v":1},"RHP 4_137907508.1.100_1",null,2,1,1,"RHP 4_137907508",{"$f":"COUNTIFS($FR$4:$FR1454,FR1454)","v":5},"RHP 4_137907508_5"]
["RHP 4","137907508","Citizens Medical Center","137907508.1.101","137907508.3.101","IT-8.2","Percentage of Low Birth- weight births","Baseline Approved","Eligible to Report in October DY4","Expansion of prenatal services in the Victoria and surrounding area to better accommodate the needs of the regional patient population and community","Percentage of Low Birth- weight births","In DY4 and DY5, the provider will reduce the percentage of babies born weighing <2,500 grams at birth over all births ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",95452,"Yes/No","RHP 4_137907508.3.101_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",95452,"Yes/No","RHP 4_137907508.3.101_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",147427.25,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",147427.25,"Numeric",7.0370370000000002E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",674254,"Numeric",6.6667000000000004E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",7.4074000000000001E-2,30,405,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,7.0370370000000002E-2,null,6.6667000000000004E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator: number of births with birthweight < 2,500g.\nDenominator: All births, excluding those where a birthweight was not available in the EMR system.","Just over 7% of babies born at CMC have low birthweight.","Percentage of Low Birth- weight births","inpatient",null,"The number of babies born weighing <2,500 grams at birth","All births ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2","","Percentage of Low Birth- weight births",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 4_137907508.1.101","RHP 4_137907508.3.101","RHP 4_137907508.1.101_137907508.3.101",{"$f":"COUNTIFS($FI$4:$FI1455,FI1455)","v":1},"RHP 4_137907508.1.101_1",null,2,1,1,"RHP 4_137907508",{"$f":"COUNTIFS($FR$4:$FR1455,FR1455)","v":6},"RHP 4_137907508_6"]
["RHP 5","020947001","Valley Regional Medical Center","020947001.2.100","020947001.3.101","IT-3.5","Risk Adjusted Diabetes 30-day Readmission Rate ","Baseline Approved","Eligible to Report in October DY4","A nurse practitioner and certified diabetes educator will facilitate an interdisciplinary collaboration to transition patients from hospital to home self-care. ","Risk Adjusted Diabetes 30-day Readmission Rate ","In DY4 and DY5 provider will improve the ratio of observed to expected readmission rates within 30 days following a discharge from an index admission related to diabetes for patients 18 years of age and older receiving services at Valley Regional Medical Center","Facility ","Valley Regional Medical Center","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",47517.834999999999,"Yes/No","RHP 5_020947001.3.101_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",47517.834999999999,"Yes/No","RHP 5_020947001.3.101_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",76249.164999999994,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",76249.17,"Numeric",1.2229237289999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",340887,"Numeric",1.1585589999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",1.287288,15.19,11.8,"CY 2014 (1): January 1, 2014 - June 30, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,1.2229237289999999,null,1.1585589999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"For the numerator we took all index admissions.  For the denominator we took all the inpatient cases for the facility.","According to our historical data we expected a readmission rate of 11.8%.  Our observed rate of readmission was 15.19%.","Risk Adjusted Diabetes 30-day Readmission Rate ","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission for Diabetes during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk Diabetes admissions during the measurement period.\n","Expected (risk-adjusted) rate of readmissions for Diabetes during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.12.2","","Risk Adjusted Diabetes 30-day Readmission Rate ",null,null,null,null,"Internal Data Historical Norms","2014-07-01","2015-06-30","2015-07-01","2016-06-30","2014-01-01","2014-06-30",null,null,"RHP 5_020947001.2.100","RHP 5_020947001.3.101","RHP 5_020947001.2.100_020947001.3.101",{"$f":"COUNTIFS($FI$4:$FI1468,FI1468)","v":1},"RHP 5_020947001.2.100_1",null,2,1,1,"RHP 5_020947001",{"$f":"COUNTIFS($FR$4:$FR1468,FR1468)","v":2},"RHP 5_020947001_2"]
["RHP 5","085144601","UT Health Science Center San Antonio","085144601.2.100","085144601.3.205","IT-5.1.d","Improved Cost Savings: Cost Utility Analysis","Baseline not yet reported","Eligible to Report in October DY4","For this project, we will translate tools and lessons learned from this inpatient screening project to implement HCV testing for baby boomers in outpatient primary care practices. ","Improved Cost Savings: Demonstrate cost savings in care delivery - Cost Utility Analysis","In DY4 and DY5 provider will demonstrate cost savings in care delivery of the HCV intervention through a  Cost Utility Analysis",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",22201.847909999997,"Yes/No","RHP 5_085144601.3.205_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",22201.847909999997,"Yes/No","RHP 5_085144601.3.205_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",32077.651589999998,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",32077.651589999998,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",98761.986359999995,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"$",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Improved Cost Savings: Cost Utility Analysis","Multiple",null,"$CostInt - $CostComp\n• Abbreviations: Int: Intervention; Comp: Comparator\n","$UtileInt - $UtileComp\nUtiles, units of utility or preference, are often measured in QALYs Abbreviations: Int: Intervention; Comp: Comparator\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.1","","Improved Cost Savings: Cost Utility Analysis",null,null,null,null,null,null,null,null,null,"","",null,null,{"$f":"A1476&\"_\"&D1476","v":"RHP 5_085144601.2.100"},{"$f":"A1476&\"_\"&E1476","v":"RHP 5_085144601.3.205"},"RHP 5_085144601.2.100_085144601.3.205",{"$f":"COUNTIFS($FI$4:$FI1476,FI1476)","v":2},"RHP 5_085144601.2.100_2",null,2,{"$f":"IF(DC1476=\"\",0,1)+IF(DG1476=\"\",0,1)+IF(DK1476=\"\",0,1)+IF(DO1476=\"\",0,1)+IF(DS1476=\"\",0,1)","v":1},1,"RHP 5_085144601",{"$f":"COUNTIFS($FR$4:$FR1476,FR1476)","v":7},{"$f":"FR1476&\"_\"&FS1476","v":"RHP 5_085144601_7"}]
["RHP 5","085144601","UT Health Science Center San Antonio","085144601.2.100","085144601.3.206","IT-5.2","Per Episode Cost of Care","Baseline not yet reported","Eligible to Report in October DY4","Implement a Hepatitis C virus (HCV) screening and linkage to care program for baby boomers using procedures and tools developed in a current CDC funded project to implement HCV testing in patients in a safety net hospital in San Antonio and apply it to five clinics in RHP Region 5.  ","Per Episode Cost of Care","In DY4 and DY5 provider will demonstrate cost savings in care delivery of the HCV intervention through an analysis of per episode cost of care. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",22201.847909999997,"Yes/No","RHP 5_085144601.3.206_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",22201.847909999997,"Yes/No","RHP 5_085144601.3.206_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",32077.651589999998,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",32077.651589999998,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",98761.986359999995,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"$",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Per Episode Cost of Care","Multiple",null,"Total cost for episode of care","Total number of episodes during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.1","","Per Episode Cost of Care",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 5_085144601.2.100","RHP 5_085144601.3.206","RHP 5_085144601.2.100_085144601.3.206",{"$f":"COUNTIFS($FI$4:$FI1477,FI1477)","v":3},"RHP 5_085144601.2.100_3",null,{"$f":"MAX(IF(AC1477=\"\",0,1)+IF(AH1477=\"\",0,1)+IF(AM1477=\"\",0,1)+IF(AR1477=\"\",0,1)+IF(AW1477=\"\",0,1)+IF(BB1477=\"\",0,1),IF(BG1477=\"\",0,1)+IF(BL1477=\"\",0,1)+IF(BQ1477=\"\",0,1)+IF(BV1477=\"\",0,1)+IF(CA1477=\"\",0,1))","v":2},1,{"$f":"FO1477-FP1477","v":1},"RHP 5_085144601",{"$f":"COUNTIFS($FR$4:$FR1477,FR1477)","v":8},"RHP 5_085144601_8"]
["RHP 5","094113001","South Texas Health System ","094113001.1.100","094113001.3.100","IT-12.1","Breast Cancer Screening","Baseline not yet reported","Eligible to Report in October DY4","Develop a mobile primary care unit, to serve the surrounding rural and McAllen/Edinburg communities. STHS will equip the mobile unit with capabilities that will offer preventive screenings particular to the RHP population. ","Breast Cancer Screening","In DY4 and DY5 provider will improve (increase) the percentage of women, seen at the Valley Care Clinics Mobile Unit, 50 to 74 years of age who had a mammogram for breast cancer every two years.","Facility ","Narrow denominator to Valley Care Clinics Mobile Unit ","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",52961.165000000001,"Yes/No","RHP 5_094113001.3.100_PM-8","Metric Carried Forward in October DY3","PM-9","Validation and submission of baseline performance",52961.165000000001,"Yes/No","RHP 5_094113001.3.100_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",79022,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",79022,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",415365.7,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Breast Cancer Screening","ambulatory",null,"Women who had mammogram during the measurement year or the 18 months prior to the measurement year.","Women 50-74 years old as of the measurement year who had at least one (1) outpatient encounter in the prior 12-month period. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.3","","Breast Cancer Screening",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 5_094113001.1.100","RHP 5_094113001.3.100","RHP 5_094113001.1.100_094113001.3.100",{"$f":"COUNTIFS($FI$4:$FI1485,FI1485)","v":1},"RHP 5_094113001.1.100_1",null,2,1,1,"RHP 5_094113001",{"$f":"COUNTIFS($FR$4:$FR1485,FR1485)","v":1},"RHP 5_094113001_1"]
["RHP 5","094113001","South Texas Health System ","094113001.2.102","094113001.3.115","IT-9.2","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","Baseline Approved","Eligible to Report in October DY4","South Texas Health System will develop a patient navigator program to track, follow-up on and help manage care for chronically ill patients who have a history of frequently visiting the ED.  ","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","In DY4 and DY5 provider will improve (decrease) the rate of (ED) visits for ACSCs out of the total number of adult ED visits to Edinburg Regional Medical Center payer source is Medicaid or uninsured/self-pay","Facility, Payer ","The denominator will be narrowed to: (1) Facility: Edinburg Regional Center located at 1102 W Trenton Rd, Edinburg, TX 78539; and (2) Payer: Medicaid and uninsured/indigent. Thus, the denominator is the total number of ED visits at Edinburg Regional Center for individuals 18 years or older classified as Medicaid, uninsured, or indigent during the measurement period.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",158883.5,"Yes/No","RHP 5_094113001.3.115_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",158883.5,"Yes/No","RHP 5_094113001.3.115_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",237066,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",237066,"Numeric",6.0730124391563015E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1246097.1000000001,"Numeric",5.7533802055164958E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",6.3926446727961064E-2,591,9245,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,6.0730124391563015E-2,null,5.7533802055164958E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator was based on total number of adult ED patients. "," 6.3% of ED patients had a primary or secondary ACSC diagnosis","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","ED",null,"Total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1","","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 5_094113001.2.102","RHP 5_094113001.3.115","RHP 5_094113001.2.102_094113001.3.115",{"$f":"COUNTIFS($FI$4:$FI1498,FI1498)","v":1},"RHP 5_094113001.2.102_1",null,2,1,1,"RHP 5_094113001",{"$f":"COUNTIFS($FR$4:$FR1498,FR1498)","v":14},"RHP 5_094113001_14"]
["RHP 5","111810101","UT Health Science Center Houston","111810101.1.100","111810101.3.100","IT-1.10","Diabetes care: HbA1c poor control (>9.0%) ","Baseline not yet reported","Eligible to Report in October DY4","This project is designed to implement a chronic disease registry, specifically diabetes, in RHP5. In doing so it will sustain and expand the Rio Grande Valley Health Information Exchange and create the first network of providers connected through the new HIE in RHP5, and provide a means to give integrated care to patients across a range of RHP5 providers. ","Diabetes care: HbA1c poor control (>9.0%) ","In DY4 and DY5 provider will improve (decrease) the percentage of all patients who have not opted out of participating in the HIE and chronic disease registry and who are receiving services in the ambulatory clinics that are partnering to use the registry 18-75 years of age with diabetes (type 2) whose most recent HbA1c level during the measurement year was greater than 9.0% (poor control) or was missing a result, or if an HbA1c test was not done during the measurement year.","Facility, Comorbid Condition ","(hhsc entry based on provider response to feedback- JW) participating in the HIE; diabetes (type 2)","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",82944.09,"Yes/No","RHP 5_111810101.3.100_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",82944.09,"Yes/No","RHP 5_111810101.3.100_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",104480.27499999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",104480.27499999999,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",430894.74,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Diabetes care: HbA1c poor control (>9.0%) ","ambulatory",null,"Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.3.1","","Diabetes care: HbA1c poor control (>9.0%) ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 5_111810101.1.100","RHP 5_111810101.3.100","RHP 5_111810101.1.100_111810101.3.100",{"$f":"COUNTIFS($FI$4:$FI1499,FI1499)","v":1},"RHP 5_111810101.1.100_1",null,2,1,1,"RHP 5_111810101",{"$f":"COUNTIFS($FR$4:$FR1499,FR1499)","v":1},"RHP 5_111810101_1"]
["RHP 5","121989102","Border Region Behavioral Health Center","121989102.1.1","121989102.3.1","IT-9.4.e","Reduce Emergency Department visits for Behavioral Health/Substance Abuse","Baseline Approved","Eligible to Report in October DY4","This project purchases telemedicine hardware and maintenance to expand this service to all counties served by Border Region Behavioral Health Center.  ","Reduce Emergency Department visits for Behavioral Health/Substance Abuse","In DY4 and DY5 provider will improve (decrease) the rate of ED utilization for BH/SA conditions or complications per 100,000 for individuals 18 years or older during the measurement period",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",13557.6,"Yes/No","RHP 5_121989102.3.1_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",13557.6,"Yes/No","RHP 5_121989102.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",13982.825000000001,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",13982.825000000001,"Numeric",1.7238327000000001E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",58198.98,"Numeric",1.6331045999999998E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",1.8145999999999999E-2,82,4519,"10/01/2013-6/30/2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,1.7238327000000001E-2,null,1.6331045999999998E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator from Starr County Memorial Hospital and numerator our Anasazi record system","Number represents actual emergency room contacts, the system (Crisis Hotline) to report all emergency room contacts to Border Region","Reduce Emergency Department visits for Behavioral Health/Substance Abuse","ED",null,"Total number of ED Visits with a primary or secondary diagnosis of behavioral health and/or substance abuse for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.11.2","","Reduce Emergency Department visits for Behavioral Health/Substance Abuse",null,null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2013-10-01","2014-06-30",null,null,"RHP 5_121989102.1.1","RHP 5_121989102.3.1","RHP 5_121989102.1.1_121989102.3.1",{"$f":"COUNTIFS($FI$4:$FI1510,FI1510)","v":1},"RHP 5_121989102.1.1_1",null,2,1,1,"RHP 5_121989102",{"$f":"COUNTIFS($FR$4:$FR1510,FR1510)","v":1},"RHP 5_121989102_1"]
["RHP 5","121989102","Border Region Behavioral Health Center","121989102.2.2","121989102.3.5","IT-9.1","Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons","Baseline not yet reported","Eligible to Report in October DY4","This project designs crisis prevention outpatient services to address  factors affecting inpatient admission rates  such as chronic homeless services, physical illness, lack of monitoring of medication compliance and decrease in functional status. ","Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons","In DY4 and DY5 provider will improve (decrease) the percentage of individuals receiving the project intervention(s) who had a potentially preventable admission/readmission to a criminal justice setting (e.g. jail, prison, etc.) within the measurement period for Individuals with a behavioral health diagnosis AND history of criminal justice involvement.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",4519.2,"Yes/No","RHP 5_121989102.3.5_PM-8","Metric Carried Forward in October DY3","PM-9","Validation and submission of baseline performance",4519.2,"Yes/No","RHP 5_121989102.3.5_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",4660.9399999999996,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",4660.9399999999996,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",19399.66,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons","ambulatory",null,"The number of individuals receiving project intervention(s) who had a potentially preventable admission/readmission to a criminal justice setting (e.g. jail, prison, etc.) within the measurement period.","Number of individuals receiving project intervention(s)",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.13.1","","Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 5_121989102.2.2","RHP 5_121989102.3.5","RHP 5_121989102.2.2_121989102.3.5",{"$f":"COUNTIFS($FI$4:$FI1520,FI1520)","v":3},"RHP 5_121989102.2.2_3",null,2,1,1,"RHP 5_121989102",{"$f":"COUNTIFS($FR$4:$FR1520,FR1520)","v":11},"RHP 5_121989102_11"]
["RHP 5","132812205","Driscoll Children's Hospital","132812205.2.1","132812205.3.2","IT-8.12","Pre-term birth rate ","Baseline Approved","Eligible to Report in April DY4","Educate and provide support to low income women with high risk pregnancies in order to foster healthy pregnancies and better health outcomes for baby and mother by expanding access to the Cadena de Madres program. The Project has two major components—a set of “educational” baby showers, nutritional and lactation consultations, and a series of home consultation visits after delivery.","Pre-term birth rate ","In DY4 and DY5 provider will improve the percentage of births delivered preterm, measuring percent of term singleton live births delivered with less than 37 completed weeks of gestation out of all births to Driscoll healthplan members in Region 5..","Payer ","Payer Denominator Subset of Driscoll healthplan members in Region 5.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",68000,"Yes/No","RHP 5_132812205.3.2_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",68000,"Yes/No","RHP 5_132812205.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",102000,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",102000,"Numeric",7.6928020999999999E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",448800,"Numeric",7.2878999999999999E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",8.0976999999999993E-2,126,1556,"DY2: Oct 1st, 2012 - Sept 30th, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,7.6928020999999999E-2,null,7.2878999999999999E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator and denominator were determined by extracting medical claims and delivery data from databases using approved specifications.","Out of the 1556 live births in RHP4 during calendar year 2012, 126 were delivered prior 37 weeks for a preterm birth rate of 8.1%.","Pre-term birth rate ","Multiple",null,"Number of singleton livebirths delivered with less than 37 completed weeks of gestation. \n","All live births. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.6.2","","Pre-term birth rate ",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 5_132812205.2.1","RHP 5_132812205.3.2","RHP 5_132812205.2.1_132812205.3.2",{"$f":"COUNTIFS($FI$4:$FI1525,FI1525)","v":1},"RHP 5_132812205.2.1_1",null,2,1,1,"RHP 5_132812205",{"$f":"COUNTIFS($FR$4:$FR1525,FR1525)","v":5},"RHP 5_132812205_5"]
["RHP 5","138708601","Tropical Texas Behavioral Health","138708601.1.101","138708601.3.101","IT-1.19","Antidepressant Medication Management ","Baseline Approved","Eligible to Report in October DY4","This project will expand the infrastructure and extend operating hours at our Weslaco outpatient clinic to better serve the residents of the many surrounding communities, an area referred to locally as the Mid-Valley.  ","Antidepressant Medication Management ","In DY4 and DY5 provider will improve (increase) the percentage of Weslaco Outpatient Clinic patients 18 years of age and older who were diagnosed with a new episode of major depression and treated with antidepressant medication, and who remained on an antidepressant medication treatment. Two rates are reported. a) Effective Acute Phase Treatment. The percentage of newly diagnosed and treated patients who remained on an antidepressant medication for at least 84 days (12 weeks).  b) Effective Continuation Phase Treatment. The percentage of newly diagnosed and treated patients who remained on an antidepressant medication for at least 180 days (6 months).","Facility ","All TTBH clients 18 and older served at our Weslaco Outpatient Clinic who are admitted to a Full Level Of Care (as defined by DSHS TRR guidelines) who are diagnosed with a new episode of major depression and treated with antidepressant medication.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",64403.78,"Yes/No","RHP 5_138708601.3.101_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",64403.78,"Yes/No","RHP 5_138708601.3.101_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",83000.52,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- Acute Phase",41500.26,"Numeric",0.597943636,"AM-1.2","Achievement of DY4 performance goal- Continious Phase",41500.26,"Numeric",0.29959999999999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- Acute Phase",226541.62,"Numeric",0.59992767700000005,"AM-2.2","Achievement of DY5 performance goal- Continious Phase",226541.62,"Numeric",0.31258000000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"%",0.59596000000000005,118,198,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",0.26262600000000003,52,198,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0.597943636,null,0.59992767700000005,null,0.29959999999999998,null,0.31258000000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator for both rates is adult clients diagnosed with a new episode of major depression and treated with antidepressant medication during the specified measurement period.  The numerator for the Effective Acute Phase Treatment rate is the clients with at least 84 days (12 weeks) of continuous treatment with antidepressant medication during the 114-day period following the IPSD.  The numerator for the Effective Continuation Phase Treatment rate is the clients with at least 180 days (6 months) of continuous treatment with antidepressant medication during the 231-day period following the IPSD.","Approximatetly 60% of adult clients diagnosed with a new episode of major depression and treated with antidepressant medication during the measurement period benefitted from at least 84 days of continuous treatment with antidepressant medication during the Acute Treatment Phase, while only 26% benefitted from at least 180 days of  continuous treatment during the Continuation Treatment Phase following the IPSD.","Antidepressant Medication Management ","ambulatory",null,"Effective Acute Phase Treatment: At least 84 days (12 weeks) of continuous treatment with antidepressant medication during the 114-day period following the IPSD (inclusive). The continuous treatment allows gaps in medication treatment up to a total of 30 days during the 114-day period. Gaps can include either washout period gaps to change medication or treatment gaps to refill the same medication.\n\nRegardless of the number of gaps, there may be no more than 30 gap days. Count any combination of gaps (e.g., two washout gaps of 15 days each, or two washout gaps of 10 days each and one treatment gap of 10 days). ","Patients 18 years and older with a diagnosis of major depression and treated with antidepressant medication.","Effective Continuation Phase Treatment: At least 180 days (6 months) of continuous treatment with antidepressant medication during the 231-day period following the IPSD (inclusive). Continuous treatment allows gaps in medication treatment up to a total of 51 days during the 231-day period. Gaps can include either washout period gaps to change medication or treatment gaps to refill the same medication.\n\nRegardless of the number of gaps, gap days may total no more than 51. Count any combination of gaps (e.g., two washout gaps, each 25 days or two washout gaps of 10 days each and one treatment gap of 10 days).","Patients 18 years and older with a diagnosis of major depression and treated with antidepressant medication.",null,null,null,null,null,null,null,null,null,null,null,"1.12.1","","Effective Acute","Effective Continuous",null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 5_138708601.1.101","RHP 5_138708601.3.101","RHP 5_138708601.1.101_138708601.3.101",{"$f":"COUNTIFS($FI$4:$FI1535,FI1535)","v":1},"RHP 5_138708601.1.101_1",null,3,2,1,"RHP 5_138708601",{"$f":"COUNTIFS($FR$4:$FR1535,FR1535)","v":3},"RHP 5_138708601_3"]
["RHP 5","138708601","Tropical Texas Behavioral Health","138708601.2.2","138708601.3.5","IT-10.1.a.ii","Assessment of Quality of Life (AQoL-6D) ","Pending Approval","Eligible to Report in October DY4","This project will create a law enforcement taskforce comprised of specially trained and certified Mental Health Officers, serving across the TTBH catchment area, with the objective of decreasing preventable admissions and readmissions into the criminal justice system.","Assessment of Quality of Life (AQoL-6D) ","In DY4 and DY5 provider will improve the reported score on the  Assessment of Quality of Life  (AQoL-6D), which represents improved health-related quality of life (HRQOL) in TTBH clients, adults age 18 and older, receiving crisis interventions from the MH Officer Task Force during the measurement period. ","Facility ","The total number of AQoL 6-D questionnaires completed by TTBH clients receiving crisis interventions from the MH Officer Task Force during the measurement period. ","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",38008.79,"Yes/No","RHP 5_138708601.3.5_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",38008.79,"Yes/No","RHP 5_138708601.3.5_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",48983.915000000001,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",48983.915000000001,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",267393.38,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"short","TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator and denominator values were determined and set up according to the prescribed measure specifications in the current HHSC Category 3 Compendium.  The denominator is the total number of AqOL questionnaires completed during the measurement period.  The numerator is the sum of the overall score from all of the AQoL questionnaires completed during the measurement period, with higher scores indicating a higher quality of life.","The instrument measures an individual's health related quality of life including independent living, mental health, relationships, coping, pain and senses, using a scale of  overall score from 0-100, with higher scores indicating a higher quality of life.  The assessment indicates that TTBH clients' average quality of life is at 35.","Assessment of Quality of Life (AQoL-6D) ","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.13.1","Scenario 3: Average Score","Assessment of Quality of Life (AQoL-6D) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-07-01","2014-09-30",null,null,"RHP 5_138708601.2.2","RHP 5_138708601.3.5","RHP 5_138708601.2.2_138708601.3.5",{"$f":"COUNTIFS($FI$4:$FI1542,FI1542)","v":1},"RHP 5_138708601.2.2_1",null,2,1,1,"RHP 5_138708601",{"$f":"COUNTIFS($FR$4:$FR1542,FR1542)","v":10},"RHP 5_138708601_10"]
["RHP 5","138708601","Tropical Texas Behavioral Health","138708601.2.5","138708601.3.9","IT-6.2.b","Visit-Specific Satisfaction Instrument (VSQ-9)","Baseline Approved","Eligible to Report in October DY4","This project will increase access to peer-provided behavioral health services through the addition of 1 veteran peer provider, 3 MH peer providers, 2 family partners and 1 program supervisor at three TTBH clinics serving communities throughout the Rio Grande Valley","Visit-Specific Satisfaction Instrument (VSQ-9)","In DY4 and DY5 provider will improve the average overall score on the  Visit-Specific Satisfaction Instrument (VSQ-9) which measures patient satisfaction with access to primary care, with the direct interaction with the physician, and with the visit overall for TTBH clients receiving peer support services. ","Facility "," TTBH clients receiving peer support services during the measurement period. ","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",64403.78,"Yes/No","RHP 5_138708601.3.9_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",64403.78,"Yes/No","RHP 5_138708601.3.9_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",83000.52,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",83000.52,"Numeric",81.078580250000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",453083.23,"Numeric",82.074444450000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",80.082719999999995,64867,810,"07/01/14 - 09/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,81.078580250000002,null,82.074444450000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator is the sum of the \"overall scores\" of all VSQ-9 surveys completed during the measurement period.   The denominator is the total number VSQ-9 surveys completed during the measurement period.  The numerator and denominator values were determined and set up according to the prescribed measure specifications in the current HHSC Category 3 Compendium.","The instrument measures an individual's level of satisfaction with their access to health care, the direct interaction with the health care provider and with the service provided, on a scale from 0-100, with higher scores indicating greater satisfaction.  The resulting baseline rate of 80 indicates the average overall satisfaction level of the clients surveyed was \"Very Good\" according to the measure's scoring categories.","Visit-Specific Satisfaction Instrument (VSQ-9)","Ambulatory",null,"Sum of all the \"overall score\" of all VSQ-9 surveys completed during the measurement period. ","The total number VSQ-9 surveys completed during the measurement period. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.18.1","","Visit-Specific Satisfaction Instrument (VSQ-9)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-07-01","2014-09-30",null,null,"RHP 5_138708601.2.5","RHP 5_138708601.3.9","RHP 5_138708601.2.5_138708601.3.9",{"$f":"COUNTIFS($FI$4:$FI1547,FI1547)","v":1},"RHP 5_138708601.2.5_1",null,2,1,1,"RHP 5_138708601",{"$f":"COUNTIFS($FR$4:$FR1547,FR1547)","v":15},"RHP 5_138708601_15"]
["RHP 5","154504801","Harlingen Medical Center ","154504801.2.100","154504801.3.100","IT-3.22","Risk Adjusted All-Cause Readmission","Baseline Approved","Eligible to Report in October DY4","This project implements medication management, CPOE, and pharmacist-led chronic disease medication management ","Risk Adjusted All-Cause Readmission","In DY4 and DY5 provider will improve the ratio of observed to expected readmissions within 30 days of a discharge from an index admission for any cause from for Medicaid/Uninsured adult patients of Harlingen Medical Center.  ","Facility, Payer ","Narrow denominator to: (1) Facility: Harlingen Medical Center at 5501 U.S. 77, Harlingen, TX 78550; and (2) Payer: Medicaid and uninsured/indigent","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",25000,"Yes/No","RHP 5_154504801.3.100_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",25000,"Yes/No","RHP 5_154504801.3.100_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",37500,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",37500,"Numeric",2.0065151509999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",165000,"Numeric",1.900909,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",2.1121210000000001,6.97,3.3,"CY 2014 (1): January 1, 2014 - June 30, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,2.0065151509999999,null,1.900909,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator is the observed (actual) rate of readmissions to the facility within 30 days following an Index Admission during the period of Jan-June 2014 for Medicaid/underinsured/uninsured patients over the age of 18 as reported from CareDiscovery/ Truven report for HMC Readmission Rates.  The denominator is the Qualified norm readmission rate calculated using Truven's RAER model.  The RAER model is created using both CMS Standard Analytic Files (SAF) and client-submitted uniform billing (UB) data, which allow the use of both current and historical patient data. The model uses the data to calculate the expected probability of a patient’s 30-day readmission to the same hospital. It uses the Agency for Healthcare Research and Quality’s (AHRQ) Clinical Classification Software to identify co-morbidities, as adjustors, for the model and implements CMS’ Planned Readmission Algorithm, which excludes readmission cases for patients who have planned admissions and scheduled procedures. The RAER model uses patient present-on-admission (POA) information to differentiate between complications and co-morbidities, and only conditions that were present at the time of admission are included in both the model creation and application. While observed readmission cases are not a direct output of the methodology, they can be identified through the Analytic Services engagements and other Truven Health Solutions.","Approximately 7% of the patients that were admitted to the facility between January 1, 2014, and June 30, 2014, that were 18 years of age or older, had Medicaid, underinsured, or uninsured, were readmitted to the facility within 30 days of discharge.  The expected rate of readmissions based on risk adjustment methodology of Truven Analytics for the facility is 3.30%.  The resulting baseline of 2.11 indicates our readmission rate is approximatly twice that which would be expected for this patient population in our facility.","Risk Adjusted All-Cause Readmission","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk admissions during the measurement period.","Expected (risk-adjusted) rate of readmissions for all-causes during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.11.2","","Risk Adjusted All-Cause Readmission",null,null,null,null,"Care Discovery/ Truven Analytics","2014-07-01","2015-06-30","2015-07-01","2016-06-30","2014-01-01","2014-06-30",null,null,"RHP 5_154504801.2.100","RHP 5_154504801.3.100","RHP 5_154504801.2.100_154504801.3.100",{"$f":"COUNTIFS($FI$4:$FI1552,FI1552)","v":1},"RHP 5_154504801.2.100_1",null,2,1,1,"RHP 5_154504801",{"$f":"COUNTIFS($FR$4:$FR1552,FR1552)","v":1},"RHP 5_154504801_1"]
["RHP 5","160709501","Doctor's Hospital at Renaissance","160709501.1.2","160709501.3.2","IT-14.1","Number of practicing primary care practitioners per 1000 individual in HPSAs or MUAs ","Baseline Approved","Eligible to Report in April DY4","This project will create a primary care/ Family Medicine residency program at DHR in collaboration with The University of Texas, adding faculty, resident trainees, and graduates to the primary care physician workforce in RHP 5. ","Number of practicing primary care practitioners per 1000 individual in HPSAs or MUAs ","In DY4 and DY5 provider will report the number of practicing primary care practitioners  a) per 1000 individuals in HPSA or b) 100 individuals in MUA.  In addition, in DY5 provider will demonstrate improvement by describing Alternative Approaches to Program & Outcome Linkages (Stretch Activity #3).  ",null,null,"P4R","SA3","PM-8","Submission of Category 3 DY3 Status Report",154076.28,"Yes/No","RHP 5_160709501.3.2_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",154076.28,"Yes/No","RHP 5_160709501.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",454611.19,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",488919.44,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",488919.44,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"number per 1K",0.37009999999999998,302000,815996,"CY 2013: Jan 1st, 2013 - Dec 31st, 2013",0.37009985343065405,30200,815996,"CY 2013: Jan 1st, 2013 - Dec 31st, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator includes all Direct Patient Care Primary Care Providers Practicing at DHR and affiliated clinics between  January 1, 2013 – December 31, 2013.  These figures include physicians with privileges at DHR and those officially employed by DHR.  We used the Texas Department of State Health Services definition of Direct Patient Care Physicians which states:  \"Physicians who work directly with patients, and do no include researchers, administrators, or teachers\".  We also used their definition of Primary Care Physicians, which states: \"Physicians who indicate that they have a primary specialty of General Practice, Family Practice/Medicine, Internal Medicine, Pediatrics, Obstetrics, and/or Gynecology, or Geriatrics and are a sub-set of Direct Patient Care Physicians\".  Our figures were compiled from DHR employment and medical staff records.  We determined the month-to-month totals for the baseline time period of January 1, 2013 - December 31, 2013, then calculated the 12 month average (302).  The average was multiplied by 1000 to equal 302,000 entered into cell P101 for the HPSA Rate and multiplied by 100 to equal 30,200 entered into cell P112 for the MUA Rate.\n\nThe denominator includes the 2013 population estimates (815,996)  for Hidalgo County from the US Census Bureau website, www.census.gov. ","During calendar year 2013 (1/1/13-12/31/13), there were 37 practicing primary care practitioners at DHR and its affiliated clinics per 1000 individuals in health-professional shortage areas (HPSAs) and 3.7 practicing primary care practitioners at DHR and its affiliated clinics per 100 individuals in the medically underserved area (MUA) of Hidalgo county.  ","Number of practicing primary care practitioners per 1000 individual in HPSAs or MUAs ","na",null,"Rate #1:Number of practicing primary care physicians in the HPSA times 1000","Rate #1: Individuals in the HPSA","Rate #2: Individuals in the MUA","Rate #2: Number of practicing primary care physicians in the MUA times 100",null,null,null,null,null,null,null,null,"We will study how the establishment of this residency program and others in conjunction with the establishment of a new regional South Texas Medical School (UT Rio Grande Valley) influences practice location and patient population choices of trainees.  We will use the following measures as guides for designing our study:   IT 14.7:  Percent of trainees who report that they plan to practice in HPSAs or MUAs based on a systematic survey and IT 14.8:  Percent of trainees who report that they plan to serve Medicaid populations based on a systematic survey.  We have not started development of the survey tool at this time.  Initial plans are to administer the survey with residents starting at DHR and other residency programs in the Rio Grande Valley in July 2015.",null,null,"1.2.4","","HPSA","MUA",null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 5_160709501.1.2","RHP 5_160709501.3.2","RHP 5_160709501.1.2_160709501.3.2",{"$f":"COUNTIFS($FI$4:$FI1564,FI1564)","v":1},"RHP 5_160709501.1.2_1",null,2,2,0,"RHP 5_160709501",{"$f":"COUNTIFS($FR$4:$FR1564,FR1564)","v":11},"RHP 5_160709501_11"]
["RHP 5","160709501","Doctor's Hospital at Renaissance","160709501.2.102","160709501.3.111","IT-3.29","Risk Adjusted Medication Complication 30-day Readmission Rate ","Pending Approval","Eligible to Report in October DY4","DHR is collaborating with the University of Houston to create a medication management program that caters to the diabetic population.  The project is designed to improve collaboration among pharmacists, physicians, and other healthcare professionals; enhance communication between patients and their healthcare team; and optimize medication use for improved patient outcomes.","Risk Adjusted Medication Complication 30-day Readmission Rate ","In DY4 and DY5 provider will improve the ratio of observed to expected readmission rates within 30 days following a discharge from an index admission related to Medication Complications for patients 18 years of age and older within the Doctors Hospital at Renaissance healthcare system","Facility","patients within the Doctors Hospital at Renaissance healthcare system","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",154076.28,"Yes/No","RHP 5_160709501.3.111_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",154076.28,"Yes/No","RHP 5_160709501.3.111_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",227305.595,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",227305.595,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",977838.88,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The population is the same denominator approved for this measure. However, the payor subset has been expanded to include all payor types.","The numerator was determined by first identifying all index admissions that were due to medication complications. These popultion was then used to identify those patients who had a readmission with 30-days of an index admission for medication complications. The result value was the observed readmission rate. The denominator was calculated using the same population for index admissions and then applying the risk-adjustment coefficients  of the normative data derived from the Texas State CY12 Medicaid Norms. This new value is determined to be the expected readmission rate.","The baseline shows a negative outcome for readmission rates related to medication complications. Basically, the rate is greater than one showing the observed value consisting of more readmissions than what should be expected. This shows the need to focus on improving the readmission rate for medication complications, specifically by addressing medication compliance and education issues.","Risk Adjusted Medication Complication 30-day Readmission Rate ","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission for Medication Complications during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk medication complication admissions during the measurement period.\n","Expected (risk-adjusted) rate of readmissions for medication complications during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.11.1","","Risk Adjusted Medication Complication 30-day Readmission Rate ",null,null,null,null,"Texas State Medicaid Norms","2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 5_160709501.2.102","RHP 5_160709501.3.111","RHP 5_160709501.2.102_160709501.3.111",{"$f":"COUNTIFS($FI$4:$FI1569,FI1569)","v":1},"RHP 5_160709501.2.102_1",null,2,1,1,"RHP 5_160709501",{"$f":"COUNTIFS($FR$4:$FR1569,FR1569)","v":16},"RHP 5_160709501_16"]
["RHP 6","020844903","Children’s Hospital of San Antonio","020844903.1.2","020844903.3.2","IT-8.20","Developmental Screening in the First Three Years of Life","Baseline Approved","Eligible to Report in October DY4","The primary goal of this objective is expand the capacity of primary care by developing a geographically dispersed network of pediatric primary clinics throughout San Antonio.","Developmental Screening in the First Three Years of Life","In DY4 and DY5 the provider will increase the percentage of children screened for risk of developmental, behavioral and social delays during the first 3 years of life at all CentroMed clinics in Bexar and Comal Counties","Facility ","All CentroMed clinics in Bexar and Comal Counties","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",54928.125,"Yes/No","RHP 6_020844903.3.2_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",54928.125,"Yes/No","RHP 6_020844903.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",88140.479999999996,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",88140.479999999996,"Numeric",0.18524742,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",421541.44,"Numeric",0.228129,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.14236599999999999,538,3779,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.18524742,null,0.228129,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"For the numerator'; records were pulled for all chidlren who had a screening for risk of developmental, behavioral and social delays using a standardized screening tool that was documented by 12 months of age; 24 months of age; and 36 months of age.  for the denominator; records were pulled for patients at all CentroMed clinics who turned 12 months; 24 months; and 36 months of age in the measurement period.","The baseline for this metric is 14.24%; since this is an improvement over self (IOS) metric, performance will need to be improved by 5% over baseline in DY4.","Developmental Screening in the First Three Years of Life","ambulatory",null,"Children who had screening for risk of developmental, behavioral and social delays using a standardized screening tool that was documented by 0 - 36 months of age","Children who turn 0 - 36 months of age between January 1 of the measurement year and December 31 of the measurement year\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1","","Developmental Screening in the First Three Years of Life",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 6_020844903.1.2","RHP 6_020844903.3.2","RHP 6_020844903.1.2_020844903.3.2",{"$f":"COUNTIFS($FI$4:$FI1577,FI1577)","v":1},"RHP 6_020844903.1.2_1",null,2,1,1,"RHP 6_020844903",{"$f":"COUNTIFS($FR$4:$FR1577,FR1577)","v":2},"RHP 6_020844903_2"]
["RHP 6","085144601","UT Health Science Center San Antonio","085144601.1.11","085144601.3.502","IT-1.1","Third next available appointment ","Baseline not yet reported","Eligible to Report in October DY4","This project will build two new medical homes that in addition to the usual primary care clinicians, we will have services provided by behavioral health professionals,\npharmacists, nutritionists and RN case management services to deal with patients with complex medical problems.","Third next available appointment ","In DY4 and DY5, the provider will improve the average number of days to the third next available appointment for an office visit at clinics where  PCMH is being implemented: UT Medicine MARC, UT Medicine Senior Health, UT Medicine Westover Hills, UT Medicine Medical Drive, and the second primary care clinic being developed.)","Facility ","Patients seen at  primary care clinics where PCMH is being implemented: UT Medicine MARC, UT Medicine Senior Health, UT Medicine Westover Hills, UT Medicine Medical Drive, and the second primary care clinic being developed.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",0,"Yes/No","RHP 6_085144601.3.502_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",31192.614445128824,"Yes/No","RHP 6_085144601.3.502_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",33079.336970064403,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",33079.336970064403,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",136205.67624314519,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"time (days)",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Third next available appointment ","ambulatory",null,"Continuous variable statement: Average number of days to third next available appointment for an office visit for each clinic and/or department MULTIPLED by the value in the denominator.  This will lead to a resulting rate of days to third next available appointment. The measure will take into account calendar days, including weekends, holidays and clinician days off.\n","Number of providers within reported clinics and/or departments included in analysis of this outcome",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1","","Third next available appointment ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 6_085144601.1.11","RHP 6_085144601.3.502","RHP 6_085144601.1.11_085144601.3.502",{"$f":"COUNTIFS($FI$4:$FI1583,FI1583)","v":3},"RHP 6_085144601.1.11_3",null,2,1,1,"RHP 6_085144601",{"$f":"COUNTIFS($FR$4:$FR1583,FR1583)","v":4},"RHP 6_085144601_4"]
["RHP 6","085144601","UT Health Science Center San Antonio","085144601.1.23","085144601.3.32","IT-1.1","Third next available appointment ","Baseline Approved","Eligible to Report in October DY4","The goal of this proposal is to improve access to epilepsy care for the Medicaid and uninsured populations of Bexar County and surrounding communities by expanding the University of Texas Medicine (UTM) Medical Arts and Research Center (MARC) Neurology Clinic with the addition of 0.25 FTE physician, 1.0 FTE mid-level provider, 1.0 FTE LVN, and 1.0 FTE social worker. ","Third next available appointment ","In DY4 and DY5, the provider will improve the average number of days to the third next available appointment for an office visit* for each clinic and/or department",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",59944.244378500007,"Yes/No","RHP 6_085144601.3.32_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",30098.545132501167,"Yes/No","RHP 6_085144601.3.32_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",31919.091568875578,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",31919.091568875578,"Numeric",76,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",131428.3129719304,"Numeric",72,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"time (days)",80,400,5,"March 1, 2014 - August 31, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,76,null,72,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator reports the average number of calendar days between the date of the report and third next available appointment for all epileptologists for the period March 2014 through August 2014. Denominator includes the count of the number of epileptologists practicing at the UT Medicine San Antonio Clinic.","Baseline rate assess the average of number of days that patients wait for an appointment with an epileptologist.","Third next available appointment ","ambulatory",null,"Continuous variable statement: Average number of days to third next available appointment for an office visit for each clinic and/or department MULTIPLED by the value in the denominator.  This will lead to a resulting rate of days to third next available appointment. The measure will take into account calendar days, including weekends, holidays and clinician days off.\n","Number of providers within reported clinics and/or departments included in analysis of this outcome",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2","","Third next available appointment ",null,null,null,null,null,"2014-09-01","2015-08-31","2015-09-01","2016-08-31","2014-03-01","2014-08-31",null,null,"RHP 6_085144601.1.23","RHP 6_085144601.3.32","RHP 6_085144601.1.23_085144601.3.32",{"$f":"COUNTIFS($FI$4:$FI1591,FI1591)","v":1},"RHP 6_085144601.1.23_1",null,2,1,1,"RHP 6_085144601",{"$f":"COUNTIFS($FR$4:$FR1591,FR1591)","v":12},"RHP 6_085144601_12"]
["RHP 6","085144601","UT Health Science Center San Antonio","085144601.1.5","085144601.3.201","IT-12.4","Pneumonia vaccination status for older adults ","Baseline not yet reported","Eligible to Report in October DY4","This project will implement a Health Information Exchange (HIE) which will automate the flow of key clinical information between disparate EHR systems. Data in the HIE will be used to populate a chronic disease registry enabling effective population management.","Pneumonia vaccination status for older adults ","In DY 4 and DY5 provider will increase the percentage of individuals that have received a pneumococcal vaccine out of all individuals aged 65 years or older receiving services at UHS or UT Medicine Primary Care Clinics","Facility ","UHS or UT Medicine Primary Care Clinics (Family Medicine, General Internal Medicine, Geriatrics)","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",36485.78524816667,"Yes/No","RHP 6_085144601.3.201_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",36639.682937785656,"Yes/No","RHP 6_085144601.3.201_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",38855.877903642817,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",38855.877903642817,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",159990.84657217204,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Pneumonia vaccination status for older adults ","Ambulatory/Inpatient",null,"The number of patients in the denominator who responded “Yes” to the question “Have you ever had a pneumonia shot? This shot is usually given only once or twice in the person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.”","The number of patients who responded “Yes” or “No” to the question “Have you ever had a pneumonia shot? This shot is usually given only once or twice in a person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.” ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.3.1","","Pneumonia vaccination status for older adults ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 6_085144601.1.5","RHP 6_085144601.3.201","RHP 6_085144601.1.5_085144601.3.201",{"$f":"COUNTIFS($FI$4:$FI1594,FI1594)","v":1},"RHP 6_085144601.1.5_1",null,2,1,1,"RHP 6_085144601",{"$f":"COUNTIFS($FR$4:$FR1594,FR1594)","v":15},"RHP 6_085144601_15"]
["RHP 6","085144601","UT Health Science Center San Antonio","085144601.2.100","085144601.3.102","IT-5.2","Per Episode Cost of Care","Baseline not yet reported","Eligible to Report in October DY4","For this project, we will translate tools and lessons learned from this inpatient screening project to implement HCV (Hepatitis C virus)  testing for baby boomers in outpatient primary care practices. ","Per Episode Cost of Care","In DY4 and DY5 provider will demonstrate improved cost savings through reductions in per capita cost. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",25869.209871000003,"Yes/No","RHP 6_085144601.3.102_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",25978.326657286394,"Yes/No","RHP 6_085144601.3.102_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",55099.313520286385,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",113436.96618458959,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"$",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"dy4","TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Per Episode Cost of Care","Multiple",null,"Total cost for episode of care","Total number of episodes during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.1","","Per Episode Cost of Care",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 6_085144601.2.100","RHP 6_085144601.3.102","RHP 6_085144601.2.100_085144601.3.102",{"$f":"COUNTIFS($FI$4:$FI1605,FI1605)","v":3},"RHP 6_085144601.2.100_3",null,{"$f":"MAX(IF(AC1605=\"\",0,1)+IF(AH1605=\"\",0,1)+IF(AM1605=\"\",0,1)+IF(AR1605=\"\",0,1)+IF(AW1605=\"\",0,1)+IF(BB1605=\"\",0,1),IF(BG1605=\"\",0,1)+IF(BL1605=\"\",0,1)+IF(BQ1605=\"\",0,1)+IF(BV1605=\"\",0,1)+IF(CA1605=\"\",0,1))","v":1},1,{"$f":"FO1605-FP1605","v":0},"RHP 6_085144601",{"$f":"COUNTIFS($FR$4:$FR1605,FR1605)","v":26},"RHP 6_085144601_26"]
["RHP 6","091308902","San Antonio Metropolitan Health District","091308902.1.1","091308902.3.3","IT-7.6","Percentage of children with urgent dental care needs","Baseline Approved","Eligible to Report in October DY4","Improve access to preventive dental services (dental sealants and fluoride varnish applications) by providing preventive oral health services in non-traditional settings to include early childhood education settings and economically disadvantaged public schools.  The project also supports early identification of children with unmet dental needs, and reinforces the importance of linking families to a “main dental home” in the community where they may receive comprehensive oral health services.","Urgent Dental Care Needs in Children: Percentage of children with urgent dental care needs","In DY4 and DY5, the provider will improve the percentage of third grade children with urgent dental care needs over all* children attending one of the 19 schools that were participating in a school-based oral health program for the first time in DY2 under a state oral health grant which ended in August 2013 seen by the Metro Health dentist","Facility, Age ","Age subset - third grade students ( 8-9 year olds); 19 schools","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",72815.804999999993,"Yes/No","RHP 6_091308902.3.3_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",72815.804999999993,"Yes/No","RHP 6_091308902.3.3_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",116931.4,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",116931.4,"Numeric",4.7163121000000002E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",338844.68,"Numeric",4.4680999999999998E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",4.9645000000000002E-2,21,423,"09/01/13-06/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,4.7163121000000002E-2,null,4.4680999999999998E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Using the approved subsets described above, the percentage of third grade participants with urgent dental needs was calculated as a portion of the total number of participating third grade students to establish the baseline rate. \nNumerator: Using the same filters, the number of children that presented with urgent dental needs was also identified, and used as the numerator in the calculation.\nDenominator: The baseline denominator was filtered by age (third grade students only) and to facility/location (those attending one of the to third grade students attending one of the 16 designated sites. \nThis approach allowed for a true baseline to be established for third grade students attending local elementary school campuses before the initiation of school-based preventive oral health services.  \n","Based on the numerator and denominator described above, the baseline rate for third grade students participating in the program was determined to be 4.96%.  \nThat is, \nNumerator:  21 third grade students presented with urgent dental needs during the limited oral evaluation performed by a SAMHD dentist\nDenominator:  423 third grade students participated in the project and received a limited oral examination performed by a SAMHD dentist\nBaseline Rate for Urgency of Need for Dental Care:  21/423=4.964","Percentage of children with urgent dental care needs","ambulatory",null,"Number of children with urgent dental care needs","Total number of children seen by a dental provider",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.8.9","","Percentage of children with urgent dental care needs",null,null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2013-09-01","2014-06-30",null,null,"RHP 6_091308902.1.1","RHP 6_091308902.3.3","RHP 6_091308902.1.1_091308902.3.3",{"$f":"COUNTIFS($FI$4:$FI1613,FI1613)","v":1},"RHP 6_091308902.1.1_1",null,2,1,1,"RHP 6_091308902",{"$f":"COUNTIFS($FR$4:$FR1613,FR1613)","v":1},"RHP 6_091308902_1"]
["RHP 6","091308902","San Antonio Metropolitan Health District","091308902.2.5","091308902.3.203","IT-8.15","Exclusive Breastfeeding at 6 Months ","Baseline Approved","Eligible to Report in October DY4","Implement the Baby Café Model in San Antonio to increase breastfeeding rates and thus reduce childhood obesity rates. Establish a “Baby Café” breastfeeding drop-in center to expand services and attract mothers of all ages and from all sectors of the community.  This will be done by providing breastfeeding help and support, from both skilled health professionals, para-professionals, and other mothers, in a friendly, non-clinical, café style environment.","Exclusive Breastfeeding at 6 Months ","In DY4 and DY5, the provider will report the number of Metro Health (inclusive of Metro WIC, Baby Café, and Baby Café satellite locations) caregivers of children born in a cohort year who indicate their child was exclusively breastfed (given nothing but breast milk) through 6 months of age out of all children born in the same cohort year at Metro Health (inclusive of Metro WIC, Baby Café, and Baby Café satellite locations).  In addition, in DY5 provider will demonstrate improvement by preparing a qualitative report on the impact of Baby Cafe services on the breast feeding self-efficacy of clients (SA3).. ","Facility ","Limit to Metro Health (inclusive of Metro WIC, Baby Café, and Baby Café satellite locations)","P4R","SA3","PM-8","Submission of Category 3 DY3 Status Report",94232.215000000011,"Yes/No","RHP 6_091308902.3.203_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",94232.215000000011,"Yes/No","RHP 6_091308902.3.203_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",302645.96999999997,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",219252.44000000003,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",219252.44000000003,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.3,9,30,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Project data was analyzed as follows:\n1. 597 women were served during DY\n2. 228 = Number of infants born in cohort year October 1, 2013 to September 30, 2014 after filtering step 1 data\n3. 40 = Number of infants born in cohort year that were at least 6 months of age (October 1, 2013 – March 30, 2014) after filtering step 2 data\n4. 10 = Records missing data need to establish the rate\n5. 30 = Number of cases available to establish the rate after removal of 10 cases in step 4\nAssessed responses in the data set to the following question:  Did your baby only get breast milk through 3 months of age (never received supplementation)?\n6.  21 = Number of cases where caregiver indicated “no”, infant did not only get breast milk through 6 months of age (infant receive supplementation prior to 6 months of age)\n7.  9  = Number of cases where caregiver reported their child was exclusively breastfed through 6 months of age.\n8.  RATE:  9/30 = 30 % \nIMPORTANT NOTE:  On October 17, 2014, provider submitted the following question to the HHSC Mailbox and received the following responses on October 24, 2014.  The responses are indicated by CAPITAL letters.\nTo: 'TXHealthcareTransformation@HHSC.state.tx.us'\nCc: Rachelle Ruiz (SAMHD); Theresa Medina (SAMHD); Christina Padilla (SAMHD); Mary Diana Montano (SAMHD); Norma Lucia Sifuentes (SAMHD)\nSubject: TPI 091308902 Project ID 091308902.2.5 Question\n\nBackground: For Project ID 091308902.2.5 Our approved denominator subset (facility) includes post partum women served through Metro Health including WIC participants, Baby Café participants and WIC-Baby Café Satellite project participants to assess our performance on three Category 3 measures – IT8.14 through IT8.16.\n\nOur original intent was to use the SAMH’s WIC population to establish the breastfeeding baseline by using local data from the Texas WIC information system.\nHowever, we have recently been informed by DSHS that this data is not a good source for this purpose due to data limitations associated with assumptions that would need to be made to compute a proportion.\nAs a result, the only data available to establish our baseline denominator is data from our first year intervention population, e.g., our main Baby Café site and 5 WIC-Baby Café satellite sites.\n\nQuestion 1: Is it permissible for us to use the intervention populations served between October 1, 2013 through September 30, 2014 at our main Baby Café Site and the 5 Baby Café WIC satellites to establish our baseline? If not, does HHSC have specific recommendations or direction? THAT IS FINE, AS THIS APPEARS TO ALIGN WITH YOUR APPROVED CAT 3 DENOMINATOR. \n\nQuestion 2: If your response is yes, it will be necessary to limit our project denominator (e.g., number of children born in the same cohort year) subset (facility) to our main Baby Café site and the 5 WIC (Baby Café satellite sites). What is the process to formally accomplish this? i.e., have the change approved.  PLEASE DESCRIBE THE COHORT IN THE QUALITATIVE FIELDS OF THE BASELINE TEMPLATE AND GIVE A DESCRIPTION OF THE SUBSET MODIFICATION REQUESTED.\n\nQuestion 3: Based on the above, should we be requesting a baseline exemption form as what we are requesting to do deviates from our approved subset? NO NEED FOR AN EXEMPTION AS WHAT  YOU DESCRIBED ABOVE IS MORE A CLARIFICATION AND YOUR BASELINE YEAR DENOMINATOR WILL ALIGN WITH WHAT YOU ARE REPORTINGIN DY4 AND DY5 (DIFFERENT COHORT BUT SAME DEFINITION)\n\n","30% is the value against which project performance will be measured in DY 4 and 5  and has a positive directionality meaning that any increase over the baseline rate is an improvement.   ","Exclusive Breastfeeding at 6 Months ","ambulatory",null,"Number of caregivers of children born in a cohort year who indicate their child was exclusively breastfed (given nothing but breast milk) through 6 months of age.\n","Number of children born in the same cohort year.",null,null,null,null,null,null,null,null,null,null,"As this is a P4R measure SA3 will also be completed to include more in depth qualitative and quantitative programmatic evaluation of facilitators and barriers to breastfeeding for project participants.",null,null,"2.7.5","","Exclusive Breastfeeding at 6 Months ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 6_091308902.2.5","RHP 6_091308902.3.203","RHP 6_091308902.2.5_091308902.3.203",{"$f":"COUNTIFS($FI$4:$FI1619,FI1619)","v":2},"RHP 6_091308902.2.5_2",null,2,1,1,"RHP 6_091308902",{"$f":"COUNTIFS($FR$4:$FR1619,FR1619)","v":7},"RHP 6_091308902_7"]
["RHP 6","094154402","Methodist Hospital","094154402.1.2","094154402.3.2","IT-9.6","Emergency department (ED) visits where patients left without being seen","Baseline Approved","Eligible to Report in April DY4","Project is to expand specialty care capacity by locating an Urgent Care Center in Central San Antonio in a community area of need.","Emergency department (ED) visits where patients left without being seen","In DY4 and DY5 provider will improve (decrease) the percentage of patients presenting to the emergency department (ED) at Methodist's campuses who did not wait after having clinical information documented about their presenting complaint, during the measurement period.","Facility ","Total number of patients presenting to the Emergency Department of TPI 094154402 during the time period.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",54928.04,"Yes/No","RHP 6_094154402.3.2_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",54928.04,"Yes/No","RHP 6_094154402.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",88140.585000000006,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",88140.585000000006,"Numeric",9.1120264555683995E-3,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",421541.25,"Numeric",8.6324461158016428E-3,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",9.5916067953351579E-3,2622,273364,"DY2: Oct 1st, 2012 - Sept 30th, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,9.1120264555683995E-3,null,8.6324461158016428E-3,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator includes all patients presenting to the Emergency Department of TPI 094154402, except for Obstetrical patients.  The data was then filtered to identify only those patients whose records indicated that they left before being seen.","During the 12-month period from 10/1/2012 to 9/30/2013, of those patients presenting to the Emergency Department at Methodist's campuses,  0.96% did not did not wait for treatment after providing clinical information regarding their reason for presenting to the Emergency Department.","Emergency department (ED) visits where patients left without being seen","ED",null,"Number of patients presenting to the emergency department (ED) who did not wait* after having clinical information documented** about their presenting complaint, during the time period","Total number of patients presenting to the emergency department (ED), during the time period",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1","","Emergency department (ED) visits where patients left without being seen",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 6_094154402.1.2","RHP 6_094154402.3.2","RHP 6_094154402.1.2_094154402.3.2",{"$f":"COUNTIFS($FI$4:$FI1627,FI1627)","v":1},"RHP 6_094154402.1.2_1",null,2,1,1,"RHP 6_094154402",{"$f":"COUNTIFS($FR$4:$FR1627,FR1627)","v":4},"RHP 6_094154402_4"]
["RHP 6","112676501","Nix Health Care System","112676501.2.1","112676501.3.3","IT-12.4","Pneumonia vaccination status for older adults ","Baseline Approved","Eligible to Report in October DY4","Implement the Medical Home Model in at least 1 primary care clinic, to strengthen the clinician-patient relationship and replace the episodic care with coordinated care and long-term healing relationships.","Pneumonia vaccination status for older adults ","In DY4 and DY5, the provider will improve the percentage of patients who have ever received a pneumococcal vaccination over all patients 65 years and older seen at the Nix Healthcare System Patient Centered Medical Home (PCMH) facility","Facility ","Restrict to PCMH Facility","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",46525.454999999994,"Yes/No","RHP 6_112676501.3.3_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",47397.486875000002,"Yes/No","RHP 6_112676501.3.3_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",79987.414999999994,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",79987.42,"Numeric",0.66,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",355926.55,"Numeric",0.67600000000000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.50750799999999996,169,333,"CY 2014 (1): January 1, 2014 - June 30, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.66,null,0.67600000000000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator consist of all the patients that are 65 years of age and older. The numerator is all of the patients that have received a pneumonia vaccination. ","This baseline for pneumonia vaccination is a representation of percentage of  patients that have received  pneumonia vaccination that are 65 years of age and older. We will continue to strive to improve the percentage of patients that received the had recieved the pneumonia vaccionation. ","Pneumonia vaccination status for older adults ","Ambulatory/Inpatient",null,"The number of patients in the denominator who responded “Yes” to the question “Have you ever had a pneumonia shot? This shot is usually given only once or twice in the person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.”","The number of patients who responded “Yes” or “No” to the question “Have you ever had a pneumonia shot? This shot is usually given only once or twice in a person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.” ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.1.1","","Pneumonia vaccination status for older adults ",null,null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2014-01-01","2014-06-30",null,null,"RHP 6_112676501.2.1","RHP 6_112676501.3.3","RHP 6_112676501.2.1_112676501.3.3",{"$f":"COUNTIFS($FI$4:$FI1636,FI1636)","v":3},"RHP 6_112676501.2.1_3",null,2,1,1,"RHP 6_112676501",{"$f":"COUNTIFS($FR$4:$FR1636,FR1636)","v":5},"RHP 6_112676501_5"]
["RHP 6","112688002","Frio Hospital Association Inc dba Frio Regional Ho","112688002.1.1","112688002.3.1","IT-1.12","Diabetes care: Retinal eye exam ","Pending Approval","Eligible to Report in October DY4","This project will expand access to primary care by recruiting additional physicians, building new clinic space and increasing efficiencies in clinic offices.","Diabetes care: Retinal eye exam ","In DY4 and DY5 provider will improve the percentage of individuals age 18-75 with diabetes that have received a retinal screening exam during the measurement year. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",16629.415000000001,"Yes/No","RHP 6_112688002.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",16629.415000000001,"Yes/No","RHP 6_112688002.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",18415.665000000001,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",18415.665000000001,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",42856.33,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Diabetes care: Retinal eye exam ","ambulatory",null,"Patients who received an eye screening for diabetic retinal disease. This includes diabetics who had the following:\n- A retinal or dilated eye exam by an eye care professional (optometrist or ophthalmologist) in the measurement year\n\nOR\n\n- A negative retinal exam or dilated eye exam (negative for retinopathy) by an eye care professional in the year prior to the measurement year.\n\nFor exams performed in the year prior to the measurement year, a result must be available.\n\n","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2",null,"Diabetes care: Retinal eye exam ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 6_112688002.1.1","RHP 6_112688002.3.1","RHP 6_112688002.1.1_112688002.3.1",{"$f":"COUNTIFS($FI$4:$FI1641,FI1641)","v":1},"RHP 6_112688002.1.1_1",null,2,1,1,"RHP 6_112688002",{"$f":"COUNTIFS($FR$4:$FR1641,FR1641)","v":1},"RHP 6_112688002_1"]
["RHP 6","112690603"," Dimmit County Memorial Hospital","112690603.1.2","112690603.3.501","IT-9.10.c","Median time from ED arrival to time of departure from the emergency room for patients admitted to the facility from the ED","Baseline not yet reported","Eligible to Report in October DY4","Introduce an urgent medical advice line while simultaneously creating a “fast track” triage system for the ED","Median time from ED arrival to time of departure from the emergency room for patients admitted to the facility from the ED","In DY4 and DY5 provider will improve (reduce) the median time from emergency department (ED) arrival to time of departure from the emergency room for patients admitted to the facility from the ED.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",32995.523333333338,"Yes/No","RHP 6_112690603.3.501_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",32995.523333333338,"Yes/No","RHP 6_112690603.3.501_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",45182.446666666663,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",45182.446666666663,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",175430.66666666666,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"time (minutes)",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Median time from ED arrival to time of departure from the emergency room for patients admitted to the facility from the ED","ED",null,"Median time from ED arrival to time of departure from the emergency room for patients admitted to the facility from the ED: Continuous variable statement: Time (in minutes) from emergency department (ED) arrival to ED departure for patients admitted to the facility from the ED",1,null,null,null,null,null,null,null,null,null,null,null,null,null,"1.6.2","","Median time from ED arrival to time of departure from the emergency room for patients admitted to the facility from the ED",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 6_112690603.1.2","RHP 6_112690603.3.501","RHP 6_112690603.1.2_112690603.3.501",{"$f":"COUNTIFS($FI$4:$FI1649,FI1649)","v":3},"RHP 6_112690603.1.2_3",null,2,1,1,"RHP 6_112690603",{"$f":"COUNTIFS($FR$4:$FR1649,FR1649)","v":4},"RHP 6_112690603_4"]
["RHP 6","119877204","Val Verde Regional Medical Center","119877204.1.1","119877204.3.5","IT-12.4","Pneumonia vaccination status for older adults ","Baseline Approved","Eligible to Report in October DY4","Expand primary care resources in this medically underserved community. The hospital has a clinic affiliated with it, and the scope of the project will be to add providers in an effort to expand access to care in Val Verde County","Pneumonia vaccination status for older adults ","In DY4 and DY5, the provider will improve the percentage of patients who have ever received a pneumococcal vaccination over all patients 65 years and older",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",18399.645,"Yes/No","RHP 6_119877204.3.5_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",18399.645,"Yes/No","RHP 6_119877204.3.5_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",28663.174999999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",28663.18,"Numeric",0.66,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",133902.12,"Numeric",0.67600000000000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.30126399999999998,858,2848,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.66,null,0.67600000000000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator and denominator where determined by extracted information from the EMR (eCW). The data ties to NQF measures reported to CMS for PQRS and Meaningful Use. The Quality Core Measure NQF 0038G Report for Pneumonia Vaccine Screening was run from our EMR.  The report pulled patient account information for both the numerator and denominator.  We then manually verified the accounts to ensure data integrity.","After reviewing the calculation we have interpreted the following.  1.) Staff in our clinic can better utilize the EMR to help capture this data.  We will re-train our clinical and medical staff on the importance of screening for pneumonia vaccine in the appropriate patient population.  2.)  While we did significantly better in screening patients for appropriate pneumonia vaccine we should strive to increase the number of patient screened for this vaccine.  3.) We need to improve our baseline rate and increase outreach efforts.  We believe we should not only improve our conversion (numerator) but we should simultaneously increase our denominator by screening more patients in our community.  ","Pneumonia vaccination status for older adults ","Ambulatory/Inpatient",null,"The number of patients in the denominator who responded “Yes” to the question “Have you ever had a pneumonia shot? This shot is usually given only once or twice in the person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.”","The number of patients who responded “Yes” or “No” to the question “Have you ever had a pneumonia shot? This shot is usually given only once or twice in a person’s lifetime and is different from the flu shot. It is also called the pneumococcal vaccine.” ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1","","Pneumonia vaccination status for older adults ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 6_119877204.1.1","RHP 6_119877204.3.5","RHP 6_119877204.1.1_119877204.3.5",{"$f":"COUNTIFS($FI$4:$FI1653,FI1653)","v":3},"RHP 6_119877204.1.1_3",null,2,1,1,"RHP 6_119877204",{"$f":"COUNTIFS($FR$4:$FR1653,FR1653)","v":3},"RHP 6_119877204_3"]
["RHP 6","121990904","Camino Real Community Services","121990904.1.1","121990904.3.201","IT-6.2.a","Client Satisfaction Questionnaire 8 (CSQ-8)","Baseline not yet reported","Eligible to Report in October DY4","Center’s intent to provide a minimum of a 10 bed Crisis Residential Facility.","Client Satisfaction Questionnaire 8 (CSQ-8)","In DY4 and DY5 provider will improve average score on the CSQ-8 out of all surveys completed during the measurement period.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",20311.564999999999,"Yes/No","RHP 6_121990904.3.201_PM-8","Metric Carried Forward in October DY3","PM-9","Validation and submission of baseline performance",20311.564999999999,"Yes/No","RHP 6_121990904.3.201_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",60625.88,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",100538,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"dy4","TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Client Satisfaction Questionnaire 8 (CSQ-8)","Ambulatory",null,"The sum of the \"overall score\" for all CSQ-8 surveys completed during the measurement period.  ","The total number of CSQ-8 surveys completed during the measurement period. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.13.1",null,"Client Satisfaction Questionnaire 8 (CSQ-8)",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 6_121990904.1.1","RHP 6_121990904.3.201","RHP 6_121990904.1.1_121990904.3.201",{"$f":"COUNTIFS($FI$4:$FI1663,FI1663)","v":2},"RHP 6_121990904.1.1_2",null,1,1,0,"RHP 6_121990904",{"$f":"COUNTIFS($FR$4:$FR1663,FR1663)","v":2},"RHP 6_121990904_2"]
["RHP 6","126844305","Bluebonnet Trails Community MHMR Center","126844305.2.2","126844305.3.4","IT-11.26.c","Adult Needs and Strength Assessment (ANSA)","Baseline Approved","Eligible to Report in October DY4","Peer Led Transitional Services Program for individuals in transitional housing. People admitted to the program will engage in psychosocial skills training and participate in a Peer led Wellness, Recovery, and Action Plan. BTCS is developing a program that includes not only transitional services but staff and resources to improve housing stock and locate and help individuals achieve Permanent Supportive Housing that comports with SAMHSA guidelines","Adult Needs and Strength Assessment (ANSA)","In DY4 and DY5, the provider will report the average score on the Adult Needs and Strength Assessment (ANSA) among all completed surveys by patients receiving services in the Transitional Homes located in Guadalupe county. In DY5, the provider will demonstrate improvement by improving the performance on CMHC.1 Follow-up after hospitalization for mental illness (7-day follow-up).","Facility ","Transitional Homes located in Guadalupe county","P4R","CMHC.1","PM-8","Submission of Category 3 DY3 Status Report",34487.004999999997,"Yes/No","RHP 6_126844305.3.4_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",34487.004999999997,"Yes/No","RHP 6_126844305.3.4_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",73841.58,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",80241.985000000001,"Yes/No","NA","AM-3.1","Achievement of DY5 performance goal for PFP measure",80241.985000000001,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Score",2.8475000000000001,219.2576,77,"10/01/13 - 09/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The total number of ANSA assessments completed during the reporting period was used for the Denominator.  When the ANSA is administered, each of the dimensions is rated on its own scale.  After administering the assessment, scores of items in each dimension should be added together then divided by the total number of items in each dimension, to create a dimension score for each dimension.  Dimension scores are determined by dividing the score of all dimension items by the number of items in the dimension.   Dimension scores for the five mandatory dimension were then added together to create an “overall score”. \n","This baseline rate indicates that the average assessment score for all or the administrations of that assessment, ANSA.  It sets a baseline against which future years can be judged to gauge improvement in the average score which should indicate program and patient change.","Adult Needs and Strength Assessment (ANSA)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,"PFP baseline under review",null,"2.13.1","Scenario 3: Average Score","Adult Needs and Strength Assessment (ANSA)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 6_126844305.2.2","RHP 6_126844305.3.4","RHP 6_126844305.2.2_126844305.3.4",{"$f":"COUNTIFS($FI$4:$FI1671,FI1671)","v":1},"RHP 6_126844305.2.2_1",null,2,1,1,"RHP 6_126844305",{"$f":"COUNTIFS($FR$4:$FR1671,FR1671)","v":4},"RHP 6_126844305_4"]
["RHP 6","133260309","Medina County Hospital District dba Medina Regional","133260309.1.100","133260309.3.100","IT-9.10.a","Median Time from ED Arrival to ED Departure for Discharged ED Patients","Baseline Approved","Eligible to Report in October DY4","The project will provide access to medical advice and direction to the appropriate level of care and increase access to appropriate healthcare by establishing a nurse call center. Additionally, an integrated system of urgent appointments/scheduling will be instituted. This will allow patients to schedule an appointment the next day in one of our Rural Health Clinics.","Median Time from ED Arrival to ED Departure for Discharged ED Patients","In DY4 and DY5 provider will improve (reduce) the median time from emergency department arrival to time of departure from the emergency room for patients discharged from the emergency department\n",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",7791.666666666667,"Yes/No","RHP 6_133260309.3.100_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",7791.666666666667,"Yes/No","RHP 6_133260309.3.100_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",13175,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",13175,"Numeric",130.15,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",67833.33,"Numeric",123.3,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"time (minutes)",137,137,1,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,130.15,null,123.3,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator - Continuous variable statement (time in minutes); Rate #1 = ED arrival to ED departure for patients discharged from the emergency department; Rate #2 = Admit decision time to time of departure from the emergency department for ED patients admitted to inpatient status; Rate #3 = Emergency department arrival to ED departure for patients admitted to the facility from the ED; Denominator - Median time for values identified in rates 1, 2, and 3.","137 minutes","Median Time from ED Arrival to ED Departure for Discharged ED Patients","ED",null,"Median Time from ED Arrival to ED Departure for Discharged ED Patients: Continuous Variable Statement: Time (in minutes) from ED arrival to ED departure for patients discharged from the emergency department. ",1,null,null,null,null,null,null,null,null,null,null,null,null,null,"1.6.2","","Median Time from ED Arrival to ED Departure for Discharged ED Patients",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 6_133260309.1.100","RHP 6_133260309.3.100","RHP 6_133260309.1.100_133260309.3.100",{"$f":"COUNTIFS($FI$4:$FI1678,FI1678)","v":1},"RHP 6_133260309.1.100_1",null,2,1,1,"RHP 6_133260309",{"$f":"COUNTIFS($FR$4:$FR1678,FR1678)","v":4},"RHP 6_133260309_4"]
["RHP 6","133340307","Hill Country Community MHMR Center ","133340307.2.2","133340307.3.3","IT-11.19","Assessment for Psychosocial Issues of Psychiatric Patients ","Baseline Approved","Eligible to Report in October DY4","This project will implement psychiatric and clinical guidance 24 hour a day, 7 day a week for primary care physicians and hospitals within the 11 counties served by Hill Country in RHP6 in order to help physicians identify and treat behavioral health symptoms earlier in order to avoid exacerbation of symptoms into a behavioral health crisis.","Assessment for Psychosocial Issues of Psychiatric Patients ","In DY4 and DY5 provider will improve the percentage of individuals that have documented assessment of psychosocial and developmental history out of all individuals receiving Psychiatric Consulting services. ","Facility ","Individuals served by Psychiatric Consulting from community providers (primary care physicians, hospitals, etc.) who have contracted for the service","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",5855.27,"Yes/No","RHP 6_133340307.3.3_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",5855.27,"Yes/No","RHP 6_133340307.3.3_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",9269.98,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",9269.98,"Numeric",0.74090909100000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",27246.46,"Numeric",0.75454545399999995,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.72727299999999995,32,44,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.74090909100000002,null,0.75454545399999995,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator-count of individuals receiving Psychiatric Consultation with a witness Psychosocial Assessment from the Primary Care provider; Denominator0count of individuals receiving Psychiatric Consultation","Primary Care recognizes the importance of collecting Psychosocial Assessments on individuals with potential psychiatric issues but increase awareness and collection of information is needed","Assessment for Psychosocial Issues of Psychiatric Patients ","Ambulatory/Inpatient",null,"Number of individuals in the denominator whose medical record documents a psychosocial/developmental history.","All individuals age 18 and older who undergo a psychiatric evaluation during the measurement period.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.16.1","","Assessment for Psychosocial Issues of Psychiatric Patients ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 6_133340307.2.2","RHP 6_133340307.3.3","RHP 6_133340307.2.2_133340307.3.3",{"$f":"COUNTIFS($FI$4:$FI1685,FI1685)","v":2},"RHP 6_133340307.2.2_2",null,2,1,1,"RHP 6_133340307",{"$f":"COUNTIFS($FR$4:$FR1685,FR1685)","v":4},"RHP 6_133340307_4"]
["RHP 6","135151206","Connally Memorial Medical Center","135151206.1.2","135151206.3.2","IT-1.10","Diabetes care: HbA1c poor control (>9.0%) ","Pending Approval","Eligible to Report in October DY4","Connally Memorial Medical Center proposes to establish additional hospital owned and operated primary care clinics.","Diabetes care: HbA1c poor control (>9.0%) ","In DY4 and DY5, the provider will improve the percentage of patients seen at Connally memorial primary Care clinic - Dr. Ekmart and Dr. Peterson,  18-75 years of age with diabetes (type 1 and type 2) whose most recent HbA1c level during the measurement year was greater than 9.0% (poor control) or was missing a result, or if an HbA1c test was not done during the measurement year.","Facility ","Connally memorial primary Care clinic - Dr. Ekmart and Dr. Peterson","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",24329.5,"Yes/No","RHP 6_135151206.3.2_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",24329.5,"Yes/No","RHP 6_135151206.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",39069.25,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",39069.25,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",186805,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The Denominator was obtained screening for patients from the age of 18-75 by the end of the measurement year (9/1/2013 thru 8/31/2014)  This was pulled using the e-Clinical Works database selecting all patient (with the above parameters that were scheduled with status: checking out of visit, rescheduled, missed, & no SHOWS. (5.04 ecw report)                    The NUMERATOR was determined as:  all patients who had had a HbA1c >9, a test not performed within this measurement year or missing a result in the patient's ambulatory care record eCW.  Numerator/denominator was abstracted using the record management system indicated in row 174 column L.","Of the targeted diabetic type 1 and type 2 patients with age 18-75 years who are  registered in the two Family Practice Clinics combined,  the targeted population to focus controlling the HbA1c  to  a level of <9% is 45%.","Diabetes care: HbA1c poor control (>9.0%) ","ambulatory",null,"Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1","","Diabetes care: HbA1c poor control (>9.0%) ",null,null,null,null,null,"2014-09-01","2015-08-31","2015-09-01","2016-08-31","2013-09-01","2014-08-31",null,null,"RHP 6_135151206.1.2","RHP 6_135151206.3.2","RHP 6_135151206.1.2_135151206.3.2",{"$f":"COUNTIFS($FI$4:$FI1693,FI1693)","v":1},"RHP 6_135151206.1.2_1",null,2,1,1,"RHP 6_135151206",{"$f":"COUNTIFS($FR$4:$FR1693,FR1693)","v":2},"RHP 6_135151206_2"]
["RHP 6","136141205","University Hospital","136141205.1.4","136141205.3.218","IT-1.7","Controlling high blood pressure ","Baseline Approved","Eligible to Report in October DY4","This project will employ telemedicine services to improve access to specialty care ","Controlling high blood pressure ","In DY4 and DY5, the provider will improve the percentage of patients seeking services at a CMA clinic, 18 to 85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90) during the measurement year","Facility ","CMA Primary care clinic patients 18 to 85 years of age by the end of the measurement year who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",264772.67499999999,"Yes/No","RHP 6_136141205.3.218_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",264772.67499999999,"Yes/No","RHP 6_136141205.3.218_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",420062.54499999998,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",420062.55,"Numeric",0.67520323400000004,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1959814.7,"Numeric",0.67696999999999996,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.67343699999999995,5504,8173,"September 1, 2013 -August 31, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.67520323400000004,null,0.67696999999999996,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Per measure specification and in alignment with subset parameters, the numerator and denominator were calculated as follows: Denominator (8,173 patients) was defined as the total number of patients ages 18-85 that had at least one outpatient encounter at the selected Community Medicine Associates location during the measurement period and had a diagnosis of hypertension within the first 6 months of the measurement year. Numerator (5,504 patients) is the total number of unique patients from the denominator who had a blood pressure reading within the measure period that was in control (<140/90).","Our interpretation is that of the 8,173 patients who met the denominator per measure specification and selected clinic subset, 5,504 patients had their hypertension under control (<140/90) by the end of the measurement period, resulting in a baseline rate of 67.34%.The project will therefore focus on increasing the number of individuals in good blood pressure control. ","Controlling high blood pressure ","ambulatory",null,"The number of patients in the denominator whose most recent BP is adequately controlled during the measurement year. For a patient’s BP to be controlled, both the systolic and diastolic BP must be <140/90 (adequate control). To determine if a patient’s BP is adequately controlled, the representative BP must be identified.\n","Patients 18 to 85 years of age by the end of the measurement year who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.7.1","","Controlling high blood pressure ",null,null,null,null,null,"2014-09-01","2015-08-31","2015-09-01","2016-08-31","2013-09-01","2014-08-31",null,null,"RHP 6_136141205.1.4","RHP 6_136141205.3.218","RHP 6_136141205.1.4_136141205.3.218",{"$f":"COUNTIFS($FI$4:$FI1703,FI1703)","v":1},"RHP 6_136141205.1.4_1",null,2,1,1,"RHP 6_136141205",{"$f":"COUNTIFS($FR$4:$FR1703,FR1703)","v":10},"RHP 6_136141205_10"]
["RHP 6","136141205","University Hospital","136141205.1.7","136141205.3.207","IT-6.1.a.v","HCAHPS Communication about Medicine","Baseline Approved","Eligible to Report in October DY4","This project will enhance awareness and establish an integrated interpretation service in order to ensure that health information is provided in a manner that is appropriate to a patient’s linguistic and cultural orientation. ","HCAHPS Communication about Medicine","In DY4 and DY5 provider will improve (increase) the percentage of top box scores for HCAHPS subdomain for Communication About Medicine",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",264772.67499999999,"Yes/No","RHP 6_136141205.3.207_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",264772.67499999999,"Yes/No","RHP 6_136141205.3.207_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",420062.54499999998,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",420062.55,"Numeric",0.60829999999999995,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1959814.7,"Numeric",0.61960000000000004,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.59699999999999998,111.042,186,"CY 2014 (1): January 1, 2014 - June 30, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.60829999999999995,null,0.61960000000000004,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Describe how the numerator and denominator values reported above were determined The data for the measure is collected per measure specifications from the National Research Corporation (NRC). The denominator (186 patients) was calculated as the total number of patients who received and completed a survey administered by NRC Picker. The numerator value (111.042) was determined by calculating the percentage of patients who responded with the most positive response (“top box” score) for the survey questions and multiplied by the number of completed surveys (0.597x186=111.042). *****Per the compendium document the top box score is a whole number resulting in a large denominator (11104.2). If this number is placed into the template the resulting baseline is 5970%.  The top box score must be converted from a percentage to a decimal number for the calculation to be correct.  The resulting baseline is 59.7%***** ","Our interpretation is that during the baseline measurement period (01/01/14-06/30/14), 59.7% of patients responded positively when questioned on the dimension of “Communication About Medicine” on the HCAPHS survey.","HCAHPS Communication about Medicine","Inpatient",null,"Patient-mix and survey mode adjusted percent \"top box\" score for a given subdomain as provided by your survey administrator, multiplied by the number of completed surveys represented in the \"top box\" score.","The number of HCAHPS surveys completed during the measurement period as reported by your survey administrator. The denominator should be the same as the multiplier used in the numerator. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.4.1","","HCAHPS Communication about Medicine",null,null,null,null,null,"2014-07-01","2015-06-30","2015-07-01","2016-06-30","2014-01-01","2014-06-30",null,null,"RHP 6_136141205.1.7","RHP 6_136141205.3.207","RHP 6_136141205.1.7_136141205.3.207",{"$f":"COUNTIFS($FI$4:$FI1707,FI1707)","v":1},"RHP 6_136141205.1.7_1",null,2,1,1,"RHP 6_136141205",{"$f":"COUNTIFS($FR$4:$FR1707,FR1707)","v":14},"RHP 6_136141205_14"]
["RHP 6","136141205","University Hospital","136141205.2.1","136141205.3.203","IT-3.22","Risk Adjusted All-Cause Readmission","Baseline Approved","Eligible to Report in October DY4","This project will implement a care transitions program specifically to improve access and will involve follow up calls to and/or home visits to better activate patient engagement by a transition coach following a routine visit and or discharge from an acute setting.","Risk Adjusted All-Cause Readmission","In DY4 and DY5 provider will improve the ratio of observed to expected rate of readmissions within 30 days following discharge from an index admission for any cause. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",264772.67499999999,"Yes/No","RHP 6_136141205.3.203_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",264772.67499999999,"Yes/No","RHP 6_136141205.3.203_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",420062.54499999998,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",420062.55,"Numeric",0.71669117699999996,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1959814.7,"Numeric",0.67897099999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",0.75441199999999997,5.1299999999999998E-2,6.8000000000000005E-2,"September 1, 2013 -August 31, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.71669117699999996,null,0.67897099999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Both the numerator and denominator were determined based on 3M’s PPR methodology. Monthly inpatient data obtained directly from University Health System covering the measurement period September 2013 to August 2014. These files were submitted in the 837 File Format (CMS Standard Format), version 5010. To enable fair comparisons among hospitals, differences in base APR-DRG, severity of illness, patient age, and MH/SA comorbidity were factored into the calculation of the expected rates for risk-adjusted HF and 3m potentially preventable readmission. Per 3M expected rates were based on the experience of the Florida all payer population (based on 2008 to 2010 claims).","Our observed rate indicates that our health system’s actual potentially preventable readmission rate (5.13%) was lower than the expected rate (6.80%), which, translates into a ratio of .7544 (5.13/6.80). Based on this ratio, University Health System’s PPR rate is lower than expected for a hospital with its case mix.","Risk Adjusted All-Cause Readmission","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk admissions during the measurement period.","Expected (risk-adjusted) rate of readmissions for all-causes during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.12.1","","Risk Adjusted All-Cause Readmission",null,null,null,null,"3M-TREO Group","2014-09-01","2015-08-31","2015-09-01","2016-08-31","2013-09-01","2014-08-31",null,null,"RHP 6_136141205.2.1","RHP 6_136141205.3.203","RHP 6_136141205.2.1_136141205.3.203",{"$f":"COUNTIFS($FI$4:$FI1712,FI1712)","v":1},"RHP 6_136141205.2.1_1",null,2,1,1,"RHP 6_136141205",{"$f":"COUNTIFS($FR$4:$FR1712,FR1712)","v":19},"RHP 6_136141205_19"]
["RHP 6","136141205","University Hospital","136141205.2.4","136141205.3.205","IT-9.4.b","Reduce Emergency Department visits for Diabetes","Baseline Approved","Eligible to Report in October DY4","This project will establish a patient navigation model comprised of social workers and case managers within the ambulatory setting","Reduce Emergency Department visits for Diabetes","In DY4 and DY5, the provider will improve the percentage of ED Visits with a primary or secondary diagnosis of diabetes for any individual 18 years and older during the measurement period over all University Hospital ED visits for CMA clinic patients 18 years or older","Facility ","Total number of ED visits at University Hospital for individuals 18 years or older seen in a CMA clinic during the measurement period.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",264772.67499999999,"Yes/No","RHP 6_136141205.3.205_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",264772.67499999999,"Yes/No","RHP 6_136141205.3.205_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",420062.54499999998,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",420062.55,"Numeric",0.19086758000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1959814.7,"Numeric",0.18082200000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.20091300000000001,88,438,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.19086758000000001,null,0.18082200000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator and denominator were calculated per measure specifications and in alignment with subset parameters. The denominator was calculated as the number of EDC visits for patients 18 years who had a visit to a selected facility (subset) during the measurement period. The numerator was calculated as the total number of EDC Visits with a primary or secondary diagnosis of diabetes for any individual 18 years and older during the measurement period. ","Our interpretation is that of patients 18 years and older who had a visit to a selected facility during the measurement year, there were 438 total EDC visits, of which there were a total of 88 visits with a primary or secondary diagnosis of diabetes thus resulting in a baseline rate of 20.09%.","Reduce Emergency Department visits for Diabetes","ED",null,"Total number of ED Visits with a primary or secondary diagnosis of diabetes for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1","","Reduce Emergency Department visits for Diabetes",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 6_136141205.2.4","RHP 6_136141205.3.205","RHP 6_136141205.2.4_136141205.3.205",{"$f":"COUNTIFS($FI$4:$FI1720,FI1720)","v":1},"RHP 6_136141205.2.4_1",null,2,1,1,"RHP 6_136141205",{"$f":"COUNTIFS($FR$4:$FR1720,FR1720)","v":27},"RHP 6_136141205_27"]
["RHP 6","136430906","Hill Country Memorial Hospital","136430906.2.1","136430906.3.1","IT-12.1","Breast Cancer Screening","Baseline Approved","Eligible to Report in April DY4","Comprehensive health screening and wellness education for at least 500 uninsured (targeting Medicaid and Indigent individuals) employed residents of Hill Country Memorial Hospital’s service area by partnering with local businesses who are not able to offer insurance to their employees or whose employees are unable to afford the insurance offered due to cost and their low incomes.","Breast Cancer Screening","In DY4 and DY5, the provider will improve the percentage of women that are Wellness Program Participants and who had mammogram during the measurement year or the 18 months prior to the measurement year at the wellness clinic or event over all women 50-74 years old as of the measurement year who had at least one (1) outpatient encounter in the prior 12-month period","Facility ","Wellness Program Participants","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",14593.834999999999,"Yes/No","RHP 6_136430906.3.1_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",14593.834999999999,"Yes/No","RHP 6_136430906.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",23418,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",23418,"Numeric",0.44819999999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",111999.33,"Numeric",0.46614,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.35483900000000002,11,31,"DY2: Oct 1st, 2012 - Sept 30th, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.44819999999999999,null,0.46614,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator was determined using a manual/paper method based on the Sex and Age of our program population : the number of women aged 50-75 in our 1115 wellness program that met the criteria for needing a mammogram.  The numerator was determined by using the patient demographic data from our denominator and manually searching thru our EMR for a record of client receiving a mammogram during the baseline measurement period of 10-1-12 thru 9-30-13.","During the time period of 10-1-12 thru 9-20-13 (before this program was implemented),  of the women aged 50-74 thus far in our program as of October 31, 2014,  35% received a mammogram.  ","Breast Cancer Screening","ambulatory",null,"Women who had mammogram during the measurement year or the 18 months prior to the measurement year.","Women 50-74 years old as of the measurement year who had at least one (1) outpatient encounter in the prior 12-month period. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.7.1","","Breast Cancer Screening",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 6_136430906.2.1","RHP 6_136430906.3.1","RHP 6_136430906.2.1_136430906.3.1",{"$f":"COUNTIFS($FI$4:$FI1729,FI1729)","v":1},"RHP 6_136430906.2.1_1",null,2,1,1,"RHP 6_136430906",{"$f":"COUNTIFS($FR$4:$FR1729,FR1729)","v":1},"RHP 6_136430906_1"]
["RHP 6","137251808","Bexar County Board for MHMR Services","137251808.1.1","137251808.3.1","IT-6.2.a","Client Satisfaction Questionnaire 8 (CSQ-8)","Pending Approval","Eligible to Report in October DY4","A crisis and respite center for children with severe emotional disturbance that will include a total of 16 beds, eight reserved for children in crisis and eight for children whose families require a brief respite. ","Client Satisfaction Questionnaire 8 (CSQ-8)","In DY4 and DY5 provider will improve average score on the CSQ-8 out of all surveys completed during the measurement period.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",117228.41499999999,"Yes/No","RHP 6_137251808.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",117228.41499999999,"Yes/No","RHP 6_137251808.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",126784.36,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",126784.36,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",550719.77,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator represents the total scores obtained by adding the responses of the eight questions to the instrument.  The denominator represents the total number of individuals that completed the survey and excludes those 3 that refused. ","6 months of data was not collected however we received approval from HHSC which we have attached the e-mail from HHSC file name 20_RHP6_137251808.1.1_Crisis_HHSC Email.pdf","Client Satisfaction Questionnaire 8 (CSQ-8)","Ambulatory",null,"The sum of the \"overall score\" for all CSQ-8 surveys completed during the measurement period.  ","The total number of CSQ-8 surveys completed during the measurement period. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.13.1","","Client Satisfaction Questionnaire 8 (CSQ-8)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 6_137251808.1.1","RHP 6_137251808.3.1","RHP 6_137251808.1.1_137251808.3.1",{"$f":"COUNTIFS($FI$4:$FI1734,FI1734)","v":1},"RHP 6_137251808.1.1_1",null,2,1,1,"RHP 6_137251808",{"$f":"COUNTIFS($FR$4:$FR1734,FR1734)","v":1},"RHP 6_137251808_1"]
["RHP 6","137251808","Bexar County Board for MHMR Services","137251808.2.5","137251808.3.11","IT-10.1.b.iii","RAND Short Form 36[1] (SF-36) Health Survey","Pending Approval","Eligible to Report in October DY4","A comprehensive, safe, structured therapeutic milieu for females at Haven for Hope (a master planned campus for homeless families and individuals), to be known as the In-House Women’s Wellness Program (IHWWP).","RAND Short Form 36[1] (SF-36) Health Survey","In DY4 and DY5 provider will improve reported scores on the SF-36 out of all surveys completed during the measurement period.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",57995.56,"Yes/No","RHP 6_137251808.3.11_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",57995.56,"Yes/No","RHP 6_137251808.3.11_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",62723.105000000003,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",62723.105000000003,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",272453.59000000003,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator and denominator values reported obove were determined by automated algorithim and exported with program participants' case number and date survey was completed. ","The baseline rate of 48.45 represents an improvement over the average pretest scores of 33 which reflects the high needs of this vulnerable population with untreated physical and behavioral health disorders and multiple traumatic experiences. ","RAND Short Form 36[1] (SF-36) Health Survey","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.13.1","Scenario 1: Pre/Posttest Baseline","RAND Short Form 36[1] (SF-36) Health Survey",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 6_137251808.2.5","RHP 6_137251808.3.11","RHP 6_137251808.2.5_137251808.3.11",{"$f":"COUNTIFS($FI$4:$FI1745,FI1745)","v":1},"RHP 6_137251808.2.5_1",null,2,1,1,"RHP 6_137251808",{"$f":"COUNTIFS($FR$4:$FR1745,FR1745)","v":12},"RHP 6_137251808_12"]
["RHP 6","138411709","Guadalupe Regional Medical Center","138411709.2.2","138411709.3.3","IT-9.4.e","Reduce Emergency Department visits for Behavioral Health/Substance Abuse","Pending Approval","Eligible to Report in October DY4","Implement the Patient Navigation project to identify patients with high utilization of ED services, and assist to match resources; such as physicians, clinics, teaching, behavioral health and prescription assistance.","Reduce Emergency Department visits for Behavioral Health/Substance Abuse","In DY4 and DY5 provider will improve (decrease) the percentage of ED visits for BH/SA conditions out of the total number of ED visits during the measurement period. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",54532.44,"Yes/No","RHP 6_138411709.3.3_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",54532.44,"Yes/No","RHP 6_138411709.3.3_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",91796.25,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",91796.25,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",442068.63,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The report identified the number of ED visits for individuals 18 years or older during the measurement period.  This number represented the denominator.  The number of visits within the denominator that had a primary or secondary diagnosis or behavioral health and/or substance abuse became our numerator.","The baseline rate was determined by taking the numerator (859) and dividing it by the denominator (25931) .  The baseline rate determines the percent of ED visits for individuals 18 years and older where behavioral health and/or substance abuse is indicated as primary or secondary diagnosis.","Reduce Emergency Department visits for Behavioral Health/Substance Abuse","ED",null,"Total number of ED Visits with a primary or secondary diagnosis of behavioral health and/or substance abuse for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1","","Reduce Emergency Department visits for Behavioral Health/Substance Abuse",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 6_138411709.2.2","RHP 6_138411709.3.3","RHP 6_138411709.2.2_138411709.3.3",{"$f":"COUNTIFS($FI$4:$FI1751,FI1751)","v":1},"RHP 6_138411709.2.2_1",null,2,1,1,"RHP 6_138411709",{"$f":"COUNTIFS($FR$4:$FR1751,FR1751)","v":6},"RHP 6_138411709_6"]
["RHP 6","159156201","Baptist Health System","159156201.1.3","159156201.3.5","IT-3.9","Risk Adjusted Acute Myocardial Infarction (AMI) 30-day Readmission Rate ","Baseline Approved","Eligible to Report in April DY4","This project will establish and staff an office of Operational Improvement. We will train Baptist staff and physicians on Lean and other Process Improvement (PI) tools.","Risk Adjusted Acute Myocardial Infarction (AMI) 30-day Readmission Rate ","In DY4 and DY5 provider will improve the ratio of observed to expected rate of readmissions within 30 days following discharge from an index admission for AMI.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",95574.94,"Yes/No","RHP 6_159156201.3.5_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",95574.94,"Yes/No","RHP 6_159156201.3.5_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",153364.44,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",153364.44,"Numeric",0.706707317,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",733482.11,"Numeric",0.669512,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",0.74390199999999995,6.7100000000000007E-2,9.0200000000000002E-2,"CY 2013: Jan 1st, 2013 - Dec 31st, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.706707317,null,0.669512,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Data was pulled directly from MIDAS and filtered for AMI patients (APRDRG 190).","Observed rate for AMI readmissions is 230 basis points better than our expected rate. Therefore we are doing better than we are expected to be doing","Risk Adjusted Acute Myocardial Infarction (AMI) 30-day Readmission Rate ","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission for AMI during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk AMI admissions during the measurement period.\n","Expected (risk-adjusted) rate of readmissions for AMI during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.10.1","","Risk Adjusted Acute Myocardial Infarction (AMI) 30-day Readmission Rate ",null,null,null,null,"Midas","2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 6_159156201.1.3","RHP 6_159156201.3.5","RHP 6_159156201.1.3_159156201.3.5",{"$f":"COUNTIFS($FI$4:$FI1756,FI1756)","v":2},"RHP 6_159156201.1.3_2",null,2,1,1,"RHP 6_159156201",{"$f":"COUNTIFS($FR$4:$FR1756,FR1756)","v":5},"RHP 6_159156201_5"]
["RHP 7","133340307","Hill Country Community MHMR Center ","133340307.2.1","133340307.3.1","IT-10.1.b.ii","RAND Short Form 12 (SF-12v2)  Health Survey","Baseline not yet reported","Eligible to Report in October DY4","Integrate primary care into the Hays County Mental Health Clinic as a means to address integrating primary and behavioral health care for individuals with Severe and Persistent Mental Illness. The project will enable individuals being treated for Severe and Persistent Mental Illness to have a Health Home at the Hays County Mental Health Center where they can receive both their psychiatric and physical health care thus avoiding potentially preventable admissions to hospitals and reduce emergency department utilization","RAND Short Form 12 (SF-12v2)  Health Survey","In DY4 and DY5, the provider will improve the reported score on the RAND SF-12 over all surveys completed during the measurement period among patients served by Primary Care Services and Mental Health Services at Hays County Mental Health Clinic","Facility ","Individuals served by Primary Care Services and Mental Health Services at Hays County Mental Health Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",16081.48,"Yes/No","RHP 7_133340307.3.1_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",16081.48,"Yes/No","RHP 7_133340307.3.1_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",25774.82,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",25774.82,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",74748.600000000006,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"RAND Short Form 12 (SF-12v2)  Health Survey","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.15.1","","RAND Short Form 12 (SF-12v2)  Health Survey",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 7_133340307.2.1","RHP 7_133340307.3.1","RHP 7_133340307.2.1_133340307.3.1",{"$f":"COUNTIFS($FI$4:$FI1770,FI1770)","v":1},"RHP 7_133340307.2.1_1",null,2,1,1,"RHP 7_133340307",{"$f":"COUNTIFS($FR$4:$FR1770,FR1770)","v":2},"RHP 7_133340307_2"]
["RHP 7","133340307","Hill Country Community MHMR Center ","133340307.2.4","133340307.3.4","IT-11.25","Daily Living Activities (DLA-20)","Baseline Approved","Eligible to Report in October DY4","Implement Trauma Informed Care Services within Hays County served by Hill Country in RHP 7 to meet the needs of adults who have experienced trauma that is impacting their behavioral health. The project will incorporate community education on the impact of trauma through Mental Health First Aid training and Trauma Informed Care training, and provide trauma services through interventions such as Seeking Safety, Trust Based Relational Intervention and Cognitive Processing Therapy to help individuals deal with trauma they have experienced","Daily Living Activities (DLA-20)","In DY4 and DY5, the provider will report the average scores on the Daily Living Activities (DLA-20) out of all instruments administered during the measurement year to individuals suffering from Trauma who are served through Trauma Informed Care Services at Hill Country MHDD. In DY5, the provider will demonstrate improvement by improving performance on CMHC.5 Adherence to Antipsychotic Medications.","Facility ","Individuals suffering from Trauma who are served through Trauma Informed Care Services at Hill Country MHDD","P4R","CMHC.5","PM-8","Submission of Category 3 DY3 Status Report",64325.919999999998,"Yes/No","RHP 7_133340307.3.4_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",64325.919999999998,"Yes/No","RHP 7_133340307.3.4_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",206198.56,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",149497.20000000001,"Yes/No","NA","AM-3.1","Achievement of DY5 performance goal for PFP measure",149497.20000000001,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Score",47.824240000000003,7891,165,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Determined all DLA-20s assessed between October 2013 through September 2014, applied the subset of individuals receiving Trauma Counseling at Hill Country, flagged first and last DLA-20 on individuals within the subset to ensure only initial and latest DLAs of individuals with multiple assessments were included in meaure, created Pivot Table in Excel to calculate number of assessment and total scores to be included in numerator and denominator","Individuals receiving the intervention have seen DLA scores increase by 13.9% which means that with the intervetion the trauma individuals have experienced has less interference with their daily functioning","Daily Living Activities (DLA-20)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,"PFP baseline not yet reported",null,"2.13.1","Scenario 1: Pre/Posttest Baseline","Daily Living Activities (DLA-20)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 7_133340307.2.4","RHP 7_133340307.3.4","RHP 7_133340307.2.4_133340307.3.4",{"$f":"COUNTIFS($FI$4:$FI1777,FI1777)","v":1},"RHP 7_133340307.2.4_1",null,2,1,1,"RHP 7_133340307",{"$f":"COUNTIFS($FR$4:$FR1777,FR1777)","v":9},"RHP 7_133340307_9"]
["RHP 7","133340307","Hill Country Community MHMR Center ","133340307.2.5","133340307.3.6","IT-11.25","Daily Living Activities (DLA-20)","Baseline Approved","Eligible to Report in October DY4","Implement Veteran Mental Health Services within Hays County served by Hill Country in RHP7 in order to meet the overall health needs of veterans dealing with behavioral health issues. The project will expand peer support services in an effort to identify veterans and their family members who need comprehensive community based wrap around behavioral health services, such as psychiatric rehabilitation, skills training, crisis intervention, supported housing and supported employment, that would complement, but not duplicate, potential services through the Veterans Administration  and provide community based wrap around behavioral health services for these veterans and their family members in order to treat symptoms prior to the need for utilization of emergency departments, inpatient hospitalization or incarceration","Daily Living Activities (DLA-20)","In DY4 and DY5, the provider will report the average scores on the Daily Living Activities (DLA-20) out of all instruments administered during the measurement year to Veterans and their family members who receive treatment through Veteran's Mental Health Services at Hill Country MHDD. In DY5, the provider will demonstrate improvement by improving performance on CMHC.5 Adherence to Antipsychotic Medications.","Facility ","Veterans and their family members who receive treatment through Veteran's Mental Health Services at Hill Country MHDD","P4R","CMHC.5","PM-8","Submission of Category 3 DY3 Status Report",44224.07,"Yes/No","RHP 7_133340307.3.6_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",44224.07,"Yes/No","RHP 7_133340307.3.6_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",141761.51,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",102779.325,"Yes/No","NA","AM-3.1","Achievement of DY5 performance goal for PFP measure",102779.325,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Score",48.96078,2497,51,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Determined all DLA-20s assessed between October 2013 through September 2014, applied the subset of individuals receiving Veteran WRAP services, flagged first and last DLA-20 on individuals within the subset to ensure only initial and latest DLAs of individuals with multiple assessments were included in meaure, created Pivot Table in Excel to calculate number of assessments and total scores to be included in numerator and denominator","Individuals receiving the intervention have seen DLA scores increase by 13.9% which means that with the intervention reduced interference with the individuals daily functioning","Daily Living Activities (DLA-20)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,"PFP baseline not yet reported",null,"2.13.1","Scenario 1: Pre/Posttest Baseline","Daily Living Activities (DLA-20)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 7_133340307.2.5","RHP 7_133340307.3.6","RHP 7_133340307.2.5_133340307.3.6",{"$f":"COUNTIFS($FI$4:$FI1778,FI1778)","v":1},"RHP 7_133340307.2.5_1",null,2,1,1,"RHP 7_133340307",{"$f":"COUNTIFS($FR$4:$FR1778,FR1778)","v":10},"RHP 7_133340307_10"]
["RHP 7","133542405","Austin Travis County Integral Care","133542405.1.3","133542405.3.201","IT-11.5","Adherence to Antipsychotic Medications for Individuals with Schizophrenia ","Baseline not yet reported","Eligible to Report in October DY4","Increase capacity and access to specialty behavioral health psychiatric assessment and medication services for the safety-net population. ATCIC will augment its existing psychiatric services by contracting with a psychiatric telemedicine provider experienced in the assessment and treatment of adults with SMI. ATCIC will initially deploy this service at its Psychiatric Emergency Services (PES) site and its two adult outpatient clinic sites","Adherence to Antipsychotic Medications for Individuals with Schizophrenia ","In DY4 and DY5, the provider will improve percentage of all adults served through telemedicine with Medicaid or are low-income/uninsured,  18 years of age or older with schizophrenia or schizoaffective disorder who are prescribed an antipsychotic medication, with adherence to the antipsychotic medication with a PDC of at least 0.8 during the measurement period.","Facility, Payer ","Low income/uninsured population for those adults receiving services under Telemedicine project.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",14598.865,"Yes/No","RHP 7_133542405.3.201_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",14598.865,"Yes/No","RHP 7_133542405.3.201_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",16815.974999999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",16815.974999999999,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",55705.84,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Adherence to Antipsychotic Medications for Individuals with Schizophrenia ","ambulatory",null,"Individuals with schizophrenia or schizoaffective disorder who filled at least two prescriptions for any antipsychotic medication and have a Proportion of Days Covered (PDC) for antipsychotic medications of at least 0.8","Individuals at least 18 years of age as of the beginning of the measurement period with schizophrenia or schizoaffective disorder with at least two claims for any antipsychotic medication during the measurement period (12 consecutive months)",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.7.1 ","","Adherence to Antipsychotic Medications for Individuals with Schizophrenia ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 7_133542405.1.3","RHP 7_133542405.3.201","RHP 7_133542405.1.3_133542405.3.201",{"$f":"COUNTIFS($FI$4:$FI1787,FI1787)","v":1},"RHP 7_133542405.1.3_1",null,2,1,1,"RHP 7_133542405",{"$f":"COUNTIFS($FR$4:$FR1787,FR1787)","v":5},"RHP 7_133542405_5"]
["RHP 7","137265806","University Medical Center at Brackenridge","137265806.1.1","137265806.3.204","IT-9.10.a","Median Time from ED Arrival to ED Departure for Discharged ED Patients","Baseline Approved","Eligible to Report in October DY4","This project intends to divert patients away from community Emergency Rooms into a more clinically appropriate and cost effective centralized Psychiatric Emergency Department","Median Time from ED Arrival to ED Departure for Discharged ED Patients","In DY4 and DY5 provider will reduce the median time from ED arrival to time of ED departure for patients age 18 years and older discharged from the UMCB Psychiatric Emergency Department.","Facility, Age ","Denominator will include patients age 18 years and older who visit the UMCB Psychiatric Emergency Department.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",45187.4,"Yes/No","RHP 7_137265806.3.204_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",45187.4,"Yes/No","RHP 7_137265806.3.204_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",74307.44,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",74307.44,"Numeric",260.3,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",353699.52,"Numeric",246.6,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"time (minutes)",274,274,1,"05/01/14 - 09/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"short",260.3,null,246.6,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator reflects the median length of stay was calculated from the available ED arrival and ED discharge times for the Psych. Emergency Department. The denominator has been entered as \"1\" per HHSC guidance. The median time was calculated among 1398 visits. ","In DY3, the median time from ED arrival to time of ED departure for patients age 18 years and older discharged from the UMCB Psychiatric Emergency Department was 274 minutes (collected among 1398 Psychiatric ED visits). The measurement period for the median time was 5/1/14 - 09/30/14; a 5-month reporting period was used because the UMCB Psych. ED did not open until 4/29/14.","Median Time from ED Arrival to ED Departure for Discharged ED Patients","ED",null,"Median Time from ED Arrival to ED Departure for Discharged ED Patients: Continuous Variable Statement: Time (in minutes) from ED arrival to ED departure for patients discharged from the emergency department. ",1,null,null,null,null,null,null,null,null,null,null,null,null,null,"1.13.1","","Median Time from ED Arrival to ED Departure for Discharged ED Patients",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-05-01","2014-09-30",null,null,"RHP 7_137265806.1.1","RHP 7_137265806.3.204","RHP 7_137265806.1.1_137265806.3.204",{"$f":"COUNTIFS($FI$4:$FI1799,FI1799)","v":1},"RHP 7_137265806.1.1_1",null,2,1,1,"RHP 7_137265806",{"$f":"COUNTIFS($FR$4:$FR1799,FR1799)","v":1},"RHP 7_137265806_1"]
["RHP 7","137265806","University Medical Center at Brackenridge","137265806.1.1","137265806.3.205","IT-9.10.c","Median time from ED arrival to time of departure from the emergency room for patients admitted to the facility from the ED","Baseline Approved","Eligible to Report in October DY4","This project intends to divert patients away from community Emergency Rooms into a more clinically appropriate and cost effective centralized Psychiatric Emergency Department","Median time from ED arrival to time of departure from the emergency room for patients admitted to the facility from the ED","In DY4 and DY5, provider will reduce the median time from ED arrival to time of ED departure for patients age 18 years and older admitted to an acute psychiatric facility from the UMCB psychiatric emergency department.","Facility, Age ","Denominator will include patients age 18 years and older who visit the UMCB Psychiatric Emergency Department.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",45187.4,"Yes/No","RHP 7_137265806.3.205_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",45187.4,"Yes/No","RHP 7_137265806.3.205_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",74307.44,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",74307.44,"Numeric",737.2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",353699.52,"Numeric",698.4,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"time (minutes)",776,776,1,"05/01/14 - 09/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"short",737.2,null,698.4,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator is the median length of stay was calculated from the available ED arrival and ED discharge times for the Psych. Emergency Department patient that were admitted to the facility. The denominator has been entered as \"1\" per HHSC guidance. The median time was calculated among 1182 visits. ","In DY3, the median time from ED arrival to time of ED departure for patients age 18 years and older admitted to an acute psychiatric facility from the UMCB psychiatric emergency department was 776 minutes (collected among 1182 Psychiatric ED visits). The measurement period for the median time was 5/1/14 - 09/30/14; a 5-month reporting period was used because the UMCB Psych. ED did not open until 4/29/14. \n\n","Median time from ED arrival to time of departure from the emergency room for patients admitted to the facility from the ED","ED",null,"Median time from ED arrival to time of departure from the emergency room for patients admitted to the facility from the ED: Continuous variable statement: Time (in minutes) from emergency department (ED) arrival to ED departure for patients admitted to the facility from the ED",1,null,null,null,null,null,null,null,null,null,null,null,null,null,"1.13.1","","Median time from ED arrival to time of departure from the emergency room for patients admitted to the facility from the ED",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-05-01","2014-09-30",null,null,"RHP 7_137265806.1.1","RHP 7_137265806.3.205","RHP 7_137265806.1.1_137265806.3.205",{"$f":"COUNTIFS($FI$4:$FI1800,FI1800)","v":2},"RHP 7_137265806.1.1_2",null,2,1,1,"RHP 7_137265806",{"$f":"COUNTIFS($FR$4:$FR1800,FR1800)","v":2},"RHP 7_137265806_2"]
["RHP 7","137265806","University Medical Center at Brackenridge","137265806.2.1","137265806.3.2","IT-12.12","Immunization and Recommended Immunization Schedule Education ","Baseline Approved","Eligible to Report in October DY4","The project would improve access to pre‐ and post‐natal care for uninsured Hispanic women through comprehensive, effective patient navigation services.  ","Immunization and Recommended Immunization Schedule Education ","In DY4 and DY5 provider will report the percentage of patients who were eligible for immunizations within the specified measurement period or parents (if patient younger than 18 years) who receive (documented) education regarding the importance of immunizations and recommended immunization schedules.  In addition, in DY5 provider will demonstrate improvement by submitting a comprehensive outcome evaluation (SA3).",null,null,"P4R","SA3","PM-8","Submission of Category 3 DY3 Status Report",67679.48,"Yes/No","RHP 7_137265806.3.2_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",67679.48,"Yes/No","RHP 7_137265806.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",222588.11,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",264876.93,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",264876.93,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",3.1949999999999999E-3,320,100167,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Any Seton patient  receving care at a Travis County hospital (UMCB, SSW, SNW, SMCA) within the baseline period are counted in the denominator. Those patients who have a valid date of immunization education, either by phone or in person, are counted in the numerator.","In the DY3 baseline period, 0.32% of patients who were eligible for immunizations or parents (if patient younger than 18 years) received (documented) education regarding the importance of immunizations and recommended immunization schedules. ","Immunization and Recommended Immunization Schedule Education ","ambulatory",null,"Number of patients or parents (if patient younger than 18 years) who receive education regarding the importance of immunizations and recommended immunization schedules","Number of patients, any age, who were eligible for immunizations within the specified measurement period.",null,null,null,null,null,null,null,null,null,null,"SA3: An Improvement Advisor (IA) from Seton's Performance Improvement group was assigned to the DSRIP project.  The IA provides ongoing support to identify  opportunities for project improvement, helps facilitate progress toward established goals and provides guidance regarding project evaluation and outcomes.  Provider is currently working with Seton's DSRIP program management team, including the assigned IA, and Seton Analytics and Health Economics to plan activities related to this stretch activity.  Provider is developing a work plan for identifying, gathering, reviewing, analyzing and formalizing necessary quantitative and qualitative information required to define next steps.",null,null,"2.9.1 ","","Immunization and Recommended Immunization Schedule Education ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 7_137265806.2.1","RHP 7_137265806.3.2","RHP 7_137265806.2.1_137265806.3.2",{"$f":"COUNTIFS($FI$4:$FI1812,FI1812)","v":2},"RHP 7_137265806.2.1_2",null,2,1,1,"RHP 7_137265806",{"$f":"COUNTIFS($FR$4:$FR1812,FR1812)","v":14},"RHP 7_137265806_14"]
["RHP 7","137265806","University Medical Center at Brackenridge","137265806.2.6","137265806.3.12","IT-11.26.e.i","Patient Health Questionnaire 9 (PHQ-9)","Baseline Approved","Eligible to Report in October DY4","This is a chronic care management program that provides direct health care and care coordination for adults who have been seriously injured and to those who have experienced a serious illness due to multiple chronic conditions.  ","Patient Health Questionnaire 9 (PHQ-9)","In DY4 and DY5, the provider will improve reported score on the PHQ-9 out of all completed surveys by individuals with diabetes. ","Comorbid Condition ","patients with a diagnosis of diabetes.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",135358.95499999999,"Yes/No","RHP 7_137265806.3.12_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",135358.95499999999,"Yes/No","RHP 7_137265806.3.12_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",222588.11,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",222588.11,"Numeric",8.4295770500000007,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1059507.71,"Numeric",7.9859150999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",8.8732389999999999,1890,213,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,8.4295770500000007,null,7.9859150999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator: Pretest cores for all PHQ-9 surveys were summed Denominator: Number of all pretest PHQ-9 surveys were counted","In DY3, the average reported score on the PHQ-9 out of all completed surveys by individuals with diabetes was 8.87.","Patient Health Questionnaire 9 (PHQ-9)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.1 ","Scenario 2: Pre Test Only Baseline","Patient Health Questionnaire 9 (PHQ-9)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 7_137265806.2.6","RHP 7_137265806.3.12","RHP 7_137265806.2.6_137265806.3.12",{"$f":"COUNTIFS($FI$4:$FI1821,FI1821)","v":1},"RHP 7_137265806.2.6_1",null,2,1,1,"RHP 7_137265806",{"$f":"COUNTIFS($FR$4:$FR1821,FR1821)","v":23},"RHP 7_137265806_23"]
["RHP 7","137265806","University Medical Center at Brackenridge","137265806.2.7","137265806.3.13","IT-13.1","Hospice and Palliative Care – Pain assessment ","Pending Approval","Eligible to Report in October DY4","This project will create a new palliative care (PC) program devoted to providing palliative care to patients through a serious illness that may be chronic, terminal or acutely devastating.  Services will be provided to inpatients and outpatients at UMCB, primary care clinics, patient homes and at specialty settings such as oncology, congestive heart failure and heart transplant clinics.","Hospice and Palliative Care – Pain assessment ","In DY4 and DY5 provider will improve the percentage of hospice or palliative care patients who screened positive for pain and who received a clinical assessment of pain within 24 hours of screening at UMCB\n","Facility ","University Medical Center Brackenridge (UMCB)","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",45119.65,"Yes/No","RHP 7_137265806.3.13_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",45119.65,"Yes/No","RHP 7_137265806.3.13_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",74196.035000000003,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",74196.035000000003,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",353169.24,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The first pain score with severity at 4 or higher after the patient's initial palliative care consult is extracted (denominator). Data from Athena and Compass are imported into a web-based data entry system called REDCap. The palliative care team provides information about their next encounter with the patient. Those encounters occuring within 24 hours of the intial pain and also documenting pain specifics are counted in the numerator.","In DY3, 6.06% of hospice or palliative care patients were screened positive for pain and received a clinical assessment of pain within 24 hours of screening at UMCB.","Hospice and Palliative Care – Pain assessment ","Ambulatory/Inpatient",null,"Patients who received a comprehensive clinical assessment to determine the severity, etiology, and impact of their pain within 24 hours of screening positive for pain","Patients enrolled in hospice or receiving palliative care who report pain when pain screening is done on the admission evaluation/initial encounter",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.10.1","","Hospice and Palliative Care – Pain assessment ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 7_137265806.2.7","RHP 7_137265806.3.13","RHP 7_137265806.2.7_137265806.3.13",{"$f":"COUNTIFS($FI$4:$FI1822,FI1822)","v":1},"RHP 7_137265806.2.7_1",null,2,1,1,"RHP 7_137265806",{"$f":"COUNTIFS($FR$4:$FR1822,FR1822)","v":24},"RHP 7_137265806_24"]
["RHP 7","137265806","University Medical Center at Brackenridge","137265806.2.9","137265806.3.203","IT-9.5","Reduce low acuity ED visits ","Baseline Approved","Eligible to Report in October DY4","This project incorporates performance improvement methodologies and evidence-based interventions to decrease 30-day readmissions for adult diabetics. Interdisciplinary care will be delivered based on standardized inpatient protocols that can reduce potentially preventable complications and develop discharge management guidelines to maximize the patient’s ability to self-manage their disease upon discharge and reduce the likelihood of preventable readmissions.","Reduce low acuity ED visits ","In DY4 and DY5, provider will report the rate of ED utilization among low acuity presenting (triaged) patients who are age 18 years or older with a diabetes-related diagnosis at University Medical Center Brackenridge. In addition, in DY5 provider will demonstrate improvement by submitting a comprehensive outcome evaluation (SA3).  ","Facility, Age, Comorbid Condition, ","Denominator will include patients age 18 years and older with diabetes-related visits to University Medical Center Brackenridge (UMCB)","P4R","SA3","PM-8","Submission of Category 3 DY3 Status Report",45187.4,"Yes/No","RHP 7_137265806.3.203_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",45187.4,"Yes/No","RHP 7_137265806.3.203_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",148614.88,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",176849.76,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",176849.76,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",1,287,287,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Data from the ED patient encounter, tracking location and provider assignments is joined and restricted by age, population and acuity level (3,4,5).  Those that received treatment by a provider are counted towards the numerator. \n All encounters count towards the denominator.","In DY3, the rate of ED utilization among low acuity presenting (triaged) patients who were age 18 years or older with a diabetes-related diagnosis at University Medical Center Brackenridge was 100%.","Reduce low acuity ED visits ","ED",null,"Total number of patients triaged as low acuity (ESI 3, 4 or 5) and receives treatment in the Emergency Department during the measurement period","Total number of patients triaged as low acuity (ESI 3, 4 or 5) upon presentation to the Emergency Department during the measurement period",null,null,null,null,null,null,null,null,null,null,"An Improvement Advisor (IA) from Seton's Performance Improvement group was assigned to the DSRIP project.  The IA provides ongoing support to identify  opportunities for project improvement, helps facilitate progress toward established goals and provides guidance regarding project evaluation and outcomes.  Provider is currently working with Seton's DSRIP program management team, including the assigned IA, and Seton Analytics and Health Economics to plan activities related to this stretch activity.  Provider is developing a work plan for identifying, gathering, reviewing, analyzing and formalizing necessary quantitative and qualitative information required to define next steps.",null,null,"2.8.4 ","","Reduce low acuity ED visits ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 7_137265806.2.9","RHP 7_137265806.3.203","RHP 7_137265806.2.9_137265806.3.203",{"$f":"COUNTIFS($FI$4:$FI1829,FI1829)","v":3},"RHP 7_137265806.2.9_3",null,2,1,1,"RHP 7_137265806",{"$f":"COUNTIFS($FR$4:$FR1829,FR1829)","v":31},"RHP 7_137265806_31"]
["RHP 7","201320302","City of Austin - HHSD","201320302.1.100","201320302.3.200","IT-14.5","Percent of graduates who work in a practice that has a high Medicaid share that reflects the distribution of Medicaid in the population ","Baseline not yet reported","Eligible to Report in October DY4","This project will expand Associate Degree in Nursing (ADN) programs to prepare 25 already-qualified, low-income, primarily minority, and first-generation-in-college adult students to become Registered Nurses, who will commit to work in community clinics and other settings serving Medicaid and indigent populations. These low-income students have completed all necessary prerequisites and are among the approximately 400 applicants currently waiting for admission to the Austin Community College Associate Degree in Nursing program","Percent of graduates who work in a practice that has a high Medicaid share that reflects the distribution of Medicaid in the population ","In DY4 and DY5, the provider will report the percentage of graduates that receive intensive support and case management services who work in a practice that has a high Medicaid share that reflects the distribution of Medicaid in the population. In DY5, the provider will demonstrate improvement by completing stretch activity 3 (SA3). ",null,null,"P4R","SA3","PM-8","Submission of Category 3 DY3 Status Report",14925.85,"Yes/No","RHP 7_201320302.3.200_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",14925.85,"Yes/No","RHP 7_201320302.3.200_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",43056.43,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",82758.145000000004,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",82758.145000000004,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Percent of graduates who work in a practice that has a high Medicaid share that reflects the distribution of Medicaid in the population ","na",null,"Number of graduates who work in a practice that has a high Medicaid share that reflects the distribution of Medicaid in the population ","Total number of graduates",null,null,null,null,null,null,null,null,null,null,"Stretch Activity status not reported in DY3",null,null,"1.2.2",null,"Percent of graduates who work in a practice that has a high Medicaid share that reflects the distribution of Medicaid in the population ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 7_201320302.1.100","RHP 7_201320302.3.200","RHP 7_201320302.1.100_201320302.3.200",{"$f":"COUNTIFS($FI$4:$FI1843,FI1843)","v":2},"RHP 7_201320302.1.100_2",null,2,1,1,"RHP 7_201320302",{"$f":"COUNTIFS($FR$4:$FR1843,FR1843)","v":2},"RHP 7_201320302_2"]
["RHP 7","201320302","City of Austin - HHSD","201320302.1.100","201320302.3.201","IT-14.8","Percent of trainees who report that they plan to serve Medicaid populations based on a systematic survey ","Baseline not yet reported","Eligible to Report in October DY4","This project will expand Associate Degree in Nursing (ADN) programs to prepare 25 already-qualified, low-income, primarily minority, and first-generation-in-college adult students to become Registered Nurses, who will commit to work in community clinics and other settings serving Medicaid and indigent populations. These low-income students have completed all necessary prerequisites and are among the approximately 400 applicants currently waiting for admission to the Austin Community College Associate Degree in Nursing program","Percent of trainees who report that they plan to serve Medicaid populations based on a systematic survey ","In DY4 and DY5 provider will report the percent of trainees that receive intensive support and case management services who report that they plan to serve Medicaid populations based on a systematic survey.  In DY5, the provider will demonstrate improvement by completing stretch activity 3 (SA3). ","Facility ","The setting and location for this denominator subset will be those students that receive intensive support and case management services through an experienced non-profit provider. ","P4R","SA3","PM-8","Submission of Category 3 DY3 Status Report",14925.85,"Yes/No","RHP 7_201320302.3.201_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",14925.85,"Yes/No","RHP 7_201320302.3.201_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",43056.43,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",82758.145000000004,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",82758.145000000004,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"DY4","P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Percent of trainees who report that they plan to serve Medicaid populations based on a systematic survey ","na",null,"Number of trainees who report that they plan to serve Medicaid populations based on a systematic survey ","Rate #1: Individuals in the HPSA ",null,null,null,null,null,null,null,null,null,null,"Stretch Activity status not reported in DY3",null,null,"1.2.2","","Percent of trainees who report that they plan to serve Medicaid populations based on a systematic survey ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 7_201320302.1.100","RHP 7_201320302.3.201","RHP 7_201320302.1.100_201320302.3.201",{"$f":"COUNTIFS($FI$4:$FI1844,FI1844)","v":3},"RHP 7_201320302.1.100_3",null,2,1,1,"RHP 7_201320302",{"$f":"COUNTIFS($FR$4:$FR1844,FR1844)","v":3},"RHP 7_201320302_3"]
["RHP 7","201320302","City of Austin - HHSD","201320302.2.5","201320302.3.7","IT-12.9","Childhood immunization status ","Pending Approval","Eligible to Report in October DY4","The Project will provide home visiting and family support services based on the evidence-based Healthy Families America model to improve families’ access to preventive services including establishing a medical home, immunizations, well-child checks, developmental assessments, parenting education, and home and personal safety practices such as car seats.","Childhood immunization status ","In DY4 and DY5, the provider will improve the percentage of African American children 2 years of age who had four diphtheria, tetanus and acellular pertussis (DtaP); three polio (IPV); one measles, mumps and rubella (MMR); three H influenza type B(HiB); three hepatitis B (HepB); one chicken pox (VZV); four pneumococcal conjugate (PCV); two hepatitis A (HepA); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday","Ethnicity, Facility ","African American women enrolled in Healthy Families","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",14925.85,"Yes/No","RHP 7_201320302.3.7_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",14925.85,"Yes/No","RHP 7_201320302.3.7_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",21528.215,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",21528.215,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",165516.29,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"There was one child who turned at least 2 years of age during DY3.  The program serves first time pregnant women; therefore, during DY3 there were not a significant number of children who met the age range to be evaluated for this outcome. The numerator and denominator will increase in DY4 and DY5 due to there being more children who meet the age requirement for the outcome evaluation.","100% of the children who turned at least 2 years old old during the reporting period had the required vaccinations by their 2nd birthday.","Childhood immunization status ","ambulatory",null,"Children who have evidence showing they received all recommended vaccines by their second birthday:\n• Four diphtheria, tetanus and acellular pertussis (DtaP)\n• Three polio (IPV)\n• One measles, mumps and rubella (MMR)\n• Three H influenza type B (HiB)\n• Three hepatitis B (HepB)\n• One chicken pox (VZV)\n• Four pneumococcal conjugate (PCV)\n• One hepatitis A (HepA)\n• Two or three rotavirus (RV); and, \n• Two influenza (flu)\n","Children who turn 2 years of age during the measurement period are eligible for inclusion.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.6.2","","Childhood immunization status ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 7_201320302.2.5","RHP 7_201320302.3.7","RHP 7_201320302.2.5_201320302.3.7",{"$f":"COUNTIFS($FI$4:$FI1854,FI1854)","v":3},"RHP 7_201320302.2.5_3",null,2,1,1,"RHP 7_201320302",{"$f":"COUNTIFS($FR$4:$FR1854,FR1854)","v":13},"RHP 7_201320302_13"]
["RHP 7","307459301","Community Care Collaborative (CCC)","307459301.1.7","307459301.3.10","IT-1.22","Asthma Percent of Opportunity Achieved","Baseline Approved","Eligible to Report in October DY4","Expand access to pulmonology specialty services for uninsured, underinsured, Medicaid, and Medicare patients by contracting with and/or hiring pulmonologists and support staff to serve in community-based primary care settings as part of the CCC’s provider network.  This project will also add pulmonology services at the comprehensive health and wellness center located in Southeast Austin, an area consistently identified as high need, that will also offer primary care, other specialty care, behavioral health, dental, preventive care, and wellness services","Asthma Percent of Opportunity Achieved","In DY4 and DY5, the provider will improve the percentage of asthma opportunities completed/fulfilled:  1.) documentation of Action/Mgmt. Plan, 2.) Severity Assessment, 3.) Controller Therapy for those who are eligible, and 4.) Spirometry within last two years over all Medical Access Program (MAP) recipients with asthma. ","Payer ","Medical Access Program (MAP) recipients","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",406644.73499999999,"Yes/No","RHP 7_307459301.3.10_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",406644.73499999999,"Yes/No","RHP 7_307459301.3.10_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",541888.505,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",541888.505,"Numeric",0.20535233999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1885369.41,"Numeric",0.24717600000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.16352900000000001,608,3718,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.20535233999999999,null,0.24717600000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator: We calculated the total applied processes as follows:\n- For each Asthma patient with Intermittent or Mildly Persistent Asthma, we added 1 process to the numerator total because the Severity Assessment occurred, then we added 1 more, if a Care Plan was documented through the NextGen Asthma Template, and another 1 if Spirometry had occurred within the last two years.\n- For each Asthma patient with Moderately or Severely Persistent Asthma, we added 1 process to the numerator total because the Severity Assessment occurred, then we added 1 more, if a Care Plan was documented through the NextGen Asthma Template, another 1 if Controller Therapy was documented through the Template, and another 1 if Spirometry had occurred within the last two years.\n- For each Asthma patient who had not received a Severity Assessment, we added 1 process to the numerator total, if a Care Plan was documented through the NextGen Asthma Template, and another 1 if Spirometry had occurred within the last two years.\n\nDenominator: We calculated the total number of applicable processes as follows: \n- For each Asthma patient with Intermittent or Mildly Persistent Asthma, we added 3 processes to the denominator total, because Controller Therapy is not required in these cases.\n- For each Asthma patient with Moderately or Severely Persistent Asthma, we added 4 processes to the denominator total, because Controller Therapy is required.\n- For each Asthma patient who had not received a Severity Assessment, we assumed the worst case and added 4 processes to the denominator total.\n","Providers are missing opportunities to monitor and improve the condition of asthmatics. Only about 16% of the recommended processes to monitor and improve the condition of asthmatics were applied during the measurement year.","Asthma Percent of Opportunity Achieved","ambulatory",null,"The number of times that each of the asthma opportunities (processes) listed below were completed/fulfilled at least once during the measurement year for all individuals with asthma (any age) :  \n1.) Documentation of Action/Management Plan, \n2.) Severity Assessment\n3.) Controller Therapy for those who are eligible, and \n4.) Documentation of spirometry assessment completed within last two years.\n","The total number of opportunities can be calculated in the following manner-\nFor each individual with an asthma diagnosis assign a count one for each of the four processes that should have been completed (should be 3-4 counts per patient) at least once during the measurement period. \n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2 ","","Asthma Percent of Opportunity Achieved",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 7_307459301.1.7","RHP 7_307459301.3.10","RHP 7_307459301.1.7_307459301.3.10",{"$f":"COUNTIFS($FI$4:$FI1865,FI1865)","v":1},"RHP 7_307459301.1.7_1",null,2,1,1,"RHP 7_307459301",{"$f":"COUNTIFS($FR$4:$FR1865,FR1865)","v":10},"RHP 7_307459301_10"]
["RHP 7","307459301","Community Care Collaborative (CCC)","307459301.2.2","307459301.3.15","IT-1.11","Diabetes care:  BP control (<140/90mm Hg) ","Baseline Approved","Eligible to Report in October DY4","Implement Chronic Care Management models to be used across its network of safety net providers. These models will define the clinical protocols, care team staffing, and patient self-management guidelines for the CCC’s 18,000 patients with Multiple Chronic Conditions","Diabetes care:  BP control (<140/90mm Hg) ","In DY4 and DY5, the provider will improve the percentage of Medical Access Program (MAP) recipients  18-64 years of age with diabetes (type 1 and type 2) whose most recent blood pressure (BP) reading is <140/90 mm Hg during the measurement year","Payer, Age ","Medical Access Program (MAP) recipients.  Also request Age subset to limit to ages 18-64.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",174276.315,"Yes/No","RHP 7_307459301.3.15_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",174276.315,"Yes/No","RHP 7_307459301.3.15_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",232237.93,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",232237.93,"Numeric",0.69669446899999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",808015.46,"Numeric",0.70310600000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.69028299999999998,2124,3077,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.69669446899999998,null,0.70310600000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"proxy","Numerator: We used the EHR to identify patients from the denominator whose most recent blood pressure (BP) reading is <140/90 mm Hg during the measurement year.\n\nDenominator: We identified diabetic MAP patients ages 18 and older as of the last day of the measurement year using demogaphic data and diagnosis from the EHR.","During the measurement year, the most recent BP reading for 69% of diabetic MAP patients 18 or older is <140/90 mm Hg.","Diabetes care:  BP control (<140/90mm Hg) ","ambulatory",null,"Patients whose most recent BP reading is <140/90 mm Hg during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.1 ","","Diabetes care:  BP control (<140/90mm Hg) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 7_307459301.2.2","RHP 7_307459301.3.15","RHP 7_307459301.2.2_307459301.3.15",{"$f":"COUNTIFS($FI$4:$FI1871,FI1871)","v":1},"RHP 7_307459301.2.2_1",null,2,1,1,"RHP 7_307459301",{"$f":"COUNTIFS($FR$4:$FR1871,FR1871)","v":16},"RHP 7_307459301_16"]
["RHP 8","020840701","Llano Memorial Healthcare System, Hospital","020840701.2.2","020840701.3.2","IT-9.2.a","Emergency Department (ED) visits per 100,000\n\n","Baseline Approved","Eligible to Report in April DY4","This project will apply continuous process improvement strategies, guided by the Institute for Healthcare Improvement (IHI) Model for Improvement, to identify causes of avoidable Sheriff Department Transport of behavioral health patients in crisis, prioritize potential solutions, and launch Plan, Do, Study, Act (PDSA) cycles on chosen improvements.","Emergency Department (ED) visits per 100,000\n\n","In DY4 and DY5 provider will improve (decrease) the rate of Emergency Department visits per 100,000 population of Llano County age 18 years and older",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",10554.75,"Yes/No","RHP 8_020840701.3.2_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",10554.75,"Yes/No","RHP 8_020840701.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",15745.5,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",15745.5,"Numeric",17564.439286586854,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",69280.5,"Numeric",16639.995113608598,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",18488.88345956511,3027,16372,"CY 2013: Jan 1st, 2013 - Dec 31st, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,17564.439286586854,null,16639.995113608598,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"NUMERATOR: A report was created to include  ED admissions at the Performing Provider between  Jainuary 1, 2013 to December 31, 2013 for patients whose residence was documented as Llano County.\n\nDENOMINATOR (as defined on the Cat 3 Provider Selection Template submitted and reviewed by HHSC): The denominator population will be Llano County. According to the 2013 Census, the population of 18+ in Llano County is 16,372. http://quickfacts.census.gov/qfd/states/48/48299.html","The rate of ED visits at the Performing Provider by adult residents of Llano County was 18,489/100,0000 between 01/01/13 - 12/31/13","Emergency Department (ED) visits per 100,000\n\n","ED",null,"Total number of ED Visits during the measurement period ","Population in Metro Area or county, age 18 years and older",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.8.1","","Emergency Department (ED) visits per 100,000\n\n",null,null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 8_020840701.2.2","RHP 8_020840701.3.2","RHP 8_020840701.2.2_020840701.3.2",{"$f":"COUNTIFS($FI$4:$FI1879,FI1879)","v":1},"RHP 8_020840701.2.2_1",null,2,1,1,"RHP 8_020840701",{"$f":"COUNTIFS($FR$4:$FR1879,FR1879)","v":2},"RHP 8_020840701_2"]
["RHP 8","081771001","Central Counties Services","081771001.2.100","081771001.3.101","IT-9.1","Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons","Baseline not yet reported","Eligible to Report in October DY4","This project provides training for law enforcement officers to assess the behavioral health acuity of someone involved in a minor criminal event, and to direct that person into the behavioral health service system instead of the criminal justice system ","Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons","In DY4 and DY5 provider will improve (decrease) the percentage of individuals receiving the project intervention(s) who had a potentially preventable admission/readmission to a criminal justice setting (e.g. jail, prison, etc.) within the measurement period for Individuals with a behavioral health diagnosis AND history of criminal justice involvement.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",43866.45,"Yes/No","RHP 8_081771001.3.101_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",43866.45,"Yes/No","RHP 8_081771001.3.101_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",34713.199999999997,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",34713.199999999997,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",168863.7,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons","ambulatory",null,"The number of individuals receiving project intervention(s) who had a potentially preventable admission/readmission to a criminal justice setting (e.g. jail, prison, etc.) within the measurement period.","Number of individuals receiving project intervention(s)",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.13.1","","Decrease in mental health admissions and readmissions to criminal justice settings such as jails or prisons",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 8_081771001.2.100","RHP 8_081771001.3.101","RHP 8_081771001.2.100_081771001.3.101",{"$f":"COUNTIFS($FI$4:$FI1887,FI1887)","v":1},"RHP 8_081771001.2.100_1",null,2,1,1,"RHP 8_081771001",{"$f":"COUNTIFS($FR$4:$FR1887,FR1887)","v":7},"RHP 8_081771001_7"]
["RHP 8","081771001","Central Counties Services","081771001.2.2","081771001.3.200","IT-15.9","Syphilis screening ","Baseline Approved","Eligible to Report in October DY4","This project provides persons (adults and adolescents) with severe and persistent mental illness (SPMI) easy access to STD education, testing and treatment by a registered nurse within the Center’s mental health clinics in Temple and Killeen (Bell County) where the patients are already accustomed to attending.","Syphilis screening ","In DY4 and DY5 provider will report the percentage of patients 18 years of age and older who were identified as sexually active and who had at least one test for syphilis during the measurement year. In addition, in DY5 provider will demonstrate improvement by improving (increasing) the PFP measure CMHC.1 Follow-up after hospitalization for mental illness. (7-day follow-up). ","Age ","Male and females 18 years or older","P4R","CMHC.1","PM-8","Submission of Category 3 DY3 Status Report",14622.15,"Yes/No","RHP 8_081771001.3.200_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",14622.15,"Yes/No","RHP 8_081771001.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",23142.133333333331,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",28143.95,"Yes/No","NA","AM-3.1","Achievement of DY5 performance goal for PFP measure",28143.95,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"%",0.96610200000000002,114,118,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator was determined by all individuals that were served in the STD clinic. Numerator is all individuals that received a Syphillis test at the clinic. ","Most individuals receive tests when they come into the clinic for services.","Syphilis screening ","ambulatory",null,"Patients aged 16-24 years with at least one syphilis test during the measurement year","Patients 16–24 years of age who were identified as sexually active.",null,null,null,null,null,null,null,null,null,null,null,"PFP baseline not yet reported",null,"2.7.1","","Syphilis screening ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 8_081771001.2.2","RHP 8_081771001.3.200","RHP 8_081771001.2.2_081771001.3.200",{"$f":"COUNTIFS($FI$4:$FI1888,FI1888)","v":1},"RHP 8_081771001.2.2_1",null,2,1,1,"RHP 8_081771001",{"$f":"COUNTIFS($FR$4:$FR1888,FR1888)","v":8},"RHP 8_081771001_8"]
["RHP 8","126844305","Bluebonnet Trails Community MHMR Center","126844305.2.1","126844305.3.4","IT-11.26.c","Adult Needs and Strength Assessment (ANSA)","Baseline Approved","Eligible to Report in October DY4","BTCS proposes to implement a Peer led transitional support services program. We will secure, prepare and staff a facility community living settings suitable for no more than  6 individuals at a time who will be provided behavioral health services in this transitional service program to improve community living skills and residential stability with the goal of achieving permanent supportive housing.","Adult Needs and Strength Assessment (ANSA)","In DY4 and DY5 provider will report the average score on the Adult Needs and Strength Assessment (ANSA) out of all instruments administered during the measurement period to individuals receiving services from Transitional homes program. In addition, in DY5 provider will improve the rate of 7 day follow-up after hospitalization (CMHC.1). ","Facility ","Transitional homes located in Williamson county","P4R","CMHC.1","PM-8","Submission of Category 3 DY3 Status Report",32944.75,"Yes/No","RHP 8_126844305.3.4_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",32944.75,"Yes/No","RHP 8_126844305.3.4_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",66812.899999999994,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",66903.5,"Yes/No","NA","AM-3.1","Achievement of DY5 performance goal for PFP measure",66903.5,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Score",3.7617069999999999,398.74090910000001,106,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The total number of ANSA assessments completed during the reporting period was used for the Denominator.  When the ANSA is administered, each of the dimensions is rated on its own scale.  After administering the assessment, scores of items in each dimension should be added together then divided by the total number of items in each dimension, to create a dimension score for each dimension.  Dimension scores are determined by dividing the score of all dimension items by the number of items in the dimension.   Dimension scores for the five mandatory dimension were then added together to create an “overall score”.","This baseline rate indicates that the average assessment score for all or the administrations of that assessment, ANSA.  It sets a baseline against which future years can be judged to gauge improvement in the average score which should indicate program and patient change.","Adult Needs and Strength Assessment (ANSA)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,"PFP baseline under review",null,"2.13.1","Scenario 3: Average Score","Adult Needs and Strength Assessment (ANSA)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 8_126844305.2.1","RHP 8_126844305.3.4","RHP 8_126844305.2.1_126844305.3.4",{"$f":"COUNTIFS($FI$4:$FI1901,FI1901)","v":1},"RHP 8_126844305.2.1_1",null,2,1,1,"RHP 8_126844305",{"$f":"COUNTIFS($FR$4:$FR1901,FR1901)","v":6},"RHP 8_126844305_6"]
["RHP 8","126936702","Williamson County & Cities Health District","126936702.1.3","126936702.3.5","IT-1.29","Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents","Baseline Approved","Eligible to Report in October DY4","Enhance and improve the quality and consistency of public health client demographic (race, ethnicity, gender, and language) data collection and interpretation to ensure health disparities are addressed appropriately","Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents","In DY4 and DY5, the provider will improve the percentage of children 3-17 years of age who had an outpatient visit with a primary care physician (PCP) or an OB/GYN and who had evidence of body mass index (BMI) percentile documentation, counseling for nutrition and counseling for physical activity among children who received a non-immunization WCCHD service, including health education during the measurement year","Age, Facility ","All children between the ages 3-17 who received a non-immunization WCCHD service, including health education, during the measurement period. WCCHD will provide or oversee the outpatient visits in lieu of PCP or OB/GYN for our clients. ","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",7182.43,"Yes/No","RHP 8_126936702.3.5_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",4788.2866666666669,"Yes/No","RHP 8_126936702.3.5_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",6264.6333333333341,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- BMI documentation",2088.2111111111112,"Numeric",0.57534428599999998,"AM-1.2","Achievement of DY4 performance goal- Counseling for nutrition",2088.2111111111112,"Numeric",0.42820000000000003,"AM-1.3","Achievement of DY4 performance goal- Counseling for physical activity",2088.2111111111112,"Numeric",0.31630000000000003,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- BMI documentation",6816.2275555555561,"Numeric",0.59711700000000001,"AM-2.2","Achievement of DY5 performance goal- Counseling for nutrition",6816.2275555555561,"Numeric",0.46299000000000001,"AM-2.3","Achievement of DY5 performance goal- Counseling for physical activity",6816.2275555555561,"Numeric",0.34954000000000002,null,null,null,null,null,null,null,null,null,null,3,"%",0.55357100000000004,124,224,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",5.8035999999999997E-2,13,224,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",5.8035999999999997E-2,13,224,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0.57534428599999998,null,0.59711700000000001,null,0.42820000000000003,null,0.46299000000000001,null,0.31630000000000003,null,0.34954000000000002,null,null,null,null,null,null,null,null,null,null,null,"The denominator is any client age 3-17 (inclusive) who visited any one of our four clinics between 4/1/2014 and 9/30/2014 for a non-immunizations reason (G3 class, Title V, CSHCN, or sports pre-participation physical). The numerator for each of the three percentages is the subset of the denominator that had a documented BMI, received nutrition counseling, or received physical activity counseling respectively.","124 of 224 (55.36%) children seen at our clinics had a documented assessment of their body mass index. 13 of 224  (5.80%) received nutritional counseling. 13 of 224 (5.80%) received counseling regarding physical activity.","Weight Assessment and Counseling for Nutrition and Physical Activity for Children/Adolescents","Ambulatory",null,"Children ages 3-17 with evidence of each of the following:\nRate #1: Documented body mass index (BMI) percentile \n","Children 3-17 years of age with at least one outpatient visit with a primary care physician (PCP) or obstetrician-gynecologist (OB-GYN) during the measurement period.","Children ages 3-17 with evidence of each of the following:\nRate #2: Counseling for nutrition \n","Children 3-17 years of age with at least one outpatient visit with a primary care physician (PCP) or obstetrician-gynecologist (OB-GYN) during the measurement period.","Children ages 3-17 with evidence of each of the following:\nRate #3: Counseling for physical activity during the measurement year","Children 3-17 years of age with at least one outpatient visit with a primary care physician (PCP) or obstetrician-gynecologist (OB-GYN) during the measurement period.",null,null,null,null,null,null,null,null,null,"1.5.3","","BMI documented","Counseling for Nutrition","Counseling for physical activity ",null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 8_126936702.1.3","RHP 8_126936702.3.5","RHP 8_126936702.1.3_126936702.3.5",{"$f":"COUNTIFS($FI$4:$FI1909,FI1909)","v":2},"RHP 8_126936702.1.3_2",null,4,3,1,"RHP 8_126936702",{"$f":"COUNTIFS($FR$4:$FR1909,FR1909)","v":5},"RHP 8_126936702_5"]
["RHP 8","126936702","Williamson County & Cities Health District","126936702.2.100","126936702.3.100","IT-6.2.a","Client Satisfaction Questionnaire 8 (CSQ-8)","Baseline not yet reported","Eligible to Report in October DY4","Development of an interdisciplinary team consisting of health educators, registered dietitians, community health workers, social workers, marketing staff, and healthcare professionals. Utilizing this team is a fundamental approach to providing evidence-based health education, nutrition counseling, health promotion, and health screening based on cultural background, English proficiency, and health literacy level of the individual or community. The purpose of this project is to prevent and reduce childhood and adolescent obesity, specifically in the underinsured, uninsured, low-income and indigent populations","Client Satisfaction Questionnaire 8 (CSQ-8)","In DY4 and DY5, the provider will improve the overall scores on the CSQ-8 among surveys completed by all clients receiving health education services delivered by WCCHD, including classes and seminars","Facility ","The total number of CSQ-8 surveys completed by all clients receiving health education services delivered by WCCHD, including classes and seminars","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",7182.43,"Yes/No","RHP 8_126936702.3.100_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",7182.43,"Yes/No","RHP 8_126936702.3.100_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",9396.9500000000007,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",9396.9500000000007,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",30673.024000000001,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Client Satisfaction Questionnaire 8 (CSQ-8)","Ambulatory",null,"The sum of the \"overall score\" for all CSQ-8 surveys completed during the measurement period.  ","The total number of CSQ-8 surveys completed during the measurement period. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.7.5","","Client Satisfaction Questionnaire 8 (CSQ-8)",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 8_126936702.2.100","RHP 8_126936702.3.100","RHP 8_126936702.2.100_126936702.3.100",{"$f":"COUNTIFS($FI$4:$FI1913,FI1913)","v":1},"RHP 8_126936702.2.100_1",null,2,1,1,"RHP 8_126936702",{"$f":"COUNTIFS($FR$4:$FR1913,FR1913)","v":9},"RHP 8_126936702_9"]
["RHP 8","133340307","Hill Country Community MHMR Center ","133340307.2.4","133340307.3.6","IT-11.25","Daily Living Activities (DLA-20)","Baseline Approved","Eligible to Report in October DY4","This project will implement Whole Health Peer Support services within the 2 counties served by Hill Country in RHP 8 to meet the overall health needs of individuals who have behavioral health issues. The project will identify and train behavioral health peers on whole health risk assessments and working with peers to address overall health issues to treat symptoms prior to the need for utilization of emergency departments (EDs) or inpatient hospitalization.  ","Daily Living Activities (DLA-20)","In DY4 and DY5 provider will report average DLA-20 score out of all instruments administered during the measurement period to individuals receiving services through Whole Health Peer Support at Hill Country MHDD. In addition, in DY5 provider will demonstrate improvement on Adherence to Antipsychotics (CMHC 5).","Facility ","Mental Health Peers who receive services through the Whole Health Peer Support at Hill Country MHDD; All individuals served by Hill Country MHDD Centers who have a completed DLA-20","P4R","CMHC.5","PM-8","Submission of Category 3 DY3 Status Report",7321.4,"Yes/No","RHP 8_133340307.3.6_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",7321.4,"Yes/No","RHP 8_133340307.3.6_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",23732.2,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",17423.599999999999,"Yes/No","NA","AM-3.1","Achievement of DY5 performance goal for PFP measure",17423.599999999999,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Score",46.236359999999998,2543,55,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Determined all DLA-20s assessed from October 2013 through September 2014, applied the subset of individuals receiving Whole Health Peer services, flagged first and last DLA-20 within the subset to ensure only initial and latest DLAs of individuals with multiple assessments were included in measure, created Pivot Table in Excel to calculate number of assessments and total scores to be included in numberator and denominator","Individuals receiving the intervention have seen DLA scores increased by 18.6% which means that with the intervention the mental illness has less interference with their daily functioning","Daily Living Activities (DLA-20)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,"PFP baseline not yet reported",null,"2.18.1","Scenario 1: Pre/Posttest Baseline","Daily Living Activities (DLA-20)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 8_133340307.2.4","RHP 8_133340307.3.6",{"$f":"A1923&\"_\"&D1923&\"_\"&E1923","v":"RHP 8_133340307.2.4_133340307.3.6"},{"$f":"COUNTIFS($FI$4:$FI1923,FI1923)","v":1},{"$f":"FI1923&\"_\"&FL1923","v":"RHP 8_133340307.2.4_1"},null,2,1,1,{"$f":"A1923&\"_\"&RIGHT(\"000000000\"&B1923,9)","v":"RHP 8_133340307"},{"$f":"COUNTIFS($FR$4:$FR1923,FR1923)","v":6},"RHP 8_133340307_6"]
["RHP 8","183086102","Little River Healthcare","183086102.1.2","183086102.3.3","IT-12.2","Cervical Cancer Screening ","Baseline not yet reported","Eligible to Report in October DY4","This project will increase the access to Specialty Care Physicians (SCPs) by expanding the number of specialty providers and/or increasing clinic hours by 5 hours per week for the specialists most in demand.  ","Cervical Cancer Screening ","In DY4 and DY5 provider will improve (increase) the percentage of women 21–64 years of age receiving services at Little River Healthcare facilities in Milam County who were screened for cervical cancer using either of the following criteria: - Women age 21–64 who had cervical cytology performed every 3 years. - Women age 30–64 who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years","Facility ","patient encounters at Little River Healthcare facilities in Milam County","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",15356.415000000001,"Yes/No","RHP 8_183086102.3.3_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",15356.415000000001,"Yes/No","RHP 8_183086102.3.3_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",27907.042499999996,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",27907.042499999996,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",137526.16499999998,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Cervical Cancer Screening ","ambulatory",null,"The number of women who were screened for cervical cancer during the measurement year or the two years prior to the measurement year.","Women 24-64 years of age as of the end of the measurement year ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2 ","","Cervical Cancer Screening ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 8_183086102.1.2","RHP 8_183086102.3.3","RHP 8_183086102.1.2_183086102.3.3",{"$f":"COUNTIFS($FI$4:$FI1928,FI1928)","v":2},"RHP 8_183086102.1.2_2",null,2,1,1,"RHP 8_183086102",{"$f":"COUNTIFS($FR$4:$FR1928,FR1928)","v":3},"RHP 8_183086102_3"]
["RHP 9","020908201","Texas Health Presbyterian Hospital Dallas","020908201.2.3","020908201.3.200","IT-1.20","Comprehensive Diabetes Care LDL Screening","Baseline Approved","Eligible to Report in April DY4","This project will build upon the existing resources and relationships THD has with Healing Hands and will focus on connecting patients to care by creating a coordinated defined process of referral from THD to Healing Hands. Healing Hands will become the primary care “home” for the referred patients.","Comprehensive Diabetes Care LDL Screening","In DY4 and DY5 provider will increase the percentage of individuals receiving services through Helping Hands aged 18 to 75 years with diabetes that received a LDL-C test during the measurement year. ","Facility ","Healing Hands Ministries clients with diabetes","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",54944.860000000008,"Yes/No","RHP 9_020908201.3.200_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",54944.860000000008,"Yes/No","RHP 9_020908201.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",58778.29,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",58778.29,"Numeric",0.70340000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",281113.33,"Numeric",0.71750999999999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.33591700000000002,130,387,"DY2: Oct 1st, 2012 - Sept 30th, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.70340000000000003,null,0.71750999999999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator and denominator were pulled from internal EMR per measure specifications in the Compendium document.","33.59% of all Diabetic patients seen had a documented LDL screening..","Comprehensive Diabetes Care LDL Screening","ambulatory",null,"Patients who had a low-density cholesterol (LDL-C test) performed during the measurement period.","Patients 18-75 years of age by the end of the measurement period who had a diagnosis of diabetes (type 1 or type 2) during the measurement period or the year prior to the measurement period.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.1.2","","Comprehensive Diabetes Care LDL Screening",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 9_020908201.2.3","RHP 9_020908201.3.200","RHP 9_020908201.2.3_020908201.3.200",{"$f":"COUNTIFS($FI$4:$FI1938,FI1938)","v":1},"RHP 9_020908201.2.3_1",null,2,1,1,"RHP 9_020908201",{"$f":"COUNTIFS($FR$4:$FR1938,FR1938)","v":5},"RHP 9_020908201_5"]
["RHP 9","020943901","Medical City Dallas Hospital","020943901.2.1","020943901.3.206","IT-1.7","Controlling high blood pressure ","Baseline Approved","Eligible to Report in October DY4","The project integrates primary and behavioral health clinic providing primary care for patients receiving OP psychiatric care at Green Oaks Hospital","Controlling high blood pressure ","In DY4 and DY5 provider will improve (increase) the percentage of Integrated Clinic patients 18 to 85 years of age who had a diagnosis of hypertension (HTN) and whose blood pressure (BP) was adequately controlled (<140/90) during the measurement year.","Facility ","Patients at Integrated Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",71693.565000000002,"Yes/No","RHP 9_020943901.3.206_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",71693.565000000002,"Yes/No","RHP 9_020943901.3.206_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",108534.3,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",108534.3,"Numeric",0.50109999999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",516977.65,"Numeric",0.52010000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.264706,9,34,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.50109999999999999,null,0.52010000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator were integrated patients with a diagnosis of HTN with a documented BP reading in the measurement period.","26% of patients with HTN diagnosis have their blood pressure controller, 74% do not. We expected to have a higher number of patients with out controlled BP as most patients have not accessed a primary care physicians  only their psychiatric provider.","Controlling high blood pressure ","ambulatory",null,"The number of patients in the denominator whose most recent BP is adequately controlled during the measurement year. For a patient’s BP to be controlled, both the systolic and diastolic BP must be <140/90 (adequate control). To determine if a patient’s BP is adequately controlled, the representative BP must be identified.\n","Patients 18 to 85 years of age by the end of the measurement year who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.15.1","","Controlling high blood pressure ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 9_020943901.2.1","RHP 9_020943901.3.206","RHP 9_020943901.2.1_020943901.3.206",{"$f":"COUNTIFS($FI$4:$FI1945,FI1945)","v":1},"RHP 9_020943901.2.1_1",null,2,1,1,"RHP 9_020943901",{"$f":"COUNTIFS($FR$4:$FR1945,FR1945)","v":5},"RHP 9_020943901_5"]
["RHP 9","020967801","Texas Health Presbyterian Hospital Denton","020967801.2.2","020967801.3.2","IT-1.10","Diabetes care: HbA1c poor control (>9.0%) ","Baseline Approved","Eligible to Report in April DY4","This project will provide the under serviced who suffer from chronic diabetes and provide them with education and management tools to help them understand their daily regimen and need for monitoring their disease process. In turn, this will reduce the number of 30-day readmissions.","Diabetes care: HbA1c poor control (>9.0%) ","In DY4 and DY5 provider will reduce the number of diabetic patients with poor control out of all diabetic patients in provider's diabetes programs or clinics  during the measurement period. ","Facility ","Entire facility diabetic patient population enrolled either in education or in outpatient clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",44484.714999999997,"Yes/No","RHP 9_020967801.3.2_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",44484.714999999997,"Yes/No","RHP 9_020967801.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",47588.105000000003,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",47588.11,"Numeric",0.50700000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",227594.93,"Numeric",0.48525000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.72,90,125,"DY3 (1): Oct 1st, 2013 - March 31st, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.50700000000000001,null,0.48525000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator was determined using measure specifications of patients age 18-75 whose most recent a1c score was > 9 or did not have a documented score.  Denominator includes all diabetic patients of this program and the certified diabetic education classes enrollees).","72.00% of all diabetic patients report an A1C level greater than 9.0 or have no level recorded.","Diabetes care: HbA1c poor control (>9.0%) ","ambulatory",null,"Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.1 ","","Diabetes care: HbA1c poor control (>9.0%) ",null,null,null,null,null,"2014-04-01","2015-03-31","2015-04-01","2016-03-31","2013-10-01","2014-03-31",null,null,"RHP 9_020967801.2.2","RHP 9_020967801.3.2","RHP 9_020967801.2.2_020967801.3.2",{"$f":"COUNTIFS($FI$4:$FI1950,FI1950)","v":1},"RHP 9_020967801.2.2_1",null,2,1,1,"RHP 9_020967801",{"$f":"COUNTIFS($FR$4:$FR1950,FR1950)","v":2},"RHP 9_020967801_2"]
["RHP 9","094192402","Medical Center of Lewisville","094192402.2.1","094192402.3.1","IT-6.1.a.ix","HCAHPS Overall Hospital Rating","Baseline Approved","Eligible to Report in April DY4","This project will create workgroups under a steering committee to implement improvement work on patient experience targets. The goal is to have multiple process improvement events each year from DY 3 through DY 5, at least 2 per year to streamline processes that are not resulting in optimal patient experiences as part of continuous quality improvement. At DY 4 and DY 5, we have routine, formalize updates to employees on the efforts the organization is undertaking to improve the experience of its patients and their families with organizational displays. We expect in DY 4 there are 7 such updates and DY 5, 10 updates.","HCAHPS Overall Hospital Rating","In DY4 and DY5 provider will improve patient satisfaction as demonstrated through the percent of 'top box' scores on the HCAHPS Overall Hospital Rating.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",29585.49,"Yes/No","RHP 9_094192402.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",29585.49,"Yes/No","RHP 9_094192402.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",31648.98,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",31648.98,"Numeric",0.746,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",151365.39000000001,"Numeric",0.752,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.74,873.2,1180,"DY2: Oct 1st, 2012 - Sept 30th, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.746,null,0.752,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The Numerator is the total number of surveys administered in the period provided by our survery administrator Gallup patient mix and mode adjusted by CMS multiplies times top box score for Overall Hospital Rating. The Denomintor is the number of suverys adminstered by Gallup for the period obtained from you Gallup website","The baseline rate above is 74% top box score for Overall Hospital Rating for the period 2012 Q4 to 2013 Q3. Top Box score is % of survey responses that rated the hospital a 9 or 10 on a scale 0-10 (0 being worst to 10 being best).","HCAHPS Overall Hospital Rating","Inpatient",null,"Patient-mix and survey mode adjusted percent \"top box\" score for a given subdomain as provided by your survey administrator, multiplied by the number of completed surveys represented in the \"top box\" score.","The number of HCAHPS surveys completed during the measurement period as reported by your survey administrator. The denominator should be the same as the multiplier used in the numerator. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.4.1 ","","HCAHPS Overall Hospital Rating",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 9_094192402.2.1","RHP 9_094192402.3.1","RHP 9_094192402.2.1_094192402.3.1",{"$f":"COUNTIFS($FI$4:$FI1955,FI1955)","v":1},"RHP 9_094192402.2.1_1",null,2,1,1,"RHP 9_094192402",{"$f":"COUNTIFS($FR$4:$FR1955,FR1955)","v":1},"RHP 9_094192402_1"]
["RHP 9","121758005","Dallas County Health and Human Services","121758005.2.1","121758005.3.4","IT-6.2.a","Client Satisfaction Questionnaire 8 (CSQ-8)","Baseline not yet reported","Eligible to Report in October DY4","This project will involve the dissemination of information on disease prevention and DCHHS services.  The goal is to expand access to health promotion to increase community awareness of disease risks and health screenings.   \n","Client Satisfaction Questionnaire 8 (CSQ-8)","In DY4 and DY5, the provider will improve the CSQ-8 scores among all individuals who complete the survey during the measurement period.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",6775,"Yes/No","RHP 9_121758005.3.4_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",6775,"Yes/No","RHP 9_121758005.3.4_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",14495.35,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",31511.63,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"dy4","TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Client Satisfaction Questionnaire 8 (CSQ-8)","Ambulatory",null,"The sum of the \"overall score\" for all CSQ-8 surveys completed during the measurement period.  ","The total number of CSQ-8 surveys completed during the measurement period. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.6.2","","Client Satisfaction Questionnaire 8 (CSQ-8)",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 9_121758005.2.1","RHP 9_121758005.3.4","RHP 9_121758005.2.1_121758005.3.4",{"$f":"COUNTIFS($FI$4:$FI1967,FI1967)","v":2},"RHP 9_121758005.2.1_2",null,1,1,0,"RHP 9_121758005",{"$f":"COUNTIFS($FR$4:$FR1967,FR1967)","v":4},"RHP 9_121758005_4"]
["RHP 9","121776204","Baylor Medical Center at Irving","121776204.1.1","121776204.3.4","IT-12.1","Breast Cancer Screening","Baseline Approved","Eligible to Report in October DY4","This project will implement increased access to two Patient-Centered Medical Home (PCMH) clinics designed to provide comprehensive and high-quality primary care services to underserved patients in the Baylor Medical Center at Irving service area.  The project is an expansion of Baylor’s Clinic strategy in Irving and Dallas County.  Historically, Baylor’s Community Care clinics have provided access to patients following discharge from Baylor Medical Center at Irving.  ","Breast Cancer Screening","In DY4 and DY5 provider will increase the percent of women who received a mammogram during the measurement year or in the 18 months prior out of all women aged 50 to 75 with Medicaid or are uninsured receiving services at the PCMH clinic","Facility , Payer ","Ambulatory Setting- Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",8240.8549999999996,"Yes/No","RHP 9_121776204.3.4_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",8240.8549999999996,"Yes/No","RHP 9_121776204.3.4_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",13223.7,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",13223.7,"Numeric",0.44819999999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",63243.64,"Numeric",0.46614,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.378307,143,378,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.44819999999999999,null,0.46614,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DSRIP base population selection criteria for all metrics: all community care clinic patients, who had at least one office visit during one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the clinics based on their most recent visit location. Numerator: Females aged 50-74 and at least one ‘MAMMOGRAM’ observation record within reporting period HDID=71. Denominator: Include: females aged 50-74 Exclude: Hx of bilateral mastectomy - ICD-V45.71, CPT-19303. Notes: none\n","During DY3 (10/01/2013- 9/30/2014), of those female adult, Uninsured/Medicaid clinic patients between the ages of 50-74 without a history of a mastectomy, 38% of eligible patients received a mammogram. ","Breast Cancer Screening","ambulatory",null,"Women who had mammogram during the measurement year or the 18 months prior to the measurement year.","Women 50-74 years old as of the measurement year who had at least one (1) outpatient encounter in the prior 12-month period. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","Breast Cancer Screening",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 9_121776204.1.1","RHP 9_121776204.3.4","RHP 9_121776204.1.1_121776204.3.4",{"$f":"COUNTIFS($FI$4:$FI1972,FI1972)","v":3},"RHP 9_121776204.1.1_3",null,2,1,1,"RHP 9_121776204",{"$f":"COUNTIFS($FR$4:$FR1972,FR1972)","v":3},"RHP 9_121776204_3"]
["RHP 9","121776204","Baylor Medical Center at Irving","121776204.2.3","121776204.3.205","IT-9.8","Care Transition: Transition Record with Specified Elements Received by ED Discharged Patients","Baseline Approved","Eligible to Report in April DY4","This project will identify and connect underserved patients in the hospital to a PCP/PCMH, create a multi‐disciplinary care plan for frequently admitted patients and provide comprehensive follow up calls to patients to ensure they have an appointment and transportation to get to it.","Care Transition: Transition Record with Specified Elements Received by Discharged Patients (Emergency Department Discharges to Ambulatory Care [Home/Self Care] or Home Health Care)","In DY4 and DY5, the provider will improve percentage of Uninsured and Medicaid ACSC visits, age 18-75 years, discharged from an emergency department (ED) to ambulatory care or home health care, or their caregiver(s), who received a transition record at the time of ED discharge including, at a minimum, all of the specified elements.","Payer, Comorbid Condition, Age, ","Uninsured and Medicaid patients age 18-75 years who are discharged from the ED with ACSC conditions","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",8781.24,"Yes/No","RHP 9_121776204.3.205_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",8781.24,"Yes/No","RHP 9_121776204.3.205_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",14090.83,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",14090.83,"Numeric",8.2962633999999993E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",67390.77,"Numeric",0.13122800000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",3.4698E-2,78,2248,"DY2: Oct 1st, 2012 - Sept 30th, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,8.2962633999999993E-2,null,0.13122800000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"We received communication and approval from HHSC on 1/21/14 to change our co-morbid subset from Diabetes to ACSC in order to capture a larger denominator for this metric. Upon preliminary data collection, we did not have a large enough sample just using diabetic patients to make an impact on this subset of the population. The way we calculated this baseline was using an annualized number for the numerator to determine our baseline. The numerator used 2 months of data, but we felt b/c ACSCs do not have seasonality (vs. Diabetes or CHF) that this was an accurate way to determine our baseline. For the denominator, we were able to use a full year of data of patients who were admitted to the ED with an ACSC condition. We also made this change because only identifying diabetic patients was a challenge as this condition does not show up as a primary or secondary condition in most patient cases. ACSC allows for a greater number of patients to be found and screened.","Numerator: Patients who received a transition record upon discharge from the ED. Denominator: Any ED visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period:  Grand mal status and other epileptic convulsions: 345 Chronic obstructive pulmonary diseases: 466.0 (only with secondary diagnosis of 491, 492, 494, 496), 491, 492, 494, 496  Asthma: 493 Heart failure and pulmonary edema: 402.01, 402.11, 402.91, 428, 518.4 Hypertension: 401.0, 401.9, 402.00, 402.10,  402.90 Angina:  411.1, 411.8, 413 Diabetes: 250.0, 250.1, 250.2, 250.3,250.8, 250.9. Exclusions: Grand mal status and other epileptic convulsions: None\nChronic obstructive pulmonary diseases: None\nAsthma: None\nHeart failure and pulmonary edema: Procedure codes 36.01, 36.02, 36.05, 36.1, 37.5, or 37.7\nHypertension: procedures: Procedure codes 36.01, 36.02, 36.05, 36.1, 37.5, or 37.7\nAngina: Procedure codes 01-86.99\nDiabetes: Diabetes with renal manifestations [250.4], diabetes with ophthalmic manifestations [250.5], diabetes with neurological manifestations [250.6] and diabetes with peripheral circulatory disorders [250.7]\n\n","During DY2 (10/01/2012- 9/30/2013), of those eligible adult, Uninsured/Medicaid patients with an ACSC condition that was admitted to the ED, 3.4% of patients received a transition record. ","Care Transition: Transition Record with Specified Elements Received by ED Discharged Patients","ED/Ambulatory",null,"Patients or their caregiver(s) who received a transition record at the time of emergency department (ED) discharge including, at a minimum, all of the following elements:\n•Summary of major procedures and tests performed during ED visit, AND \n•Principal clinical diagnosis at discharge which may include the presenting chief complaint, AND \n•Patient instructions, AND \n•Plan for follow-up care (OR statement that none required), including primary physician, other health care professional, or site designated for follow-up care, AND \n•List of new medications and changes to continued medications that patient should take after ED discharge, with quantity prescribed and/or dispensed (OR intended duration) and instructions for each\n\n","All patients, regardless of age, discharged from an emergency department (ED) to ambulatory care (home/self-care) or home health care",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1 ","","Care Transition: Transition Record with Specified Elements Received by ED Discharged Patients",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 9_121776204.2.3","RHP 9_121776204.3.205","RHP 9_121776204.2.3_121776204.3.205",{"$f":"COUNTIFS($FI$4:$FI1980,FI1980)","v":1},"RHP 9_121776204.2.3_1",null,2,1,1,"RHP 9_121776204",{"$f":"COUNTIFS($FR$4:$FR1980,FR1980)","v":11},"RHP 9_121776204_11"]
["RHP 9","121776204","Baylor Medical Center at Irving","121776204.2.5","121776204.3.19","IT-1.4","Annual monitoring for patients on persistent medications- Diuretic ","Baseline Approved","Eligible to Report in October DY4","This project will provide medication management and reconciliation services to uninsured and Medicaid patients at the Baylor Clinic on the Baylor Medical Center at Irving campus. Patients who are 150% or below the FPL and/or have chronic illnesses can qualify for prescription assistance. A clinical pharmacist will be responsible for oversight of prescriptions, educate patients about how and why to take their medications and review utilization, appropriateness and efficacy of medications that patients have been prescribed. This project is a new initiative and contributes to creating a complete PCMH for underserved patients.","Annual monitoring for patients on persistent medications- Diuretic ","In DY4 and DY5 provider will increase the percentage of individuals (18-75 years) with Medicaid or are Uninsured receiving care at a Baylor primary care clinic with a positive history for diuretics for at least 180 treatment days the receive a potassium and either a BUN or Creat test during the measurement year.","Facility , Payer ","Ambulatory Setting- Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",5043.585,"Yes/No","RHP 9_121776204.3.19_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",5043.585,"Yes/No","RHP 9_121776204.3.19_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",8093.1949999999997,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",8093.2,"Numeric",0.86095517300000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",38706.49,"Numeric",0.86673800000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.85517200000000004,124,145,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.86095517300000002,null,0.86673800000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DSRIP base population selection criteria for all metrics: all community care clinic patients, who had at least one office visit during one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the clinics based on their most recent visit location.  Numerator: Patients from denominator group with at least one serum K measurement and BUN or creatinine measurement during reporting period. Denominator: Include: Patients aged 18 and above with at least 180 day diuretics treatment during report year. . Medication GPI codes selected according to the medications list.","During DY3 (10/01/2013- 9/30/2014), of those eligible adult, Uninsured/Medicaid clinic patients, 85% of patients received one serum K measurement and BUN or creatinine measurement to verify medication appropriateness.","Annual monitoring for patients on persistent medications- Diuretic ","ambulatory",null,"Patients from the denominator with at least one serum potassium and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test in the measurement year ","Patients* 18 years of age and older as of the last day of the measurement year on persistent diuretics**-- defined as patients who received at least 180 treatment days*** of ambulatory medication during the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.11.3","","Diuretic",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 9_121776204.2.5","RHP 9_121776204.3.19","RHP 9_121776204.2.5_121776204.3.19",{"$f":"COUNTIFS($FI$4:$FI1986,FI1986)","v":2},"RHP 9_121776204.2.5_2",null,2,1,1,"RHP 9_121776204",{"$f":"COUNTIFS($FR$4:$FR1986,FR1986)","v":17},"RHP 9_121776204_17"]
["RHP 9","121790303","Baylor Medical Center at Garland","121790303.2.1","121790303.3.9","IT-1.10","Diabetes care: HbA1c poor control (>9.0%) ","Baseline Approved","Eligible to Report in October DY4","The project purpose is to provide focused education and point of care testing\nfor underserved patients who have diabetes, CVD and/or Respiratory disease that are in need\nof education, clinical management and training within a primary care setting. We will co‐locate\nprimary care and chronic disease management services to improve clinical outcomes.","Diabetes care: HbA1c poor control (>9.0%) ","In DY4 and DY5 provider will reduce the percentage of individuals whose most recent A1c level was >9% or missing during the measurement year out of all individuals 18-75 years of age with diabetes (Type I and Type II), insured by Medicaid or are uninsured and are receiving services at the PCMH clinic. ","Facility, Payer ","Ambulatory Setting- Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",13800.08,"Yes/No","RHP 9_121790303.3.9_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",13800.08,"Yes/No","RHP 9_121790303.3.9_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",22144.525000000001,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",22144.525000000001,"Numeric",0.26407340000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",105908.33,"Numeric",0.25017479999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.277972,159,572,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.26407340000000001,null,0.25017479999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DSRIP base population selection criteria for all metrics: all community care clinic patients, who had at least one office visit during one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the clinics based on their most recent visit location.  Numerator: Patients with last HgA1c measurement <= 9.0 within reporting period. Denominator: Include: ICD-9 code 250.*, Patient age btw 18-75 Exclude: ICD-9 codes 256.4, 648.8, 251.8, 962.0. Note: Missing HgA1C values are treated as ‘Not Controlled’.\n\n","During DY3 (10/01/2013- 9/30/2014), of those adult, Uninsured/Medicaid clinic patients with a diagnosis of Type I or Type II diabetes, 28% of patients had an uncontrolled A1c (A1c > 9).       ","Diabetes care: HbA1c poor control (>9.0%) ","ambulatory",null,"Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.2 ","","Diabetes care: HbA1c poor control (>9.0%) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 9_121790303.2.1","RHP 9_121790303.3.9","RHP 9_121790303.2.1_121790303.3.9",{"$f":"COUNTIFS($FI$4:$FI1994,FI1994)","v":2},"RHP 9_121790303.2.1_2",null,2,1,1,"RHP 9_121790303",{"$f":"COUNTIFS($FR$4:$FR1994,FR1994)","v":7},"RHP 9_121790303_7"]
["RHP 9","121790303","Baylor Medical Center at Garland","121790303.2.5","121790303.3.209","IT-1.33","Medical Assistance With Smoking and Tobacco Use Cessation","Baseline Approved","Eligible to Report in October DY4","This project will provide medication management and reconciliation services to uninsured and Medicaid patients at the Baylor Clinic on the Baylor Medical Center at Garland campus. Patients who are 150% or below the FPL and/or have chronic illnesses can qualify for prescription assistance. A clinical pharmacist will be responsible for oversight of prescriptions, educate patients about how and why to take their medications and review utilization, appropriateness and efficacy of medications that patients have been prescribed.","Medical Assistance With Smoking and Tobacco Use Cessation","In DY4 and DY5 provider will increase the number of individuals (18-75 years) who were advised to quit, were counseled on cessation medications and cessation strategies out of all individuals that indicated tobacco use that receive services at the Baylor primary care clinic with Medicaid or are Uninsured over the age of 18 with any of the following chronic conditions: Diabetes, CHF, COPD, Asthma.","Facility, Payer, Comorbid Condition, ","Ambulatory Setting- Clinic, include Payer subset (Medicaid and Uninsured) and Co-morbid condition subset (Diabetes, CHF, COPD/Asthma)","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",5154.2449999999999,"Yes/No","RHP 9_121790303.3.209_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",5154.2449999999999,"Yes/No","RHP 9_121790303.3.209_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",8270.8449999999993,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- Medical advice to quit",2756.9483333333333,"Numeric",0.71430000000000005,"AM-1.2","Achievement of DY4 performance goal- Cessation Medications",2756.9483333333333,"Numeric",0.34089999999999998,"AM-1.3","Achievement of DY4 performance goal- Cessation Methods/Strategies",2756.9483333333333,"Numeric",0.37459999999999999,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- Medical advice to quit",13185.373333333335,"Numeric",0.72423000000000004,"AM-2.2","Achievement of DY5 performance goal- Cessation Medications",13185.373333333335,"Numeric",0.35747000000000001,"AM-2.3","Achievement of DY5 performance goal- Cessation Methods/Strategies",13185.373333333335,"Numeric",0.39376,null,null,null,null,null,null,null,null,null,null,3,"%",6.1538461538461542E-2,4,65,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",0.1076923076923077,7,65,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",6.1538461538461542E-2,4,65,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0.71430000000000005,null,0.72423000000000004,null,0.34089999999999998,null,0.35747000000000001,null,0.37459999999999999,null,0.39376,null,null,null,null,null,null,null,null,null,null,"We communicated with HHSC regarding the fact that our n will be less than 3 for this measure because we had several operational issues that we encountered and prevented us from getting a large sample size for this metric. We did not receive approval so we are reporting this metric because we feel the baseline is represenative of our achievement ","DSRIP base population selection criteria for all metrics: all community care clinic patients, who had at least one office visit during one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the clinics based on their most recent visit location.  Numerator: Smoking cessation program observations. HDID values: 410727 – Advise, 410728 – Strategy, 410729 – Medication. Denominator: DSRIP patients with chronic disease intake form observation (HDID=410650) and following smoking status observation (HDID=300015) values: (‘smoker’, ‘current smoker’, ‘current’, ‘current every day smoker’, ‘current some day smoker’). \n\n\n","During DY3 (04/01/2014- 9/30/2014), of those eligible adult, Uninsured/Medicaid clinic patients with CHF/Diabetes/Asthma/COPD who are identified smokers- 11% of patients were advised on medications to help with smoking cessation, 6% were counseled on strategies to help with tobacco cessation and 6% were advised on tobacco cessation.\n","Medical Assistance With Smoking and Tobacco Use Cessation","ambulatory",null,"The number of patients in the denominator who indicated that they had received advice to quit from a doctor or other health provider: Advising to Quit\n","The number of eligible patients who responded to the survey and indicated that they were current smokers or tobacco users","The number of patients in the denominator who indicated that they had received advice to quit from a doctor or other health provider: Discussing Strategies\n","The number of eligible patients who responded to the survey and indicated that they were current smokers or tobacco users","The number of patients in the denominator who indicated that they had received advice to quit from a doctor or other health provider: Discussing Medications\n","The number of eligible patients who responded to the survey and indicated that they were current smokers or tobacco users",null,null,null,null,null,null,null,null,null,"2.11.3","","Advising to Quit","Discussing Strategies","Discussion Medications",null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 9_121790303.2.5","RHP 9_121790303.3.209","RHP 9_121790303.2.5_121790303.3.209",{"$f":"COUNTIFS($FI$4:$FI2005,FI2005)","v":3},"RHP 9_121790303.2.5_3",null,4,3,1,"RHP 9_121790303",{"$f":"COUNTIFS($FR$4:$FR2005,FR2005)","v":18},"RHP 9_121790303_18"]
["RHP 9","121988304","Lakes Regional MHMR Center","121988304.1.2","121988304.3.2","IT-6.2.a","Client Satisfaction Questionnaire 8 (CSQ-8)","Baseline Approved","Eligible to Report in October DY4","This project will implement telemedicine and telehealth services to provide consultations and increase capacity for behavioral health and other specialty provider services to the Medicaid and indigent target population.","Client Satisfaction Questionnaire 8 (CSQ-8)","In DY4 and DY5 provider will improve the average score on all CSQ-8 surveys administered during the measurement period. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",27339.485000000001,"Yes/No","RHP 9_121988304.3.2_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",27339.485000000001,"Yes/No","RHP 9_121988304.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",29192.06,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",29192.06,"Numeric",25.103000000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",134386.53,"Numeric",25.466000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",24.74,2474,100,"07/01/14 - 09/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"short",25.103000000000002,null,25.466000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator was determined by identifying the estimated population of the region served and a percentage was determined which would best represent that population. The numerator was determined by running an electronic report based on the CSQ-8 survey reponses.","The baseline is based on individuals who have had experiences with similar services in the past or have some knowledge of the array of services offered. The findings of the baseline surveys will assist the program in improving areas of potential gaps which will in turn serve the individuals more effectively.  The total maximum score possible on the CSQ-8 equals 32. The baseline derived above indicates an average satisfaction score of  24.74 out of a total possble of 32.","Client Satisfaction Questionnaire 8 (CSQ-8)","Ambulatory",null,"The sum of the \"overall score\" for all CSQ-8 surveys completed during the measurement period.  ","The total number of CSQ-8 surveys completed during the measurement period. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.7.1 ","","Client Satisfaction Questionnaire 8 (CSQ-8)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-07-01","2014-09-30",null,null,"RHP 9_121988304.1.2","RHP 9_121988304.3.2","RHP 9_121988304.1.2_121988304.3.2",{"$f":"COUNTIFS($FI$4:$FI2008,FI2008)","v":1},"RHP 9_121988304.1.2_1",null,2,1,1,"RHP 9_121988304",{"$f":"COUNTIFS($FR$4:$FR2008,FR2008)","v":3},"RHP 9_121988304_3"]
["RHP 9","126686802","UT Southwestern Faculty Practice Plan ","126686802.1.100","126686802.3.100","IT-9.2.a","Emergency Department (ED) visits per 100,000\n\n","Pending Approval","Eligible to Report in October DY4","The project proposes to establish a Sickle Cell Disease Day Treatment Program that would provide access to trained staff that could provide immediate assessment and treatment of the patients’ problems.   The Day Treatment Program would start with 3 exam rooms and 3 infusion chairs, since these patients often need an infusion to control their pain","Emergency Department (ED) visits per 100,000\n\n","In DY4 and DY5, the provider will improve the rate of ED Visits during the measurement period over the entire population in Metro Area or county, age 18 years and older with Sickle Cell Disease.","Comorbid Condition ","Patients with Sickle Cell Disease","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",182800.22,"Yes/No","RHP 9_126686802.3.100_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",182800.22,"Yes/No","RHP 9_126686802.3.100_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",229081.44499999995,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",229081.44499999995,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",943317.92,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator- Number of Patients with Primary DX of  pain and Secondary DX of Sickle Cell who go to the ED;   Denominator- All Sick Cell patients during Measure Period.   ","The current baseline reflects a little more than a third of the Sickle Cell population visited the ED during the measurement year.","Emergency Department (ED) visits per 100,000\n\n","ED",null,"Total number of ED Visits during the measurement period ","Population in Metro Area or county, age 18 years and older",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2","","Emergency Department (ED) visits per 100,000\n\n",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 9_126686802.1.100","RHP 9_126686802.3.100","RHP 9_126686802.1.100_126686802.3.100",{"$f":"COUNTIFS($FI$4:$FI2016,FI2016)","v":1},"RHP 9_126686802.1.100_1",null,2,1,1,"RHP 9_126686802",{"$f":"COUNTIFS($FR$4:$FR2016,FR2016)","v":5},"RHP 9_126686802_5"]
["RHP 9","126686802","UT Southwestern Faculty Practice Plan ","126686802.1.7","126686802.3.37","IT-14.2","Number of practicing nurse practitioners and physician assistants per 1000 individuals in HPSAs or MUAs","Baseline not yet reported","Eligible to Report in October DY4","UTSW Office of CME will significant expand the volume of continuing medical education offerings with relevant DSRIP topic content targeted to primary care providers in the Region, particularly providers providing services to Medicaid and low-income populations. In addition, the CME will be offered in a variety of modalities, from live conferences and symposia, grand rounds, and live webinars, to on-demand on-line webinars and on-line courses, as well as on-site hands-on training and consultations.","Number of practicing nurse practitioners and physician assistants per 1000 individuals in HPSAs or MUAs","In DY4 and DY5 provider will report the number of practicing physician extenders (NPs and PAs) per 1000 individuals in the MUA or HPSA.  In addition, in DY5 provider will demonstrate improvement by providing a report describing a comprehensive program evaluation using one of the approved alternative approaches to program and outcome linkages (SA3). ",null,null,"P4R","SA3","PM-8","Submission of Category 3 DY3 Status Report",91400.11,"Yes/No","RHP 9_126686802.3.37_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",91400.11,"Yes/No","RHP 9_126686802.3.37_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",229081.44499999995,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",235829.48,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",235829.48,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"number per 1K",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"DY4","P4R",null,"P4R",null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Number of practicing nurse practitioners and physician assistants per 1000 individuals in HPSAs or MUAs","na",null,"Rate #1: Number of practicing nurse practitioners and physician assistants in the HPSA times 1000","Rate #1: Individuals in the HPSA ","Rate #2: Number of practicing nurse practitioners and physician assistants in the MUA times 100","Rate #2: Individuals in the MUA",null,null,null,null,null,null,null,null,"Stretch Activity status not reported in DY3",null,null,"1.2.1 ","","HPSA","MUA",null,null,null,null,null,null,null,null,"","",null,null,"RHP 9_126686802.1.7","RHP 9_126686802.3.37","RHP 9_126686802.1.7_126686802.3.37",{"$f":"COUNTIFS($FI$4:$FI2022,FI2022)","v":2},"RHP 9_126686802.1.7_2",null,2,2,0,"RHP 9_126686802",{"$f":"COUNTIFS($FR$4:$FR2022,FR2022)","v":11},"RHP 9_126686802_11"]
["RHP 9","126686802","UT Southwestern Faculty Practice Plan ","126686802.2.5","126686802.3.27","IT-3.2","Congestive Heart Failure (CHF) 30-day Readmission Rate","Baseline Approved","Eligible to Report in October DY4","This project will develop, implement and evaluate standardized protocols and evidence-based care delivery model through a network of post-acute care providers and community organizations to improve care delivered to people during transitions of care.","Congestive Heart Failure (CHF) 30-day Readmission Rate","In DY4 and DY5 provider will improve the rate of readmissions  that occur within 30 days following discharge for an index admission for CHF for patients discharged under hospitalists services (UTSCAP Network patients). ","Facility ","Patients  (UTSCAP) Network (Patients discharged under Hospitalists Service)","P4R","SA1","PM-8","Submission of Category 3 DY3 Status Report",182800.22,"Yes/No","RHP 9_126686802.3.27_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",182800.22,"Yes/No","RHP 9_126686802.3.27_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",458162.8899999999,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",471658.96,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",471658.96,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.231405,28,121,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator:  The total number of hospital stays for CHF during the measurement year.  Numerator:  Total number of admissions (index stay) with at least one subsequent\nreadmission (hospital stay) for any reason within 30 days during the\nmeasurement year.","Heart Failure is the largest volume of cohorts in our hospital and 20% of Heart Failure patients are cared for by GIM/ Hospitalists; we received feedback from CMS through the Penalty Reduction Program directing us to focus on that specific area for improvement.   Of 121 inpatient admissions to GIM/Hospitalist Service for CHF in DY3, 28 were readmitted within 30-days, for a readmission rate of 23%.  We are putting initiatives in place, as part of this project, to reduce our CHF 30-day readmission rate in DY4 and DY5.","Congestive Heart Failure (CHF) 30-day Readmission Rate","inpatient",null,"Total number of admissions (index stay) with at least one subsequent readmission (hospital stay) for any reason within 30 days during the measurement year. ","Total number of hospital stays for CHF during the measurement year for patients 18 years and older.",null,null,null,null,null,null,null,null,null,null,"SA1",null,null,"2.12.1","","Congestive Heart Failure (CHF) 30-day Readmission Rate",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 9_126686802.2.5","RHP 9_126686802.3.27","RHP 9_126686802.2.5_126686802.3.27",{"$f":"COUNTIFS($FI$4:$FI2030,FI2030)","v":1},"RHP 9_126686802.2.5_1",null,2,1,1,"RHP 9_126686802",{"$f":"COUNTIFS($FR$4:$FR2030,FR2030)","v":19},"RHP 9_126686802_19"]
["RHP 9","127295703","Parkland Memorial Hospital","127295703.1.101","127295703.3.104","IT-12.15","Abnormal Pap test follow-up rate ","Baseline Approved","Eligible to Report in October DY4","Expand gynecology specialty services 10 hours per week per site at 8 existing Women’s Health Center sites throughout Dallas County. The project will initiate specialty gynecology services at existing clinic locations.","Abnormal Pap test follow-up rate ","In DY4 and DY5 provider will improve (increase) the percentage of women aged 12 to 65 years old who undergo follow‐up after an abnormal Pap test at the Gynecology Specialty Clinic and the Woman's Health Centers","Facility ","Gynecology Specialty Clinic and the Woman's Health Centers","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",444794.46,"Yes/No","RHP 9_127295703.3.104_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",444794.46,"Yes/No","RHP 9_127295703.3.104_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",702895.09,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",702895.09,"Numeric",0.76192214111922141,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",3322884.62,"Numeric",0.77445255474452557,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.74939172749391725,308,411,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.76192214111922141,null,0.77445255474452557,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The Women's Specialty Health clinic runs a report in Cerner to provide a list of cases with the specified diagnosis.  The Cerner report is then sorted in Excel for age range and cases that fall outside of the date range are manually excluded.  From this report a random sample is run in order to derive the denominator.   The denominator report is then supplied to Decision Support to run a query on the cases through EPSi to determine the number of patients who receive a colposcopy procedure after receiving abnormal pap test results (numerator).","The baseline rate of 74% is the percentage of women aged 12 to 65 years old who undergo follow‐up colposcopy after a Pap test identification of high‐grade squamous intraepithelial lesions (HSIL), atypical squamous cells (ASC‐H), atypical glandular cells (AGC), or cancer‐in‐situ","Abnormal Pap test follow-up rate ","ambulatory",null,"The number of women aged 12 to 65 years old who undergo follow‐up Colposcopy after a Pap test identification of high‐grade squamous intraepithelial lesions (HSIL), atypical squamous cells (ASC‐H), atypical glandular cells (AGC), or cancer‐in‐situ.\n","The number of women aged 12 to 65 years old with a Pap test identification of high‐grade squamous intraepithelial lesions (HSIL), atypical squamous cells (ASC‐H), atypical glandular cells (AGC), or cancer‐in‐situ.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.1","","Abnormal Pap test follow-up rate ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 9_127295703.1.101","RHP 9_127295703.3.104","RHP 9_127295703.1.101_127295703.3.104",{"$f":"COUNTIFS($FI$4:$FI2038,FI2038)","v":1},"RHP 9_127295703.1.101_1",null,2,1,1,"RHP 9_127295703",{"$f":"COUNTIFS($FR$4:$FR2038,FR2038)","v":7},"RHP 9_127295703_7"]
["RHP 9","127295703","Parkland Memorial Hospital","127295703.1.4","127295703.3.201","IT-9.2","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","Baseline Approved","Eligible to Report in April DY4","This project implements the Quality Through Transformation Initiative (“QTTI”) which will provide the infrastructure, governance and integrated oversight for Parkland’s sixteen Waiver projects and will provide leadership and consultative support for the Region’s transformational projects, learning collaboratives and integrated improvement outcome achievement.","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","In DY4 and DY5 provider will improve (decrease) the rate of ED utilization",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",444794.45500000002,"Yes/No","RHP 9_127295703.3.201_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",444794.45500000002,"Yes/No","RHP 9_127295703.3.201_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",702895.09,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",702895.09,"Numeric",0.39559430600000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",3322884.62,"Numeric",0.374774,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.41641499999999998,28549,68559,"DY2: Oct 1st, 2012 - Sept 30th, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.39559430600000001,null,0.374774,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator is determined from the total number of ED visits for individuals 18 years or older during the measurement period. The numerator is determined from the total number of ED visits for individuals 18 years or older with any primary or secondary ACSC diagnosis during the measurement period.","The percentage of patients arriving in the Main ED at Parkland hospital with a primary or secondary ACSC diagnosis (i.e. patients arriving at the Main ED that could have been seen in an outpatient setting).","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","ED",null,"Total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.10.3","","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 9_127295703.1.4","RHP 9_127295703.3.201","RHP 9_127295703.1.4_127295703.3.201",{"$f":"COUNTIFS($FI$4:$FI2047,FI2047)","v":1},"RHP 9_127295703.1.4_1",null,2,1,1,"RHP 9_127295703",{"$f":"COUNTIFS($FR$4:$FR2047,FR2047)","v":16},"RHP 9_127295703_16"]
["RHP 9","127295703","Parkland Memorial Hospital","127295703.1.7","127295703.3.216","IT-3.22","Risk Adjusted All-Cause Readmission","Baseline Approved","Eligible to Report in April DY4","Parkland will expand access to interpretation services. Additionally, Parkland will implement an evidence-based ‘Health Literate Care Model’ which incorporates health literacy strategies into the Care Model to better engage patients in their care.","Risk Adjusted All-Cause Readmission","In DY4 and DY5 provider will improve the ratio of observed to expected readmissions that occur within 30 days following discharge for an index admission for any reason. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",440346.51,"Yes/No","RHP 9_127295703.3.216_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",440346.51,"Yes/No","RHP 9_127295703.3.216_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",695866.14,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",695866.14,"Numeric",0.71793893129770991,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",3289655.77,"Numeric",0.74816793893129774,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",0.75572519083969469,9.9000000000000005E-2,0.13100000000000001,"DY2: Oct 1st, 2012 - Sept 30th, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.71793893129770991,null,0.74816793893129774,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator inclusion for this metric was calculated by an internally developed risk adjustment algorithm and was discussed with HHSC prior to use. The exclusions are in alignment with the compendium document.  The numerator shows the actual rate of readmission within 30 days and the inclusions/exclusions are in alignment with the compendium.   ","The baseline for this measure is 9.89%, meaning that 9.89% of the 34,121 patients admitted to Parkland Health and Hospital System  were readmitted within a 30-day trimeframe after discharge.","Risk Adjusted All-Cause Readmission","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk admissions during the measurement period.","Expected (risk-adjusted) rate of readmissions for all-causes during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.4.1","","Risk Adjusted All-Cause Readmission",null,null,null,null,"HEDIS adjustment tables for Plan All-Cause Readmission (NQF 1768)","2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,{"$f":"A2052&\"_\"&D2052","v":"RHP 9_127295703.1.7"},{"$f":"A2052&\"_\"&E2052","v":"RHP 9_127295703.3.216"},"RHP 9_127295703.1.7_127295703.3.216",{"$f":"COUNTIFS($FI$4:$FI2052,FI2052)","v":1},"RHP 9_127295703.1.7_1",null,2,{"$f":"IF(DC2052=\"\",0,1)+IF(DG2052=\"\",0,1)+IF(DK2052=\"\",0,1)+IF(DO2052=\"\",0,1)+IF(DS2052=\"\",0,1)","v":1},1,"RHP 9_127295703",{"$f":"COUNTIFS($FR$4:$FR2052,FR2052)","v":21},{"$f":"FR2052&\"_\"&FS2052","v":"RHP 9_127295703_21"}]
["RHP 9","127295703","Parkland Memorial Hospital","127295703.2.101","127295703.3.227","IT-3.22","Risk Adjusted All-Cause Readmission","Baseline Approved","Eligible to Report in October DY4","This program will develop and implement a multidisciplinary care transition team for hospitalized HIV patients to improve transition from inpatient to outpatient care. The project will also establish a post-hospital discharge clinic to provide continuity of care. ","Risk Adjusted All-Cause Readmission","In DY4 and DY5 provider will improve the ratio of observed to expected readmissions that occur within 30 days following discharge for an index admission for any reason in patients diagnosed with HIV. ","Comorbid Condition ","HIV Patients","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",444794.46,"Yes/No","RHP 9_127295703.3.227_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",444794.46,"Yes/No","RHP 9_127295703.3.227_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",702895.09,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",702895.09,"Numeric",0.77500000000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",3322884.62,"Numeric",0.73421052631578942,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",0.81578947368421051,0.155,0.19,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.77500000000000002,null,0.73421052631578942,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator inclusion for this metric was calculated by an internally developed risk adjustment algorithm and was discussed with HHSC prior to use. The exclusions are in alignment with the compendium document.  The numerator shows the actual rate of readmission within 30 days and the inclusions/exclusions are in alignment with the compendium.   ","The baseline for this measure is 14.61% meaning that 14.61% of the 1,033 patients admitted to Parkland Health and Hospital System  were readmitted within a 30-day trimeframe after discharge.","Risk Adjusted All-Cause Readmission","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk admissions during the measurement period.","Expected (risk-adjusted) rate of readmissions for all-causes during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.12.1","","Risk Adjusted All-Cause Readmission",null,null,null,null,"HEDIS adjustment tables for Plan All-Cause Readmission (NQF 1768)","2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 9_127295703.2.101","RHP 9_127295703.3.227","RHP 9_127295703.2.101_127295703.3.227",{"$f":"COUNTIFS($FI$4:$FI2060,FI2060)","v":1},"RHP 9_127295703.2.101_1",null,2,1,1,"RHP 9_127295703",{"$f":"COUNTIFS($FR$4:$FR2060,FR2060)","v":29},"RHP 9_127295703_29"]
["RHP 9","127295703","Parkland Memorial Hospital","127295703.2.12","127295703.3.219","IT-3.22","Risk Adjusted All-Cause Readmission","Baseline Approved","Eligible to Report in April DY4","This project will expand capacity of the Outpatient Parenteral Antimicrobial Therapy (OPAT) program.  The OPAT program is a post-discharge program that allows patients receiving antibiotics in the hospital to be discharged in order to self-administer their medications at home.","Risk Adjusted All-Cause Readmission","In DY4 and DY5 provider will improve the ratio of observed to expected readmissions that occur within 30 days following discharge for an index admission for any reason. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",444794.45500000002,"Yes/No","RHP 9_127295703.3.219_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",444794.45500000002,"Yes/No","RHP 9_127295703.3.219_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",702895.09,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",702895.09,"Numeric",0.71793893129770991,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",3322884.62,"Numeric",0.74816793893129774,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",0.75572519083969469,9.9000000000000005E-2,0.13100000000000001,"DY2: Oct 1st, 2012 - Sept 30th, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.71793893129770991,null,0.74816793893129774,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator inclusion for this metric was calculated by an internally developed risk adjustment algorithm and was discussed with HHSC prior to use. The exclusions are in alignment with the compendium document.  The numerator shows the actual rate of readmission within 30 days and the inclusions/exclusions are in alignment with the compendium.   ","The baseline for this measure is 9.89%, meaning that 9.89% of the 34,121 patients admitted to Parkland Health and Hospital System  were readmitted within a 30-day trimeframe after discharge.","Risk Adjusted All-Cause Readmission","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk admissions during the measurement period.","Expected (risk-adjusted) rate of readmissions for all-causes during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.8.4 ","","Risk Adjusted All-Cause Readmission",null,null,null,null,"HEDIS adjustment tables for Plan All-Cause Readmission (NQF 1768)","2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 9_127295703.2.12","RHP 9_127295703.3.219","RHP 9_127295703.2.12_127295703.3.219",{"$f":"COUNTIFS($FI$4:$FI2064,FI2064)","v":1},"RHP 9_127295703.2.12_1",null,2,1,1,"RHP 9_127295703",{"$f":"COUNTIFS($FR$4:$FR2064,FR2064)","v":33},"RHP 9_127295703_33"]
["RHP 9","127295703","Parkland Memorial Hospital","127295703.2.7","127295703.3.210","IT-3.22","Risk Adjusted All-Cause Readmission","Baseline Approved","Eligible to Report in April DY4","Develop and implement a new patient navigation program to provide support and assistance with connections to care for Parkland patients with mental health disorders that present in the emergency department or at community health clinics.","Risk Adjusted All-Cause Readmission","In DY4 and DY5 provider will improve the ratio of observed to expected readmissions that occur within 30 days following discharge for an index admission for any reason. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",444794.45500000002,"Yes/No","RHP 9_127295703.3.210_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",444794.45500000002,"Yes/No","RHP 9_127295703.3.210_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",702895.09,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",702895.09,"Numeric",0.71793893129770991,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",3322884.62,"Numeric",0.74816793893129774,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"ratio",0.75572519083969469,9.9000000000000005E-2,0.13100000000000001,"DY2: Oct 1st, 2012 - Sept 30th, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.71793893129770991,null,0.74816793893129774,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator inclusion for this metric was calculated by an internally developed risk adjustment algorithm and was discussed with HHSC prior to use. The exclusions are in alignment with the compendium document.  The numerator shows the actual rate of readmission within 30 days and the inclusions/exclusions are in alignment with the compendium.   ","The baseline for this measure is 9.89%, meaning that 9.89% of the 34,121 patients admitted to Parkland Health and Hospital System  were readmitted within a 30-day trimeframe after discharge.","Risk Adjusted All-Cause Readmission","inpatient",null,"Observed (Actual) rate of readmissions within 30 days following an Index Admission during the measurement year \n\nThe Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk admissions during the measurement period.","Expected (risk-adjusted) rate of readmissions for all-causes during the measurement year. \n\nThe Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.\nCase-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1 ","","Risk Adjusted All-Cause Readmission",null,null,null,null,"HEDIS adjustment tables for Plan All-Cause Readmission (NQF 1768)","2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 9_127295703.2.7","RHP 9_127295703.3.210","RHP 9_127295703.2.7_127295703.3.210",{"$f":"COUNTIFS($FI$4:$FI2074,FI2074)","v":1},"RHP 9_127295703.2.7_1",null,2,1,1,"RHP 9_127295703",{"$f":"COUNTIFS($FR$4:$FR2074,FR2074)","v":43},"RHP 9_127295703_43"]
["RHP 9","135032405","Methodist Dallas Medical Center","135032405.2.3","135032405.3.200","IT-1.11","Diabetes care:  BP control (<140/90mm Hg) ","Baseline Approved","Eligible to Report in October DY4","The purpose of “The Medical Home” project is to expand and improve a community-based, multi-stakeholder, health care access program increasing the capacity to care for more uninsured Dallas County residents while demonstrating accountability for improved health outcomes. ","Diabetes care:  BP control (<140/90mm Hg) ","In DY4 and DY5, the provider will improve the percentage of patients whose most recent BP reading is <140/90 mm Hg during the measurement year over all Community Clinic patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.","Facility ","All Community Clinic patients 18-75 years of age who had a diagnosis of diabetes (type 1 or type 2 during the measurement year or the year prior to the measurement year.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",34442.639999999999,"Yes/No","RHP 9_135032405.3.200_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",34442.639999999999,"Yes/No","RHP 9_135032405.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",55430.53,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",55430.53,"Numeric",0.66411924499999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",266251.99,"Numeric",0.67415000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.654088,104,159,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.66411924499999997,null,0.67415000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The nominator and denominator includes clinic patients diagnosed with diabetes (type 1 or type 2)  with at least 1 visit between October 1, 2013 - September 30, 2014. Patients with diabetes ICD-9 codes (excluding those for gestational diabetes and steroid-induced diabetes) were extracted from the EMR and their most recent blood pressures were recorded from the EMR or paper charts.  Patient charts (in EMR and paper) were reviewed to ensure that the identified population had visits within the measurement year.  ","Percentage of clinic diabetic patients seen in the measurement year with blood pressures are less than 140/90.","Diabetes care:  BP control (<140/90mm Hg) ","ambulatory",null,"Patients whose most recent BP reading is <140/90 mm Hg during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.1.1 ","","Diabetes care:  BP control (<140/90mm Hg) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 9_135032405.2.3","RHP 9_135032405.3.200","RHP 9_135032405.2.3_135032405.3.200",{"$f":"COUNTIFS($FI$4:$FI2081,FI2081)","v":1},"RHP 9_135032405.2.3_1",null,2,1,1,"RHP 9_135032405",{"$f":"COUNTIFS($FR$4:$FR2081,FR2081)","v":3},"RHP 9_135032405_3"]
["RHP 9","136360803","Denton County Health and Human Services","136360803.2.1","136360803.3.1","IT-1.10","Diabetes care: HbA1c poor control (>9.0%) ","Baseline Approved","Eligible to Report in October DY4","The project will implement a chronic disease registry to track Medicaid and low income diabetic patients. This will facilitate a comprehensive listing of Medicaid and low income diabetes patients in Denton County. In addition, diabetes care will be provided incorporating the Chronic Care Model developed by Wagner. In this way diabetes clients will be contacted twice a month to encourage taking medications in accordance with physician’s orders, keeping appointments, proper diets, exercise, and other self‐management techniques to improve health outcomes.","Diabetes care: HbA1c poor control (>9.0%) ","In DY4 and DY5 provider will reduce the percentage of individuals whose most recent A1c result was greater than 9% or was not tested during the measurement year out of all individuals aged 18 to 75 with diabetes receiving services at Denton County Health Department. ","Facility ","Denton County Health Department Patients with Diabetes ","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",61046,"Yes/No","RHP 9_136360803.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",61046,"Yes/No","RHP 9_136360803.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",65305,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",65305,"Numeric",0.415015574,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",283935,"Numeric",0.40106900000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.42896200000000001,314,732,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.415015574,null,0.40106900000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null," Numerator:\nA patient whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year.  \nDenominator\n Patients who are 18-75 years of age by the end of the measurement year, or who have been diagnosis with diabetes (type 1 or type 2) during the measurement year, or the year prior to the measurement year.\n","The CDEMS registry currently houses the patient names, specific biometrics, appointment, and referral information on all diabetic patients. Currently 732 patients are diagnosed with either Type 1 or 2 diabetes, and are being monitored by a medical provider at the Denton or Lewisville clinics. Of those 314 diagnosed with type 1 or type 2 diabetes are considered high risk due to an HbA1c >9%.  of the 42.9% of patients at DCHD that have been diagnosed with type 1 or 2 diabetes, need additional education, screening test, preventive test and clinical services. All 314 patients diagnosed with type 1 or 2 diabetes, have had an opportunity to participate in the Diabetic Education and Empowerment Program of diabetic education and empowerment. Each of the 314 patients have been contacted a minimum of three letters and numerous phone calls, that can be found in the patients record. e Text","Diabetes care: HbA1c poor control (>9.0%) ","ambulatory",null,"Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.1 ","","Diabetes care: HbA1c poor control (>9.0%) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 9_136360803.2.1","RHP 9_136360803.3.1","RHP 9_136360803.2.1_136360803.3.1",{"$f":"COUNTIFS($FI$4:$FI2087,FI2087)","v":1},"RHP 9_136360803.2.1_1",null,2,1,1,"RHP 9_136360803",{"$f":"COUNTIFS($FR$4:$FR2087,FR2087)","v":1},"RHP 9_136360803_1"]
["RHP 9","136360803","Denton County Health and Human Services","136360803.2.2","136360803.3.2","IT-2.19","Flu and pneumonia Admission Rate ","Baseline Approved","Eligible to Report in October DY4","This project will promote and provide preventive immunizations to adult Medicaid and adult low income individuals in Denton County.  The immunizations will include meningitis, shingles, pneumonia, influenza, hepatitis A, hepatitis B, pertussis, tetanus, and measles, mumps, and rubella.","Flu and pneumonia Admission Rate ","In DY4 and DY5, the provider will report the rate of discharges of age 18 years and older with ICD-9-CM principal diagnosis code for flu and pneumonia out of all Denton county residents greater than 18 years old. In DY5, the provider will demonstrate improvement by completing Stretch Activity #3 (SA3)- Outcome Evaluation. ","Facility ","Denton County","P4R","SA3","PM-8","Submission of Category 3 DY3 Status Report",61046,"Yes/No","RHP 9_136360803.3.2_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",61046,"Yes/No","RHP 9_136360803.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",130610,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",141967.5,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",141967.5,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",384.6,2803,728799,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The goal of this project is to target low income Denton County adults with vaccines that will help them stay healthy, stay on the job, and prevent disease and hospitalization.  The specific vaccines to be administered include: meningitis, shingles, pneumonia, influenza, hepatitis A, hepatitis B, pertussis, tetanus, and measles, mumps, and rubella.  Provision of these vaccines, especially to the low income families of Denton County is a highly cost effective proposition.     This project will create a vaccination team, establish outreach, and increase awareness to maximize voluntary immunizations among low income populations in Denton County, Texas. The most immediate goal of the project is to administer 12,000 doses of vaccines to low income Denton County families.  In doing so, cases of disease will be prevented.  Hospitalizations will be avoided; and substantial savings in health care expenditures may be experienced.","The interpretation of the baseline is that Denton County residents have a high percentage of vaccinated individual. Less than one half of one percent of the population had an admission to the hospital for Flu or Pneumonia. This could also be related to a weak flu season, or an uncommonly warm and dry winter. Flu is very unpredictable and can fluctuate with the season.  ","Flu and pneumonia Admission Rate ","inpatient",null,"Discharges, for patients ages 18 years and older, with a principal ICD-9-CM diagnosis code for bacterial pneumonia and influenza x 100,000*.","Population ages 18 years and older in metropolitan area  or county. ",null,null,null,null,null,null,null,null,null,null,"SA is due DY5",null,null,"2.7.6 ","","Flu and pneumonia Admission Rate ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 9_136360803.2.2","RHP 9_136360803.3.2","RHP 9_136360803.2.2_136360803.3.2",{"$f":"COUNTIFS($FI$4:$FI2088,FI2088)","v":1},"RHP 9_136360803.2.2_1",null,2,1,1,"RHP 9_136360803",{"$f":"COUNTIFS($FR$4:$FR2088,FR2088)","v":2},"RHP 9_136360803_2"]
["RHP 9","137252607","Dallas County MHMR dba Metrocare Services","137252607.1.1","137252607.3.1","IT-6.2.a","Client Satisfaction Questionnaire 8 (CSQ-8)","Pending Approval","Eligible to Report in October DY4","The goal of the project is to enhance access and reduce shortages in specialty behavioral health care and to improve consumer choice, by expanding the number of behavioral health professionals—Psychiatrist, Child Psychiatrists, Psychologist, Licensed Master Social Workers (LMSW), Licensed Professional Counselors (LPC) and Licensed Marriage &Family Therapists (LMFT) trained in a community mental health setting (i.e., at the Center for Education and Research at Metrocare (CER).","Client Satisfaction Questionnaire 8 (CSQ-8)","In DY4 and DY5 provider will improve the sum of the \"overall score\" on the CSQ-8 surveys completed during the measurement period out of the total number of CSQ-8 surveys completed.",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",38107.480000000003,"Yes/No","RHP 9_137252607.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",38107.480000000003,"Yes/No","RHP 9_137252607.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",43555.42,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",43555.42,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",207078.92,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator value was calculated by the sum of the overall score for all CSQ-8 surveys completed during the measurement period. The denominator was calculated by the total number of CSQ-8 surveys completed during the measurement period. Please note that while cell L101 references CSQ-9, 137252607_1_1 actually used CSQ-8.  ","The baseline calculation for DY3 = 46% of CER clients indicated that they are satisfied with the services received through the CER during DY3. The baseline calcation is not equal to .46%, but 46%. ","Client Satisfaction Questionnaire 8 (CSQ-8)","Ambulatory",null,"The sum of the \"overall score\" for all CSQ-8 surveys completed during the measurement period.  ","The total number of CSQ-8 surveys completed during the measurement period. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.14.1","","Client Satisfaction Questionnaire 8 (CSQ-8)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 9_137252607.1.1","RHP 9_137252607.3.1","RHP 9_137252607.1.1_137252607.3.1",{"$f":"COUNTIFS($FI$4:$FI2089,FI2089)","v":1},"RHP 9_137252607.1.1_1",null,2,1,1,"RHP 9_137252607",{"$f":"COUNTIFS($FR$4:$FR2089,FR2089)","v":1},"RHP 9_137252607_1"]
["RHP 9","137252607","Dallas County MHMR dba Metrocare Services","137252607.1.100","137252607.3.100","IT-11.26.c","Adult Needs and Strength Assessment (ANSA)","Baseline Approved","Eligible to Report in October DY4","Metrocare Services will expand behavioral health services to the underserved by opening an additional outpatient clinic in the Northwest region of Dallas County","Adult Needs and Strength Assessment (ANSA)","In DY4 and DY5, the provider will report the overall scores on the Adult Needs and Strength Assessment (ANSA) among all patients seen at the Northwest Dallas County Metrocare clinic. In DY5, the provider will demonstrate improvement by improving performance on CMHC.5 Adherence to Antipsychotic Medications","Facility ","All patients that meet the ANSA administration requirements at the clinic located in the Northwest area of Dallas County.","P4R","CMHC.5","PM-8","Submission of Category 3 DY3 Status Report",70975.184999999998,"Yes/No","RHP 9_137252607.3.100_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",70975.184999999998,"Yes/No","RHP 9_137252607.3.100_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",162243.94,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",192842.245,"Yes/No","NA","AM-3.1","Achievement of DY5 performance goal for PFP measure",192842.245,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Score",4.0394439999999996,72.709999999999994,18,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator values reported above equals the sum total of the overall score from all surveys completed during the measurement period. The denominator value above equals the total number of surveys completed during the measurement period.  Scenario #3 is the correct scenario for 137252607_1_2. Provider was allowed to submit the Category 3 baseline template after the DY3 Status Update Template was submitted. ","In DY3, the baseline rate is 4.04. 4.04 represents the average ANSA score of all surveys completed during the measurement year. ","Adult Needs and Strength Assessment (ANSA)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,"PFP baseline not yet reported",null,"1.12.2","Scenario 3: Average Score","Adult Needs and Strength Assessment (ANSA)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 9_137252607.1.100","RHP 9_137252607.3.100","RHP 9_137252607.1.100_137252607.3.100",{"$f":"COUNTIFS($FI$4:$FI2090,FI2090)","v":1},"RHP 9_137252607.1.100_1",null,2,1,1,"RHP 9_137252607",{"$f":"COUNTIFS($FR$4:$FR2090,FR2090)","v":2},"RHP 9_137252607_2"]
["RHP 9","137252607","Dallas County MHMR dba Metrocare Services","137252607.1.100","137252607.3.101","IT-11.26.d","Children and Adolescent Needs and Strengths Assessment\n(CANS-MH)\n","Baseline Approved","Eligible to Report in October DY4","Metrocare Services will expand behavioral health services to the underserved by opening an additional outpatient clinic in the Northwest region of Dallas County","Children and Adolescent Needs and Strengths Assessment\n(CANS-MH)\n","In DY4 and DY5, the provider will report the overall scores on the Children and Adolescent Needs and Strengths Assessment (CANS-MH) among all patients seen at the Northwest Dallas County Metrocare clinic. In DY5, the provider will demonstrate improvement by improving performance on CMHC.5 Adherence to Antipsychotic Medications","Facility ","All patients that meet the ANSA administration requirements at the clinic located in the Northwest area of Dallas County.","P4R","CMHC.5","PM-8","Submission of Category 3 DY3 Status Report",70975.184999999998,"Yes/No","RHP 9_137252607.3.101_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",70975.184999999998,"Yes/No","RHP 9_137252607.3.101_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",162243.94,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",192842.245,"Yes/No","NA","AM-3.1","Achievement of DY5 performance goal for PFP measure",192842.245,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Score",3.6375000000000002,43.65,12,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator values reported above equals the sum total of the overall score from all surveys completed during the measurement period. The denominator value above equals the total number of surveys completed during the measurement period.  Scenario #3 is the correct scenario for 137252607_1_2. Provider was allowed to submit the Category 3 baseline template after the DY3 Status Update Template was submitted. ","In DY3, the baseline rate is 2.80. 2.80 represents the average CANS  score of all surveys completed during the measurement year. ","Children and Adolescent Needs and Strengths Assessment\n(CANS-MH)\n","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,"PFP baseline not yet reported",null,"1.12.2","Scenario 3: Average Score","Children and Adolescent Needs and Strengths Assessment\n(CANS-MH)\n",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 9_137252607.1.100","RHP 9_137252607.3.101","RHP 9_137252607.1.100_137252607.3.101",{"$f":"COUNTIFS($FI$4:$FI2091,FI2091)","v":2},"RHP 9_137252607.1.100_2",null,2,1,1,"RHP 9_137252607",{"$f":"COUNTIFS($FR$4:$FR2091,FR2091)","v":3},"RHP 9_137252607_3"]
["RHP 9","137252607","Dallas County MHMR dba Metrocare Services","137252607.1.2","137252607.3.12","IT-11.26.c","Adult Needs and Strength Assessment (ANSA)","Baseline Approved","Eligible to Report in April DY4","Establish a community mental health clinic located in Grand Prairie to provide behavioral health services to the underserved in that area.  Services will include psychiatric evaluations, pharmacy services, counseling, rehabilitation and skills training and case management.","Adult Needs and Strength Assessment (ANSA)","In DY4 and DY5, the provider will report the overall scores on the Adult Needs and Strength Assessment (ANSA) among all patients seen at the Grand Prairie Clinic.  In DY5, the provider will demonstrate improvement by improving performance on CMHC.5 Adherence to Antipsychotic Medications","Facility ","Patients served at the Grand Prairie Clinic location ","P4R","CMHC.5","PM-8","Submission of Category 3 DY3 Status Report",37631.14,"Yes/No","RHP 9_137252607.3.12_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",37631.14,"Yes/No","RHP 9_137252607.3.12_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",86021.96,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",102245.22,"Yes/No","NA","AM-3.1","Achievement of DY5 performance goal for PFP measure",102245.22,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Score",3.3112149999999998,599.33000000000004,181,"CY 2013: Jan 1st, 2013 - Dec 31st, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator values reported above equals the sum total of the overall score from all surveys completed during the measurement period. The denominator value above equals the total number of surveys completed during the measurement period.  Scenario #3 is the correct scenario for 137252607_1_2. Provider was allowed to submit the Category 3 baseline template after the DY3 Status Update Template was submitted. ","In DY3, the baseline rate is 3.31. 3.31 represents the average ANSA score of all surveys completed during the measurement year. ","Adult Needs and Strength Assessment (ANSA)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,"PFP baseline not yet reported",null,"1.12.2","Scenario 3: Average Score","Adult Needs and Strength Assessment (ANSA)",null,null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 9_137252607.1.2","RHP 9_137252607.3.12","RHP 9_137252607.1.2_137252607.3.12",{"$f":"COUNTIFS($FI$4:$FI2092,FI2092)","v":1},"RHP 9_137252607.1.2_1",null,2,1,1,"RHP 9_137252607",{"$f":"COUNTIFS($FR$4:$FR2092,FR2092)","v":4},"RHP 9_137252607_4"]
["RHP 9","137252607","Dallas County MHMR dba Metrocare Services","137252607.1.2","137252607.3.200","IT-11.26.d","Children and Adolescent Needs and Strengths Assessment\n(CANS-MH)\n","Baseline Approved","Eligible to Report in April DY4","Establish a community mental health clinic located in Grand Prairie to provide behavioral health services to the underserved in that area.  Services will include psychiatric evaluations, pharmacy services, counseling, rehabilitation and skills training and case management.","Children and Adolescent Needs and Strengths Assessment\n(CANS-MH)\n","In DY4 and DY5, the provider will report the overall scores on the Children and Adolescent Needs and Strengths Assessment (CANS-MH) among all patients seen at the Grand Prairie Clinic. In DY5, the provider will demonstrate improvement by improving performance on CMHC.5 Adherence to Antipsychotic Medications","Facility ","Patients served at the Grand Prairie Clinic location ","P4R","CMHC.5","PM-8","Submission of Category 3 DY3 Status Report",37631.14,"Yes/No","RHP 9_137252607.3.200_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",37631.14,"Yes/No","RHP 9_137252607.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",86021.96,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",102245.22,"Yes/No","NA","AM-3.1","Achievement of DY5 performance goal for PFP measure",102245.22,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Score",2.799426,926.61,331,"CY 2013: Jan 1st, 2013 - Dec 31st, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator values reported above equals the sum total of the overall score from all surveys completed during the measurement period. The denominator value above equals the total number of surveys completed during the measurement period.  Scenario #3 is the correct scenario for 137252607_1_2. Provider was allowed to submit the Category 3 baseline template after the DY3 Status Update Template was submitted. ","In DY3, the baseline rate is 2.80. 2.80 represents the average CANS  score of all surveys completed during the measurement year. ","Children and Adolescent Needs and Strengths Assessment\n(CANS-MH)\n","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,"PFP baseline not yet reported",null,"1.12.2","Scenario 3: Average Score","Children and Adolescent Needs and Strengths Assessment\n(CANS-MH)\n",null,null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 9_137252607.1.2","RHP 9_137252607.3.200","RHP 9_137252607.1.2_137252607.3.200",{"$f":"COUNTIFS($FI$4:$FI2093,FI2093)","v":2},"RHP 9_137252607.1.2_2",null,2,1,1,"RHP 9_137252607",{"$f":"COUNTIFS($FR$4:$FR2093,FR2093)","v":5},"RHP 9_137252607_5"]
["RHP 9","137252607","Dallas County MHMR dba Metrocare Services","137252607.2.1","137252607.3.2","IT-1.7","Controlling high blood pressure ","Baseline Approved","Eligible to Report in October DY4","Establish an integrated model of easy, open access to primary care services for persons who are receiving behavioral health services in our community based behavioral health clinics. This effectively establishes a ‘one stop shop’ for patients to receive both behavioral and primary care services on the same day.","Controlling high blood pressure ","In DY4 and DY5, the provider will improve on the percent of patients seen at Metrocare behavioral health clinics (Lancaster-Kiest, Samuell, Westmoreland, and Pathways) in the denominator whose most recent BP is adequately controlled during the measurement year over patients 18 to 85 years of age by the end of the measurement year who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year.","Facility ","Metrocare behavioral health clinics (Lancaster-Kiest, Samuell, Westmoreland, and Pathways) ","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",66688.09,"Yes/No","RHP 9_137252607.3.2_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",66688.09,"Yes/No","RHP 9_137252607.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",76221.985000000001,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",76221.990000000005,"Numeric",0.58424157899999996,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",362388.11,"Numeric",0.59611499999999995,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.57236799999999999,87,152,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.58424157899999996,null,0.59611499999999995,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator reported above includes individuals who did  receive the intervention associated with the Category 2 project. Merely, the denominator and numerator values are different than the Category 2 population based on the Category 3 inclusion and exclusion criteria. ","The baseline calculation for blood pressure measures in DY3 is 57.24%. This baseline falls between the QISMC HPM and MPL rates. ","Controlling high blood pressure ","ambulatory",null,"The number of patients in the denominator whose most recent BP is adequately controlled during the measurement year. For a patient’s BP to be controlled, both the systolic and diastolic BP must be <140/90 (adequate control). To determine if a patient’s BP is adequately controlled, the representative BP must be identified.\n","Patients 18 to 85 years of age by the end of the measurement year who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.15.1","","Controlling high blood pressure ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 9_137252607.2.1","RHP 9_137252607.3.2","RHP 9_137252607.2.1_137252607.3.2",{"$f":"COUNTIFS($FI$4:$FI2094,FI2094)","v":1},"RHP 9_137252607.2.1_1",null,2,1,1,"RHP 9_137252607",{"$f":"COUNTIFS($FR$4:$FR2094,FR2094)","v":6},"RHP 9_137252607_6"]
["RHP 9","137252607","Dallas County MHMR dba Metrocare Services","137252607.2.100","137252607.3.102","IT-1.22","Asthma Percent of Opportunity Achieved","Baseline Approved","Eligible to Report in October DY4","Integrated model of easy, open access to primary care services for children and adolescents, age’s birth to 18 years of age, who are receiving treatment in our community-based behavioral health clinics, intellectual or developmental delay services or early childhood intervention (ECI) program","Asthma Percent of Opportunity Achieved","In DY4 and DY5, the provider will improve the percentage of asthma opportunities completed/fulfilled for all eligible patients at Metrocare's two pediatric integrated primary and behavioral healthcare clinics: Metrocare at Samuell, and the second clinic has not been identified. :  1.) documentation of Action/Mgmt. Plan, 2.) Severity Assessment, 3.) Controller Therapy for those who are eligible, and 4.) Spirometry within last two years over all asthma appropriate opportunities times the number of asthma patients","Facility ","This measure will be administered, monitored and recorded for all eligible patients at Metrocare's two pediatric integrated primary and behavioral healthcare clinics. Metrocare at Samuell is the first clinic. The second clinic has not been identified. ","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",146713.79999999999,"Yes/No","RHP 9_137252607.3.102_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",146713.79999999999,"Yes/No","RHP 9_137252607.3.102_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",167688.36499999999,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",167688.36499999999,"Numeric",0.64590909100000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",797253.84,"Numeric",0.66454500000000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.62727299999999997,69,110,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.64590909100000005,null,0.66454500000000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator reported above includes all individuals who received Category 2 intervention. Although, the value is distinct in that not all Category 2 project population receive the Category 3 intervention based on specifications such as diagnosis of asthma is needed. The numerator values were calculated based on the completion of the four asthma opportunities stated per the measure.","The baseline calculation for asthma surveys in DY3 is 62.73.Provider will be required to increase this percentage by 5% in DY4 and 10% in DY5.  ","Asthma Percent of Opportunity Achieved","ambulatory",null,"The number of times that each of the asthma opportunities (processes) listed below were completed/fulfilled at least once during the measurement year for all individuals with asthma (any age) :  \n1.) Documentation of Action/Management Plan, \n2.) Severity Assessment\n3.) Controller Therapy for those who are eligible, and \n4.) Documentation of spirometry assessment completed within last two years.\n","The total number of opportunities can be calculated in the following manner-\nFor each individual with an asthma diagnosis assign a count one for each of the four processes that should have been completed (should be 3-4 counts per patient) at least once during the measurement period. \n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.15.1","","Asthma Percent of Opportunity Achieved",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 9_137252607.2.100","RHP 9_137252607.3.102","RHP 9_137252607.2.100_137252607.3.102",{"$f":"COUNTIFS($FI$4:$FI2095,FI2095)","v":1},"RHP 9_137252607.2.100_1",null,2,1,1,"RHP 9_137252607",{"$f":"COUNTIFS($FR$4:$FR2095,FR2095)","v":7},"RHP 9_137252607_7"]
["RHP 9","137252607","Dallas County MHMR dba Metrocare Services","137252607.2.101","137252607.3.103","IT-6.2.a","Client Satisfaction Questionnaire 8 (CSQ-8)","Baseline not yet reported","Eligible to Report in October DY4","Metrocare will provide patient navigation services to patients who are at high risk of disconnecting from institutionalized health care services or are identified as not having a primary care physician to address their needs.  The objective of this project is to improve outpatient treatment adherence while decreasing subsequent emergency department (ED) utilization rates by using navigation coaches","Client Satisfaction Questionnaire 8 (CSQ-8)","In DY4 and DY5, the provider will improve scores on the Client Satisfaction Questionnaire (CSQ-8) among all patients enrolled in the patient navigation program. ","Facility ","All clients enrolled in the Patient Navigation Program during the measurement period","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",59066.595000000001,"Yes/No","RHP 9_137252607.3.103_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",59066.595000000001,"Yes/No","RHP 9_137252607.3.103_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",135021.79999999999,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",320972.33,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"DY4","TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Client Satisfaction Questionnaire 8 (CSQ-8)","Ambulatory",null,"The sum of the \"overall score\" for all CSQ-8 surveys completed during the measurement period.  ","The total number of CSQ-8 surveys completed during the measurement period. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1","","Client Satisfaction Questionnaire 8 (CSQ-8)",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 9_137252607.2.101","RHP 9_137252607.3.103","RHP 9_137252607.2.101_137252607.3.103",{"$f":"COUNTIFS($FI$4:$FI2096,FI2096)","v":1},"RHP 9_137252607.2.101_1",null,1,1,0,"RHP 9_137252607",{"$f":"COUNTIFS($FR$4:$FR2096,FR2096)","v":8},"RHP 9_137252607_8"]
["RHP 9","137252607","Dallas County MHMR dba Metrocare Services","137252607.2.102","137252607.3.104","IT-10.1.a.iv","Assessment of Quality of Life (AQoL-8D) ","Baseline not yet reported","Eligible to Report in October DY4","The Rapid Assessment and Prevention (RAP) Program will include case management services for adults with severe mental illness as they are making the transition from a psychiatric hospital or an incarceration back into the community","Assessment of Quality of Life (AQoL-8D) ","In DY4 and DY5, the provider will improve reported scores on the AQoL-8D among all individuals who complete the assessment. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",107653.63,"Yes/No","RHP 9_137252607.3.104_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",107653.63,"Yes/No","RHP 9_137252607.3.104_PM-9","Metric Carried Forward in October DY3","PM-10","Successful reporting to approved measure specifications",123044.06,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",123044.06,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",584997.94999999995,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,0,"Assessment of Quality of Life (AQoL-8D) ","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.13.1","","Assessment of Quality of Life (AQoL-8D) ",null,null,null,null,null,null,null,null,null,"","",null,null,"RHP 9_137252607.2.102","RHP 9_137252607.3.104","RHP 9_137252607.2.102_137252607.3.104",{"$f":"COUNTIFS($FI$4:$FI2097,FI2097)","v":1},"RHP 9_137252607.2.102_1",null,2,1,1,"RHP 9_137252607",{"$f":"COUNTIFS($FR$4:$FR2097,FR2097)","v":9},"RHP 9_137252607_9"]
["RHP 9","137252607","Dallas County MHMR dba Metrocare Services","137252607.2.103","137252607.3.105","IT-10.4.a","Developmental Profile 3 (DP-3)","Baseline Approved","Eligible to Report in October DY4","Applied Behavior Analysis (ABA) based program to children on the autism spectrum and/or children with other developmental disabilities. The program will be structured as a tiered system; offering 1:1 staff/ client ratio for Level 1, 1:2 staff/ client ratio for Level 2 and group participation for Level 3.  Services will also include speech and occupational therapy for those clients that demonstrate a need for those services.","Developmental Profile 3 (DP-3)","In DY4 and DY5, the provider will report scores on the Developmental Profile 3, DP-3 among children served at the CCAM II and CCAM III sites.  In DY5, the provider will demonstrate improvement by validating the P4R outcome (SA.1).","Facility ","CCAM II and CCAM III locations will receive the approved measure. CCAM II will be located in the Northwest area of Dallas County. CCAM III will be located in the Southwest area of Dallas County","P4R","SA1","PM-8","Submission of Category 3 DY3 Status Report",81454.740000000005,"Yes/No","RHP 9_137252607.3.105_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",81454.740000000005,"Yes/No","RHP 9_137252607.3.105_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",186199.42,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",221315.595,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",221315.595,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",49.066670000000002,736,15,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator and denominator values reported above were actually from our CCAM I location. For purposes of calculating the DY3 baseline, HHSC approved the use of DY3 assessments from the CCAM I location as the CCAM II 137252607.3.105 baseline (via email from Jennifer Woodard on 3/20/14). The numerator for baseline calculations includes pretest scores only. It represents the sum total of all pretest assessments completed during the baseline measurement period (4/1/14-9/30/14). The denominator for baseline calculations represents the total number of individuals completing pretest assessments during the same baseline measurement period. ","The baseline rate of 49.07  is for DY3 and represents the average overall score for DP3 assessments completed during the baseline period. ","Developmental Profile 3 (DP-3)","Multiple",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,"CCAM has been completing the DP3 Assessments to obtain the scores to analyze for the Stretch activity. CCAM has shared these scores with other participants in the LC that are utilizing the same assessments as CCAM. ",null,null,"2.13.1","Scenario 2: Pre Test Only Baseline","Developmental Profile 3 (DP-3)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 9_137252607.2.103","RHP 9_137252607.3.105","RHP 9_137252607.2.103_137252607.3.105",{"$f":"COUNTIFS($FI$4:$FI2098,FI2098)","v":1},"RHP 9_137252607.2.103_1",null,2,1,1,"RHP 9_137252607",{"$f":"COUNTIFS($FR$4:$FR2098,FR2098)","v":10},"RHP 9_137252607_10"]
["RHP 9","137252607","Dallas County MHMR dba Metrocare Services","137252607.2.103","137252607.3.106","IT-10.4.b","Vineland Adaptive Behavior Scales, 2nd Edition (VABS II)","Baseline Approved","Eligible to Report in October DY4","Applied Behavior Analysis (ABA) based program to children on the autism spectrum and/or children with other developmental disabilities. The program will be structured as a tiered system; offering 1:1 staff/ client ratio for Level 1, 1:2 staff/ client ratio for Level 2 and group participation for Level 3.  Services will also include speech and occupational therapy for those clients that demonstrate a need for those services.","Vineland Adaptive Behavior Scales, 2nd Edition (VABS II)","In DY4 and DY5, the provider will report scores on the Vineland Adaptive Behavior Scales, 2nd Edition (VABS II) among children served at the CCAM II and CCAM III sites.  In DY5, the provider will demonstrate improvement by validating the P4R outcome (SA.1).","Facility ","CCAM II and CCAM III locations will receive the approved measure. CCAM II will be located in the Northwest area of Dallas County. CCAM III will be located in the Southwest area of Dallas County","P4R","SA1","PM-8","Submission of Category 3 DY3 Status Report",81454.740000000005,"Yes/No","RHP 9_137252607.3.106_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",81454.740000000005,"Yes/No","RHP 9_137252607.3.106_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",186199.42,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",221315.595,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",221315.595,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",62.266669999999998,934,15,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator and denominator values reported above were actually from our CCAM I location. For purposes of calculating the DY3 baseline, HHSC approved the use of DY3 assessments from the CCAM I location as the CCAM II 137252607.3.105 baseline (via email from Jennifer Woodard on 3/20/14). The numerator for baseline calculations includes pretest scores only. It represents the sum total of all pretest assessments completed during the baseline measurement period (4/1/14-9/30/14). The denominator for baseline calculations represents the total number of individuals completing pretest assessments during the same baseline measurement period. ","The baseline rate of 62.27  is for DY3 and represents the average overall score for Vineland assessments completed during the baseline period. ","Vineland Adaptive Behavior Scales, 2nd Edition (VABS II)","Multiple",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,"CCAM has been completing the VABS Assessments to obtain the scores to analyze for the Stretch activity. CCAM has shared these scores with other participants in the LC that are utilizing the same assessments as CCAM. ",null,null,"2.13.1","Scenario 2: Pre Test Only Baseline","Vineland Adaptive Behavior Scales, 2nd Edition (VABS II)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 9_137252607.2.103","RHP 9_137252607.3.106","RHP 9_137252607.2.103_137252607.3.106",{"$f":"COUNTIFS($FI$4:$FI2099,FI2099)","v":2},"RHP 9_137252607.2.103_2",null,2,1,1,"RHP 9_137252607",{"$f":"COUNTIFS($FR$4:$FR2099,FR2099)","v":11},"RHP 9_137252607_11"]
["RHP 9","137252607","Dallas County MHMR dba Metrocare Services","137252607.2.2","137252607.3.3","IT-11.26.b","Aberrant Behavior Checklist (ABC)","Baseline Approved","Eligible to Report in October DY4","The ACT Team will be on‐call to travel to the acute care facility, jail or school to help assess and stabilize consumers and will also provide follow‐up services to those clients to ensure the destructive pattern that led to the need for acute services is eliminated or significantly reduced.","Aberrant Behavior Checklist (ABC)","In DY4 and DY5, the provider will report on the sum of total scores of all ABC checklists completed during the measurement period over the total number of checklists completed by ACT-DD participants during the measurement period. In addition, in DY5 provider will demonstrate improvement by providing a report describing a comprehensive program evaluation using one of the approved alternative approaches to program and outcome linkages (SA3). ","Facility ","Patients enrolled into the ACT-DD program.","P4R","SA3","PM-8","Submission of Category 3 DY3 Status Report",38107.480000000003,"Yes/No","RHP 9_137252607.3.3_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",38107.480000000003,"Yes/No","RHP 9_137252607.3.3_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",87110.84,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",103539.46,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",103539.46,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",84.629630000000006,4570,54,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator for baseline calculations includes the sum total from all pretest scores completed during the baseline period. The denominator for baseline calculations includes the total number of individuals completing pretest assessments during the baseline period. ","The baseline calculation for ABC assessments in DY3 is 84.63. 84.63 represents the total score under Scenario 2. ","Aberrant Behavior Checklist (ABC)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,"Provider has presented program information to various colleagues, and participated in statewide teleconferences to review progress and challenges of different DSRIP programs in the state, however, the BTC team has not formally worked on the stretch activity in DY3. ",null,null,"2.13.1","Scenario 2: Pre Test Only Baseline","Aberrant Behavior Checklist (ABC)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 9_137252607.2.2","RHP 9_137252607.3.3","RHP 9_137252607.2.2_137252607.3.3",{"$f":"COUNTIFS($FI$4:$FI2100,FI2100)","v":1},"RHP 9_137252607.2.2_1",null,2,1,1,"RHP 9_137252607",{"$f":"COUNTIFS($FR$4:$FR2100,FR2100)","v":12},"RHP 9_137252607_12"]
["RHP 9","137252607","Dallas County MHMR dba Metrocare Services","137252607.2.3","137252607.3.5","IT-10.1.a.v","Pediatric Quality of Life Inventory (PedsQL)","Baseline Approved","Eligible to Report in October DY4","FPP is a short‐term, intensive program that provides crisis intervention, medication management, counseling and case management services to children recently released from the psychiatric hospital or those at‐risk for out‐of‐home placement and their families. As part of this intensive model, clients will receive at minimum 8 hours of services per month.","Pediatric Quality of Life Inventory (PedsQL)","In DY4 and DY5, the provider will improve the reported scores of the PedsQL instrument among all individuals in the FPP program who complete the PedsQL assessment. ","Facility ","Patients enrolled into the FPP program.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",38107.480000000003,"Yes/No","RHP 9_137252607.3.5_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",38107.480000000003,"Yes/No","RHP 9_137252607.3.5_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",43555.42,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",43555.42,"Numeric",70.235059759999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",207078.92,"Numeric",75.235059759999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",65.235060000000004,16374,251,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,70.235059759999999,null,75.235059759999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator values reported above included the sum of the overall scores from all of the surveys completed during the measurement period. The denominator values reported above includes the total number of surveys completed during the measurement period. ","The baseline rate of 65.25 is for DY3 and represents the average score of all surveys completed during the measurement year. The baseline will be compared to DY4 and DY5 calculations. Provider is required to demonstrate a minimum 5% improvement over the baseline in DY4 and a minimum 10% improvement ind DY5.  ","Pediatric Quality of Life Inventory (PedsQL)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.13.1","Scenario 3: Average Score","Pediatric Quality of Life Inventory (PedsQL)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 9_137252607.2.3","RHP 9_137252607.3.5","RHP 9_137252607.2.3_137252607.3.5",{"$f":"COUNTIFS($FI$4:$FI2101,FI2101)","v":1},"RHP 9_137252607.2.3_1",null,2,1,1,"RHP 9_137252607",{"$f":"COUNTIFS($FR$4:$FR2101,FR2101)","v":13},"RHP 9_137252607_13"]
["RHP 9","137252607","Dallas County MHMR dba Metrocare Services","137252607.2.4","137252607.3.7","IT-10.4.a","Developmental Profile 3 (DP-3)","Baseline Approved","Eligible to Report in October DY4","CCAM will provide an applied behavior analysis based program to children on the autism spectrum and/or children with other developmental disabilities. The program will structured as a tiered system; offering 1:1 staff/ client ratio for Level 1, 1:2 staff/ client ratio for Level 2 and group participation for Level 3.","Developmental Profile 3 (DP-3)","In DY4 and DY5, the provider will report scores on the Developmental Profile 3, DP-3 among children served at the original CCAM.  In DY5, the provider will demonstrate improvement by validating the P4R outcome (SA.1).","Facility ","The facility subset to be used for this calculation includes all clients served at the original CCAM facility (5-year project).","P4R","SA1","PM-8","Submission of Category 3 DY3 Status Report",19053.740000000002,"Yes/No","RHP 9_137252607.3.7_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",19053.740000000002,"Yes/No","RHP 9_137252607.3.7_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",43555.42,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",51769.73,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",51769.73,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",49.066670000000002,736,15,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator for baseline calculations includes pretest scores only. It represents the sum total of all pretest assessments completed during the baseline measurement period (4/1/14-9/30/14). The denominator for baseline calculations represents the total number of individuals completing pretest assessments during the same baseline measurement period.  ","The baseline rate of 49.07  is for DY3 and represents the average overall score for DP3 assessments completed during the baseline period. ","Developmental Profile 3 (DP-3)","Multiple",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,"CCAM has been completing the DP3 Assessments to obtain the scores to analyze for the Stretch activity. CCAM has shared these scores with other participants in the LC that are utilizing the same assessments as CCAM. ",null,null,"2.13.1","Scenario 2: Pre Test Only Baseline","Developmental Profile 3 (DP-3)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 9_137252607.2.4","RHP 9_137252607.3.7","RHP 9_137252607.2.4_137252607.3.7",{"$f":"COUNTIFS($FI$4:$FI2102,FI2102)","v":1},"RHP 9_137252607.2.4_1",null,2,1,1,"RHP 9_137252607",{"$f":"COUNTIFS($FR$4:$FR2102,FR2102)","v":14},"RHP 9_137252607_14"]
["RHP 9","137252607","Dallas County MHMR dba Metrocare Services","137252607.2.4","137252607.3.8","IT-10.4.b","Vineland Adaptive Behavior Scales, 2nd Edition (VABS II)","Baseline Approved","Eligible to Report in October DY4","CCAM will provide an applied behavior analysis based program to children on the autism spectrum and/or children with other developmental disabilities. The program will structured as a tiered system; offering 1:1 staff/ client ratio for Level 1, 1:2 staff/ client ratio for Level 2 and group participation for Level 3.","Vineland Adaptive Behavior Scales, 2nd Edition (VABS II)","In DY4 and DY5, the provider will report scores on the Vineland Adaptive Behavior Scales, 2nd Edition (VABS II) among children served at the original CCAM.  In DY5, the provider will demonstrate improvement by validating the P4R outcome (SA.1).","Facility ","The facility subset to be used for this calculation includes all clients served at the original CCAM facility (5-year project).","P4R","SA1","PM-8","Submission of Category 3 DY3 Status Report",19053.740000000002,"Yes/No","RHP 9_137252607.3.8_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",19053.740000000002,"Yes/No","RHP 9_137252607.3.8_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",43555.42,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",51769.73,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",51769.73,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score ",62.266669999999998,934,15,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator for baseline calculations includes pretest scores only. It represents the sum total of all pretest assessments completed during the baseline measurement period (4/1/14-9/30/14). The denominator for baseline calculations represents the total number of individuals completing pretest assessments during the same baseline measurement period. ","The baseline rate of 62.27  is for DY3 and represents the average overall score for Vineland assessments completed during the baseline period. ","Vineland Adaptive Behavior Scales, 2nd Edition (VABS II)","Multiple",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,"CCAM has been completing the VABS Assessments to obtain the scores to analyze for the Stretch activity. CCAM has shared these scores with other participants in the LC that are utilizing the same assessments as CCAM. ",null,null,"2.13.1","Scenario 2: Pre Test Only Baseline","Vineland Adaptive Behavior Scales, 2nd Edition (VABS II)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 9_137252607.2.4","RHP 9_137252607.3.8","RHP 9_137252607.2.4_137252607.3.8",{"$f":"COUNTIFS($FI$4:$FI2103,FI2103)","v":2},"RHP 9_137252607.2.4_2",null,2,1,1,"RHP 9_137252607",{"$f":"COUNTIFS($FR$4:$FR2103,FR2103)","v":15},"RHP 9_137252607_15"]
["RHP 9","137252607","Dallas County MHMR dba Metrocare Services","137252607.2.5","137252607.3.9","IT-11.26.b","Aberrant Behavior Checklist (ABC)","Baseline Approved","Eligible to Report in October DY4","The Behavioral Day Program will provide short‐term behavior intervention and urgent safety net services for individuals with intellectual/developmental disabilities and mental health issues. The individuals will receive crisis diversion services and an intensive package of behavioral services to help stabilize them within their natural environment or if needed within a Respite Facility. While enrolled in the Behavioral Day Program, clients will receive three hours of treatment services per day, five times per week, resulting in 15 hours of services per week.","Aberrant Behavior Checklist (ABC)","In DY4 and DY5, the provider will report on the sum of total scores of all ABC checklists completed during the measurement period over the total number of checklists completed during the measurement period by consumers enrolled at the Behavioral Treatment Center. In addition, in DY5 provider will demonstrate improvement by providing a report describing a comprehensive program evaluation using one of the approved alternative approaches to program and outcome linkages (SA3). ","Facility ","consumers enrolled at the Behavioral Treatment Center ","P4R","SA3","PM-8","Submission of Category 3 DY3 Status Report",40012.855000000003,"Yes/No","RHP 9_137252607.3.9_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",40012.855000000003,"Yes/No","RHP 9_137252607.3.9_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",91466.38,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",108716.435,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",108716.435,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"Score",60.4,2114,35,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The numerator for baseline calculations includes the sum total from all pretest scores completed during the baseline period. The denominator for baseline calculations includes the total number of individuals completing pretest assessments during the baseline period. ","The baseline calculation for ABC assessments in DY3 is 60. 60 represents the total score under Scenario 2. ","Aberrant Behavior Checklist (ABC)","Ambulatory",null,"The sum of the all survey scores as defined by selected reporting scenario","The total number of survey scores as defined by selected reporting scenario ",null,null,null,null,null,null,null,null,null,null,"Provider has presented program information to various colleagues, and participated in statewide teleconferences to review progress and challenges of different DSRIP programs in the state, however, the BTC team has not formally worked on the stretch activity in DY3. ",null,null,"2.13.1","Scenario 2: Pre Test Only Baseline","Aberrant Behavior Checklist (ABC)",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 9_137252607.2.5","RHP 9_137252607.3.9","RHP 9_137252607.2.5_137252607.3.9",{"$f":"COUNTIFS($FI$4:$FI2104,FI2104)","v":1},"RHP 9_137252607.2.5_1",null,2,1,1,"RHP 9_137252607",{"$f":"COUNTIFS($FR$4:$FR2104,FR2104)","v":16},"RHP 9_137252607_16"]
["RHP 9","138910807","Children's Medical Center of Dallas","138910807.1.1","138910807.3.1","IT-9.3","\nReduce Pediatric Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC)","Pending Approval","Eligible to Report in October DY4","Expand the capacity of pediatric primary care in Dallas County through 16\nadditional Children’s Medical Center (CMC) primary care centers and a medical home for\nchildren with complex chronic illness, integrated with critical support services across a\ncontinuum of care to better accommodate the needs of the pediatric population (Medicaid and CHIP), so that children receive the right care at the right time, have access to same‐day appointment thereby reducing the unnecessary use of Emergency Department services. This project will also establish pediatric urgent care services on the Dallas campus and implement telemedicine to connect school settings with pediatricians.","\nReduce Pediatric Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC)","In DY4 and DY5, the provider will improve the rate of ED Visits with a primary or secondary ACSC diagnosis for any individual 6 – 17 years old during the measurement period over all ED visits at Children's Dallas and Legacy Emergency Departments for individuals 6 - 17 years during the measurement period","Facility ","MyChildren's patients seen in the Children's Dallas and Legacy Emergency Departments","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",258033.35,"Yes/No","RHP 9_138910807.3.1_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",258033.35,"Yes/No","RHP 9_138910807.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",385326.85,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",385326.85,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1706927.8,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator: ED Visits in Dallas and Plano hospital locations for patients aged 6 to 17 years \nNumerator: ED Visits in Denominator with primary or secondary diagnosis of an Ambulatory Care Sensitive Condition ","17.84% of ED visits during the measurement period for patients aged 6 to 17 years had one of the following pediatric ambulatory care sensitive condition diagnoses (Asthma, Diabetes Short-Term Complications, Gastroenteritis, Urinary Tract Infection)","\nReduce Pediatric Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC)","ED",null,"Total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 6 – 17 years old during the measurement period","Total number of ED visits for individuals 6 - 17 years old during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1 ","","\nReduce Pediatric Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC)",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 9_138910807.1.1","RHP 9_138910807.3.1","RHP 9_138910807.1.1_138910807.3.1",{"$f":"COUNTIFS($FI$4:$FI2105,FI2105)","v":1},"RHP 9_138910807.1.1_1",null,2,1,1,"RHP 9_138910807",{"$f":"COUNTIFS($FR$4:$FR2105,FR2105)","v":1},"RHP 9_138910807_1"]
["RHP 9","138910807","Children's Medical Center of Dallas","138910807.1.100","138910807.3.100","IT-9.3","\nReduce Pediatric Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC)","Pending Approval","Eligible to Report in October DY4","Expand community-based health services cost-effectively by use of a telemedicine program involving community-based nurses and pediatric clinical personnel at Children’s to better accommodate the needs of the pediatric population during the school day (reduce unnecessary use of emergency department services).  Telemedicine services may also be developed in other community settings such as daycare centers, after school programs and community centers. \n","\nReduce Pediatric Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC)","In DY4 and DY5, the provider will improve the rate of ED Visits with a primary or secondary ACSC diagnosis for any individual 6 – 17 years old during the measurement period over all ED visits at Children's Dallas and Legacy Emergency Departments for individuals 6 - 17 years during the measurement period","Facility ","Patients who visit the Children's Dallas and Legacy locations.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",258033.35,"Yes/No","RHP 9_138910807.3.100_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",258033.35,"Yes/No","RHP 9_138910807.3.100_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",385326.85,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",385326.85,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1706927.8,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator: ED Visits in Dallas and Plano hospital locations for patients aged 6 to 17 years \nNumerator: ED Visits in Denominator with primary and secondary diagnosis of an Ambulatory Care Sensitive Condition ","17.84% of ED visits during the measurement period for patients aged 6 to 17 years had one of the following pediatric ambulatory care sensitive condition diagnoses (Asthma, Diabetes Short-Term Complications, Gastroenteritis, Urinary Tract Infection)","\nReduce Pediatric Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC)","ED",null,"Total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 6 – 17 years old during the measurement period","Total number of ED visits for individuals 6 - 17 years old during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.7.3","","\nReduce Pediatric Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC)",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 9_138910807.1.100","RHP 9_138910807.3.100","RHP 9_138910807.1.100_138910807.3.100",{"$f":"COUNTIFS($FI$4:$FI2106,FI2106)","v":1},"RHP 9_138910807.1.100_1",null,2,1,1,"RHP 9_138910807",{"$f":"COUNTIFS($FR$4:$FR2106,FR2106)","v":2},"RHP 9_138910807_2"]
["RHP 9","138910807","Children's Medical Center of Dallas","138910807.1.2","138910807.3.2","IT-9.3","\nReduce Pediatric Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC)","Pending Approval","Eligible to Report in October DY4","The purpose of this project is to expand the hours of operation to include nights\nand weekends at the MyChildren’s locations and to establish a 24 hour RN triage telephone\nservice. It is an expansion of an existing initiative.","\nReduce Pediatric Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC)","In DY4 and DY5, the provider will improve the rate of ED Visits with a primary or secondary ACSC diagnosis for any individual 6 – 17 years old during the measurement period over all ED visits at Children's Dallas and Legacy Emergency Departments for individuals 6 - 17 years during the measurement period","Facility ","MyChildren's patients seen at the Children's Dallas and Legacy Emergency Departments","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",258033.35,"Yes/No","RHP 9_138910807.3.2_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",258033.35,"Yes/No","RHP 9_138910807.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",385326.85,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",385326.85,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1706927.8,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator: ED Visits in Dallas and Plano hospital locations for patients aged 6 to 17 years \nNumerator: ED Visits in Denominator with primary or secondary diagnosis of an Ambulatory Care Sensitive Condition ","17.84% of ED visits during the measurement period for patients aged 6 to 17 years had one of the following pediatric ambulatory care sensitive condition diagnoses (Asthma, Diabetes Short-Term Complications, Gastroenteritis, Urinary Tract Infection)","\nReduce Pediatric Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC)","ED",null,"Total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 6 – 17 years old during the measurement period","Total number of ED visits for individuals 6 - 17 years old during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","\nReduce Pediatric Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC)",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 9_138910807.1.2","RHP 9_138910807.3.2","RHP 9_138910807.1.2_138910807.3.2",{"$f":"COUNTIFS($FI$4:$FI2107,FI2107)","v":1},"RHP 9_138910807.1.2_1",null,2,1,1,"RHP 9_138910807",{"$f":"COUNTIFS($FR$4:$FR2107,FR2107)","v":3},"RHP 9_138910807_3"]
["RHP 9","138910807","Children's Medical Center of Dallas","138910807.1.3","138910807.3.3","IT-2.23","Pediatric Asthma Admission Rate","Pending Approval","Eligible to Report in October DY4","The purpose of this project is to implement a disease management program at\nthe MyChildren’s location and in school‐based primary care settings in RHP 9","Pediatric Asthma Admission Rate","In DY4 and DY5, the provider will report the rate of admissions to the Children's Dallas and Legacy Hospitals for asthma out of the total number of Medicaid and indigent/uninsured individuals in the metro or county area. In addition, in DY5 provider will demonstrate improvement by improvement in the  Population Focused Priority measure PPA 6: Risk adjusted Pediatric Asthma PPA.\n ","Facility ","active patients of  MyChildrens ambulatory clinics in RHP 9","P4R","PPA.6","PM-8","Submission of Category 3 DY3 Status Report",258033.35,"Yes/No","RHP 9_138910807.3.3_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",258033.35,"Yes/No","RHP 9_138910807.3.3_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",770653.7,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",853463.9,"Yes/No","NA","AM-3.1","Achievement of DY5 performance goal for PFP measure",853463.9,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"number per 100K",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator: Discharges during measurement year for age 0-17 years old.\nNumerator: Discharges in Denominator with a primary diagnosis of asthma","4.87% is the of  rate of admissions due to asthma for pediatric patients, age 0-17 years old.","Pediatric Asthma Admission Rate","inpatient",null,"All discharges of age 17 years or younger with a principal diagnosis code of asthma x 100,000.","Population ages 17 years and younger in metropolitan area  or county. ",null,null,null,null,null,null,null,null,null,null,null,"PFP baseline not yet reported",null,"1.3.1 ","","Pediatric Asthma Admission Rate",null,null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 9_138910807.1.3","RHP 9_138910807.3.3","RHP 9_138910807.1.3_138910807.3.3",{"$f":"COUNTIFS($FI$4:$FI2108,FI2108)","v":1},"RHP 9_138910807.1.3_1",null,2,1,1,"RHP 9_138910807",{"$f":"COUNTIFS($FR$4:$FR2108,FR2108)","v":4},"RHP 9_138910807_4"]
["RHP 9","138910807","Children's Medical Center of Dallas","138910807.1.4","138910807.3.4","IT-11.6","Follow-up Care for Children Prescribed ADHD Medication (ADD)","Baseline Approved","Eligible to Report in April DY4","The purpose of this project is to bring behavioral health services into the primary care setting through the MyChildren’s offices.  Provide behavioral health services to children in the medical home setting to allow for more rapid access to behavioral health services and better coordination of behavioral and medical services for children and their families.","Follow-up Care for Children Prescribed ADHD Medication (ADD)","In DY4 and DY5 provider will improve the percentage of children  receiving services at MyChildren's clinics that are newly prescribed attention-deficit/hyperactivity disorder (ADHD) medication AND  who had at least three follow-up care visits within a 10-month period, one of which was within 30 days of when the first ADHD medication was dispensed . This rate is reported in two parts- the initiation and continuation phases.   ","Facility ","Patients seen at participating MyChildren's practices","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",258033.35,"Yes/No","RHP 9_138910807.3.4_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",258033.35,"Yes/No","RHP 9_138910807.3.4_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",385326.85,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- Initiation Phase",192663.42499999999,"Numeric",0.361570909,"AM-1.2","Achievement of DY4 performance goal- C&M Phase",192663.42499999999,"Numeric",0.3836,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- Initiation Phase",853463.9,"Numeric",0.37970747399999999,"AM-2.2","Achievement of DY5 performance goal- C&M Phase",853463.9,"Numeric",0.40834999999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,2,"%",0.34343400000000002,68,198,"CY 2013: Jan 1st, 2013 - Dec 31st, 2013",0.32323232323232326,64,198,"CY 2013: Jan 1st, 2013 - Dec 31st, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0.361570909,null,0.37970747399999999,null,0.3836,null,0.40834999999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator:   Patients ages 6 to 12 with ambulatory prescription for ADHD medication during the measurement year \nNumerator1: Patients in Denominator who had a follow-up visit with a practitioner with prescribing authority during the 0-30day initiation phase\nNumerator2:  Patients in Denominator who satisfy Numerator1 condition AND who had at least 2 follow-up visits during the 31-300day continuation and maintenance phase","86.36% is the percentage of children ages 6 to 12 with ambulatory prescription for ADHD medication during the measurement year who had at least 3 follow-up visits within a 10-month period, one of which was within 30 days of when the first ADHD medication was prescribed/ordered.","Follow-up Care for Children Prescribed ADHD Medication (ADD)","ambulatory",null,"Initiation Phase: Patients from the denominator with one face-to-face outpatient, intensive outpatient or partial hospitalization follow-up visit with a practitioner with prescribing authority, within 30 days after the Index Prescription Start Date \n","Initiation Phase: Patients 6 years as of March 1 of the year prior to the measurement year to 12 years as of February 28 of the measurement year who were dispensed an attention deficit/hyperactivity disorder (ADHD) medication during the 12-month Intake Period \n","Continuation Phase: All patients who meet the following criteria:\n• An Initiation Phase visit in the first 30 days\n• At least two follow-up visits from 31-300 days (10 months) after the IPSD (one of the two visits may be a telephone visit with practitioner). \n","Continuation Phase: Patients 6 years as of March 1 of the year prior to the measurement year to 12 years as of February 28 of the measurement year who had continuous treatment for at least 210 days out of the 300-day period ",null,null,null,null,null,null,null,null,null,null,null,"1.12.2","","Initiation Phase","Continuation Phase",null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 9_138910807.1.4","RHP 9_138910807.3.4","RHP 9_138910807.1.4_138910807.3.4",{"$f":"COUNTIFS($FI$4:$FI2109,FI2109)","v":1},"RHP 9_138910807.1.4_1",null,3,2,1,"RHP 9_138910807",{"$f":"COUNTIFS($FR$4:$FR2109,FR2109)","v":5},"RHP 9_138910807_5"]
["RHP 9","138910807","Children's Medical Center of Dallas","138910807.2.1","138910807.3.5","IT-1.22","Asthma Percent of Opportunity Achieved","Baseline Approved","Eligible to Report in April DY4","The purpose of this project is to transform the MyChildren’s primary care offices into an NCQA‐certified medical homes. It is a new initiative.\n","Asthma Percent of Opportunity Achieved","In DY4 and DY5 provider will improve the percentage of asthma opportunities achieved for children  receiving services at MyChildren's. ","Facility ","All medical home patients that are part of MyChildren's practices","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",258033.35,"Yes/No","RHP 9_138910807.3.5_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",258033.35,"Yes/No","RHP 9_138910807.3.5_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",385326.85,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",385326.85,"Numeric",0.38577148900000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1706927.8,"Numeric",0.418099,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.35344399999999998,3972,11238,"CY 2013: Jan 1st, 2013 - Dec 31st, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.38577148900000002,null,0.418099,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator: the number of opportunities for providing the recommended care (either 3 or 4, depending on persistence or non-persistence of asthma severity) for patients 5-17 years old\nNumerator: the number of opportunities Completed for providing the recommended care","35.34% is the sum of the number of times recommended care was completed Divided by the sum of the total number of recommended opportunities for patients 5-17 years old.","Asthma Percent of Opportunity Achieved","ambulatory",null,"The number of times that each of the asthma opportunities (processes) listed below were completed/fulfilled at least once during the measurement year for all individuals with asthma (any age) :  \n1.) Documentation of Action/Management Plan, \n2.) Severity Assessment\n3.) Controller Therapy for those who are eligible, and \n4.) Documentation of spirometry assessment completed within last two years.\n","The total number of opportunities can be calculated in the following manner-\nFor each individual with an asthma diagnosis assign a count one for each of the four processes that should have been completed (should be 3-4 counts per patient) at least once during the measurement period. \n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.1.1 ","","Asthma Percent of Opportunity Achieved",null,null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 9_138910807.2.1","RHP 9_138910807.3.5","RHP 9_138910807.2.1_138910807.3.5",{"$f":"COUNTIFS($FI$4:$FI2110,FI2110)","v":1},"RHP 9_138910807.2.1_1",null,2,1,1,"RHP 9_138910807",{"$f":"COUNTIFS($FR$4:$FR2110,FR2110)","v":6},"RHP 9_138910807_6"]
["RHP 9","138910807","Children's Medical Center of Dallas","138910807.2.100","138910807.3.101","IT-1.9","Depression Remission at Twelve Months  ","Pending Approval","Eligible to Report in October DY4","Design, implement and evaluate care management programs and that integrate primary and behavioral health needs of individual pediatric patients covered by Medicaid or uninsured. \n","Depression management: Depression Remission at Twelve Months  ","In DY4 and DY5, the provider will improve the percentage of patients age 11 to 17 year seen at MyChildren's pediatric primary care practices with major depression or dysthymia and an initial PHQ-9 score > 9 who demonstrate remission at twelve months defined as a PHQ-9 score less than 5","Facility, Age ","MyChildren's pediatric primary care practices, age 11-17 years","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",258033.35,"Yes/No","RHP 9_138910807.3.101_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",258033.35,"Yes/No","RHP 9_138910807.3.101_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",385326.85,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",385326.85,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1706927.8,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator:age 11 to 17 years old with major depression or dysthymia \nNumerator: Patients in the Denominator  who demonstrate remission at twelve months (defined as a PHQ-9 score less than 5)","5.26% is the percentage of patients age 11 to 17 years old with major depression or dysthymia who demonstrate remission at twelve months( defined as a PHQ-9 score less than 5).","Depression Remission at Twelve Months  ","ambulatory",null,"Adults age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine who achieve remission at twelve months as demonstrated by a twelve month (+/- 30 days) PHQ-9 score of less than five.","Adults age 18 and older with a diagnosis of major depression or dysthymia and an initial PHQ-9 score greater than nine (including, patients who do not have a follow-up PHQ-9 score at twelve months (+/- 30 days)",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.19.1","","Depression Remission at Twelve Months  ",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 9_138910807.2.100","RHP 9_138910807.3.101","RHP 9_138910807.2.100_138910807.3.101",{"$f":"COUNTIFS($FI$4:$FI2111,FI2111)","v":1},"RHP 9_138910807.2.100_1",null,2,1,1,"RHP 9_138910807",{"$f":"COUNTIFS($FR$4:$FR2111,FR2111)","v":7},"RHP 9_138910807_7"]
["RHP 9","138910807","Children's Medical Center of Dallas","138910807.2.2","138910807.3.6","IT-9.4.h","Pediatric/Young Adult Asthma Emergency Department Visits  ","Pending Approval","Eligible to Report in October DY4","The purpose of this project is to work with agencies and organizations in Dallas County through a formal steering committee to align and coordinate community-based prevention and wellness activities in the focused areas of asthma and diabetes to improve the health and self-management of children and their families.  This is a new initiative for Children’s. \n","Pediatric/Young Adult Asthma Emergency Department Visits  ","In DY4 and DY5 provider will reduce the percentage of children ages 2 - 20 presenting to Children's Dallas or Legacy Emergency Departments with  an asthma diagnosis out of all children ages 2 to 20 with an asthma diagnosis. ","Facility ","Children's Dallas and Legacy Emergency Departments","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",258033.35,"Yes/No","RHP 9_138910807.3.6_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",258033.35,"Yes/No","RHP 9_138910807.3.6_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",385326.85,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",385326.85,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1706927.8,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator: Patients with a primary or secondary (any-level) diagnosis of asthma during the measurement period\nNumerator: Patients in Denominator who had one or more Emergency Department Visits and had a primary diagnosis of asthma on the same ED Visit","6.24% is the percentage of children ages 2-20 years diagnosed with asthma during the measurement year with 1 or more asthma-related emergency room (ER) visits","Pediatric/Young Adult Asthma Emergency Department Visits  ","ED",null,"Number of patients with asthma who have greater than or equal to one visit to the emergency room during the measurement period","Denominator is all patients age two through 20, diagnosed with asthma during the measurement period.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.6.1 ","","Pediatric/Young Adult Asthma Emergency Department Visits  ",null,null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 9_138910807.2.2","RHP 9_138910807.3.6","RHP 9_138910807.2.2_138910807.3.6",{"$f":"COUNTIFS($FI$4:$FI2112,FI2112)","v":1},"RHP 9_138910807.2.2_1",null,2,1,1,"RHP 9_138910807",{"$f":"COUNTIFS($FR$4:$FR2112,FR2112)","v":8},"RHP 9_138910807_8"]
["RHP 9","138910807","Children's Medical Center of Dallas","138910807.2.3","138910807.3.7","IT-9.3","\nReduce Pediatric Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC)","Pending Approval","Eligible to Report in October DY4","We propose to develop and utilize a high‐intensity, culturally appropriate care management system for Medicaid and safety net children and families, most of whom utilize\nChildren’s Medical Center’s ED, specialty clinics and inpatient hospital as a safety net provider for children.","\nReduce Pediatric Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC)","In DY4 and DY5, the provider will improve the rate of ED Visits with a primary or secondary ACSC diagnosis for any individual 6 – 17 years old during the measurement period over all ED visits at Children's Dallas and Legacy Emergency Departments for individuals 6 - 17 years during the measurement period","Facility ","Patients who visit the Children's Dallas and Legacy locations.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",258033.35,"Yes/No","RHP 9_138910807.3.7_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",258033.35,"Yes/No","RHP 9_138910807.3.7_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",385326.85,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",385326.85,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1706927.8,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator: ED Visits in Dallas and Plano hospital locations for patients aged 6 to 17 years \nNumerator: ED Visits in Denominator with primary and secondary diagnosis of an Ambulatory Care Sensitive Condition ","17.84% of ED visits during the measurement period for patients aged 6 to 17 years had one of the following pediatric ambulatory care sensitive condition diagnoses (Asthma, Diabetes Short-Term Complications, Gastroenteritis, Urinary Tract Infection)","\nReduce Pediatric Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC)","ED",null,"Total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 6 – 17 years old during the measurement period","Total number of ED visits for individuals 6 - 17 years old during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1 ","","\nReduce Pediatric Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC)",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 9_138910807.2.3","RHP 9_138910807.3.7","RHP 9_138910807.2.3_138910807.3.7",{"$f":"COUNTIFS($FI$4:$FI2113,FI2113)","v":1},"RHP 9_138910807.2.3_1",null,2,1,1,"RHP 9_138910807",{"$f":"COUNTIFS($FR$4:$FR2113,FR2113)","v":9},"RHP 9_138910807_9"]
["RHP 9","138910807","Children's Medical Center of Dallas","138910807.2.4","138910807.3.8","IT-9.2","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","Pending Approval","Eligible to Report in October DY4","A standardized approach to transitioning an adolescent with special health care needs or at risk for loss of medical services will be developed and applied to multiple medical and social conditions of the patient and family.  The plan will be customizable as needed but contain a standardized approach to the transition process.  \n","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","In DY4 and DY5, the provider will improve the rate of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period overall ED visits to the Children's Dallas and Legacy locations for individuals 18 years or older during the measurement period","Facility ","Patients who visit the Children's Dallas and Legacy locations.","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",258033.35,"Yes/No","RHP 9_138910807.3.8_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",258033.35,"Yes/No","RHP 9_138910807.3.8_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",385326.85,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",385326.85,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",1706927.8,"Numeric","TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"TBD",null,"TBD",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Denominator: ED Visits in Dallas and Plano hospital locations for patients aged 18 to 35 years \nNumerator: ED Visits in Denominator with primary and secondary diagnosis of an adult Ambulatory Care Sensitive Condition ","16.38% of ED visits during the measurement period for patients aged 18 to 35 years had one of the  adult ambulatory care sensitive condition diagnoses","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","ED",null,"Total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.12.2","","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ",null,null,null,null,null,"2014-01-01","2014-12-31","2015-01-01","2015-12-31","2013-01-01","2013-12-31",null,null,"RHP 9_138910807.2.4","RHP 9_138910807.3.8","RHP 9_138910807.2.4_138910807.3.8",{"$f":"COUNTIFS($FI$4:$FI2114,FI2114)","v":1},"RHP 9_138910807.2.4_1",null,2,1,1,"RHP 9_138910807",{"$f":"COUNTIFS($FR$4:$FR2114,FR2114)","v":10},"RHP 9_138910807_10"]
["RHP 9","139485012","Baylor University Medical Center","139485012.1.1","139485012.3.1","IT-1.7","Controlling high blood pressure ","Baseline Approved","Eligible to Report in October DY4","This project will implement increased access to three (3) Patient-Centered Medical Home (PCMH) clinics designed to provide comprehensive and high-quality primary care services to underserved patients in the Baylor University Medical Center service area.  The project is an expansion of Baylor’s Clinic strategy in Dallas County.  Historically, Baylor’s Community Care clinics have provided access to patients following discharge from Baylor University Medical Center.  This expansion will focus on the recruitment of more underserved (Medicaid/Uninsured) patients from the community at-large and patients awaiting access to other public resources.","Controlling high blood pressure ","In DY4 and DY5 provider will increase the percent of individuals whose most recent blood pressure was adequately controlled (<140/90) out of all individuals receiving services at the PCMH clinics aged 18 to 85 years with Medicaid or who are uninsured and have a diagnosis of hypertension. ","Facility, Payer ","Ambulatory Setting- Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",48402.78,"Yes/No","RHP 9_139485012.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",48402.78,"Yes/No","RHP 9_139485012.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",77669.475000000006,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",77669.48,"Numeric",0.67368399099999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",371462.71,"Numeric",0.67561899999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.67174900000000004,1498,2230,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.67368399099999998,null,0.67561899999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DSRIP base population selection criteria for all metrics: all community care clinic patients, who had at least one office visit during one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the clinics based on their most recent visit location. Numerator: Patients with last SBP < 140 and DBP < 90 within reporting period, Denominator: Patients with HT: ICD-9 401.*-405.* and age between 18 and 85. Note: Includes only those patients with recorded BP measurement.","During DY3 (10/01/2013- 9/30/2014), of those adult, Uninsured/Medicaid clinic patients with a diagnosis of hypertension, 67% of patients had controlled hypertension (BP less than 140/90). ","Controlling high blood pressure ","ambulatory",null,"The number of patients in the denominator whose most recent BP is adequately controlled during the measurement year. For a patient’s BP to be controlled, both the systolic and diastolic BP must be <140/90 (adequate control). To determine if a patient’s BP is adequately controlled, the representative BP must be identified.\n","Patients 18 to 85 years of age by the end of the measurement year who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","Controlling high blood pressure ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 9_139485012.1.1","RHP 9_139485012.3.1",{"$f":"A2115&\"_\"&D2115&\"_\"&E2115","v":"RHP 9_139485012.1.1_139485012.3.1"},{"$f":"COUNTIFS($FI$4:$FI2115,FI2115)","v":1},{"$f":"FI2115&\"_\"&FL2115","v":"RHP 9_139485012.1.1_1"},null,2,1,1,"RHP 9_139485012",{"$f":"COUNTIFS($FR$4:$FR2115,FR2115)","v":1},"RHP 9_139485012_1"]
["RHP 9","139485012","Baylor University Medical Center","139485012.1.1","139485012.3.200","IT-12.3","Colorectal Cancer Screening ","Baseline Approved","Eligible to Report in October DY4","This project will implement increased access to three (3) Patient-Centered Medical Home (PCMH) clinics designed to provide comprehensive and high-quality primary care services to underserved patients in the Baylor University Medical Center service area.  The project is an expansion of Baylor’s Clinic strategy in Dallas County.  Historically, Baylor’s Community Care clinics have provided access to patients following discharge from Baylor University Medical Center.  This expansion will focus on the recruitment of more underserved (Medicaid/Uninsured) patients from the community at-large and patients awaiting access to other public resources.","Colorectal Cancer Screening ","In DY4 and DY5 provider will increase the percent of individuals who received screening for colorectal cancer out of all individuals aged 50 to 75 with Medicaid or are uninsured receiving services at the PCMH clinic","Facility, Payer ","Ambulatory Setting- Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",48402.78,"Yes/No","RHP 9_139485012.3.200_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",48402.78,"Yes/No","RHP 9_139485012.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",77669.475000000006,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",77669.48,"Numeric",0.55295310799999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",371462.71,"Numeric",0.57373600000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.53217000000000003,976,1834,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.55295310799999997,null,0.57373600000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DSRIP base population selection criteria for all metrics: all community care clinic patients, who had at least one office visit during one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the clinics based on their most recent visit location. Numerator: Adults aged 51-75 and at least one colonoscopy observation within 10 years or one FOBT within 1 year prior to the report date. HDIDs: (27, 2323)\n","During DY3 (10/01/2013- 9/30/2014), of those eligble adult, Uninsured/Medicaid clinic patients between the ages of 51-75, 53% of patients received a colorectal cancer screening- most likely an FOBT based on the ambulatory setting criteria. ","Colorectal Cancer Screening ","ambulatory",null,"One or more screenings for colorectal cancer. Any of the following meet the criteria: \n\n• Fecal occult blood test (FOBT) during the measurement year. For administrative data, assume the required number of samples were returned regardless of FOBT type.\n• Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year.\n• Colonoscopy during the measurement year or the nine years prior to the measurement year.\n","Patients 51–75 years of age as of the end of the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","Colorectal Cancer Screening ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,{"$f":"A2116&\"_\"&D2116","v":"RHP 9_139485012.1.1"},{"$f":"A2116&\"_\"&E2116","v":"RHP 9_139485012.3.200"},"RHP 9_139485012.1.1_139485012.3.200",{"$f":"COUNTIFS($FI$4:$FI2116,FI2116)","v":2},"RHP 9_139485012.1.1_2",null,2,{"$f":"IF(DC2116=\"\",0,1)+IF(DG2116=\"\",0,1)+IF(DK2116=\"\",0,1)+IF(DO2116=\"\",0,1)+IF(DS2116=\"\",0,1)","v":1},1,"RHP 9_139485012",{"$f":"COUNTIFS($FR$4:$FR2116,FR2116)","v":2},{"$f":"FR2116&\"_\"&FS2116","v":"RHP 9_139485012_2"}]
["RHP 9","139485012","Baylor University Medical Center","139485012.1.1","139485012.3.4","IT-12.1","Breast Cancer Screening","Baseline Approved","Eligible to Report in October DY4","This project will implement increased access to three (3) Patient-Centered Medical Home (PCMH) clinics designed to provide comprehensive and high-quality primary care services to underserved patients in the Baylor University Medical Center service area.  The project is an expansion of Baylor’s Clinic strategy in Dallas County.  Historically, Baylor’s Community Care clinics have provided access to patients following discharge from Baylor University Medical Center.  This expansion will focus on the recruitment of more underserved (Medicaid/Uninsured) patients from the community at-large and patients awaiting access to other public resources.","Breast Cancer Screening","In DY4 and DY5 provider will increase the percent of women who received a mammogram during the measurement year or in the 18 months prior out of all women aged 50 to 75 with Medicaid or are uninsured receiving services at the PCMH clinic","Facility, Payer ","Ambulatory Setting- Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",48402.78,"Yes/No","RHP 9_139485012.3.4_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",48402.78,"Yes/No","RHP 9_139485012.3.4_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",77669.475000000006,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",77669.48,"Numeric",0.44819999999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",371462.71,"Numeric",0.46614,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.42409200000000002,514,1212,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.44819999999999999,null,0.46614,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DSRIP base population selection criteria for all metrics: all community care clinic patients, who had at least one office visit during one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the clinics based on their most recent visit location. Numerator: Females aged 50-74 and at least one ‘MAMMOGRAM’ observation record within reporting period HDID=71. Denominator: Include: females aged 50-74 Exclude: Hx of bilateral mastectomy - ICD-V45.71, CPT-19303. Notes: none\n","During DY3 (10/01/2013- 9/30/2014), of those female adult, Uninsured/Medicaid clinic patients between the ages of 50-74 without a history of a mastectomy, 42% of eligible patients received a mammogram. ","Breast Cancer Screening","ambulatory",null,"Women who had mammogram during the measurement year or the 18 months prior to the measurement year.","Women 50-74 years old as of the measurement year who had at least one (1) outpatient encounter in the prior 12-month period. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.2 ","","Breast Cancer Screening",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 9_139485012.1.1","RHP 9_139485012.3.4","RHP 9_139485012.1.1_139485012.3.4",{"$f":"COUNTIFS($FI$4:$FI2117,FI2117)","v":3},"RHP 9_139485012.1.1_3",null,{"$f":"MAX(IF(AC2117=\"\",0,1)+IF(AH2117=\"\",0,1)+IF(AM2117=\"\",0,1)+IF(AR2117=\"\",0,1)+IF(AW2117=\"\",0,1)+IF(BB2117=\"\",0,1),IF(BG2117=\"\",0,1)+IF(BL2117=\"\",0,1)+IF(BQ2117=\"\",0,1)+IF(BV2117=\"\",0,1)+IF(CA2117=\"\",0,1))","v":2},1,{"$f":"FO2117-FP2117","v":1},{"$f":"A2117&\"_\"&RIGHT(\"000000000\"&B2117,9)","v":"RHP 9_139485012"},{"$f":"COUNTIFS($FR$4:$FR2117,FR2117)","v":3},"RHP 9_139485012_3"]
["RHP 9","139485012","Baylor University Medical Center","139485012.1.2","139485012.3.210","IT-1.22","Asthma Percent of Opportunity Achieved","Baseline Approved","Eligible to Report in October DY4","This project will increase access to needed specialty care services (i.e. outpatient visits with specialty physicians, hospital-based procedures) for uninsured patients under the care of a Baylor clinics in Dallas. This is a new project and will provide specialty services previously unattainable for Medicaid/Uninsured patients.","Asthma Percent of Opportunity Achieved","In DY4 and DY5 provider will increase the percent of asthma opportunities achieved ( 1.) documentation of Action/Mgmt. Plan, 2.) Severity Assessment, 3.) Controller Therapy for those who are eligible, and 4.) Spirometery within last two years) for all individuals with asthma aged 18 years or greater, receiving services in the primary/specialty care clinic and who receive Medicaid or are Uninsured. ","Facility, Payer, Age, ","Ambulatory Setting- Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",59722.785000000003,"Yes/No","RHP 9_139485012.3.210_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",59722.785000000003,"Yes/No","RHP 9_139485012.3.210_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",95834.115000000005,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",95834.12,"Numeric",0.56550387599999996,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",458337.05,"Numeric",0.58837200000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.54263600000000001,560,1032,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.56550387599999996,null,0.58837200000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DSRIP base population selection criteria for all metrics: all community care clinic patients, who had at least one office visit during one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the clinics based on their most recent visit location. Numerator:  Number of times each of the asthma opportunities was met for patients 18 to 65 with Asthma (ICD code 493). Observed Asthma Opportunities are derived from:\na) Symptom Assessment using OBS term ASTHSEV1 (HDID: 30785) or OBS term ASTHSEV2 (HDID: 30786). If assessment date within 1 year of last visit. b) Action Management Plan using variable ASTHGUIACTPL (HDID: 36409). If plan is within 1 year of last visit. c) Controller Therapy using variable ASTHSERVERITY (HDID: 13800218) along with appropriate controller medication per generic list with start date prior to end of audit period. If therapy is begun prior to the end of the report period. d) Spirometry Measures using OBS term FEV1/FVC ( HDID: 95) or OBS term PREFEV1/FVC (HDID: 25296) or OBS term PULM FNC TST (HDID: 4636) that are current or within the past two years of last visit date within audit period. Denominator: Total number of asthma opportunities (3 or 4 opportunities) that should have been completed (expected) during the measurement period for patients 18 to 65 with Asthma (ICD code 493). Expected Asthma Opportunities: a) Symptom Assessment. b) Action Management Plan. c) Controller Therapy (not counted if patient did not require medication). d) Spirometry Measures. Note: Achievement Value, (expressed in percentage) is calculated by dividing the numerator count by the denominator count.\n\n","During DY3 (10/01/2013- 9/30/2014), of those adult, Uninsured/Medicaid clinic patients with a diagnosis of asthma , 54% of patients had the asthma percent of opportunities fulfilled.       ","Asthma Percent of Opportunity Achieved","ambulatory",null,"The number of times that each of the asthma opportunities (processes) listed below were completed/fulfilled at least once during the measurement year for all individuals with asthma (any age) :  \n1.) Documentation of Action/Management Plan, \n2.) Severity Assessment\n3.) Controller Therapy for those who are eligible, and \n4.) Documentation of spirometry assessment completed within last two years.\n","The total number of opportunities can be calculated in the following manner-\nFor each individual with an asthma diagnosis assign a count one for each of the four processes that should have been completed (should be 3-4 counts per patient) at least once during the measurement period. \n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2 ","","Asthma Percent of Opportunity Achieved",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 9_139485012.1.2","RHP 9_139485012.3.210","RHP 9_139485012.1.2_139485012.3.210",{"$f":"COUNTIFS($FI$4:$FI2118,FI2118)","v":1},"RHP 9_139485012.1.2_1",null,2,1,1,"RHP 9_139485012",{"$f":"COUNTIFS($FR$4:$FR2118,FR2118)","v":4},"RHP 9_139485012_4"]
["RHP 9","139485012","Baylor University Medical Center","139485012.1.2","139485012.3.7","IT-12.2","Cervical Cancer Screening ","Baseline Approved","Eligible to Report in October DY4","This project will increase access to needed specialty care services (i.e. outpatient visits with specialty physicians, hospital-based procedures) for uninsured patients under the care of a Baylor clinics in Dallas. This is a new project and will provide specialty services previously unattainable for Medicaid/Uninsured patients.","Cervical Cancer Screening ","In DY4 and DY5 provider will increase the percentage of women aged 21 to 64 who were screened for cervical cancer out of all women in this age range receiving services in primary/specialty care clinic with Medicaid or who are uninsured. ","Facility, Payer ","Ambulatory Setting- Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",59722.785000000003,"Yes/No","RHP 9_139485012.3.7_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",59722.785000000003,"Yes/No","RHP 9_139485012.3.7_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",95834.115000000005,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",95834.12,"Numeric",0.68369999999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",458337.05,"Numeric",0.69384000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.52868999999999999,1336,2527,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.68369999999999997,null,0.69384000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DSRIP base population selection criteria for all metrics: all community care clinic patients, who had at least one office visit during one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the clinics based on their most recent visit location. Numerator: Females aged 21-64 and at least one ‘PAP’ observation record within reporting period HDIDs: (73,6759,16048,11438). Denominator: Include: females aged 21-64 Exclude: Hx of radical hysterectomy – ICD Procedure codes: 68.4, 68.6, 68.7. \n","During DY3 (10/01/2013- 9/30/2014), of those eligible female adult, Uninsured/Medicaid clinic patients between the ages of 21-64, 52% of patients had a cervical cancer screen completed. ","Cervical Cancer Screening ","ambulatory",null,"The number of women who were screened for cervical cancer during the measurement year or the two years prior to the measurement year.","Women 24-64 years of age as of the end of the measurement year ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2 ","","Cervical Cancer Screening ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 9_139485012.1.2","RHP 9_139485012.3.7","RHP 9_139485012.1.2_139485012.3.7",{"$f":"COUNTIFS($FI$4:$FI2119,FI2119)","v":2},"RHP 9_139485012.1.2_2",null,2,1,1,"RHP 9_139485012",{"$f":"COUNTIFS($FR$4:$FR2119,FR2119)","v":5},"RHP 9_139485012_5"]
["RHP 9","139485012","Baylor University Medical Center","139485012.2.1","139485012.3.201","IT-1.21","Adult Body Mass Index (BMI) Assessment ","Baseline Approved","Eligible to Report in October DY4","The project purpose is to provide focused education and point of care testing for underserved patients who have diabetes, CVD and/or Respiratory disease that are in need of education, clinical management and training within a primary care setting. We will co‐locate primary care and chronic disease management services to improve clinical outcomes. This project is new because it will provide CHF and Asthma education and point of care testing, all which have not been done before. We have had some Diabetes education in our Clinics but not a formal and focused program for the Medicaid/Uninsured population.","Adult Body Mass Index (BMI) Assessment ","In DY4 and DY5, the provider will improve the percentage of Medicaid/uninsured patients with diabetes, COPD/Asthma, and/or CHF receiving services at the facility 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. ","Facility, Payer, Comorbid Condition, ","Diabetes, CHF, Asthma, COPD Medicaid/Uninsured patients served by the clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",64406.925000000003,"Yes/No","RHP 9_139485012.3.201_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",64406.925000000003,"Yes/No","RHP 9_139485012.3.201_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",103350.515,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",103350.52,"Numeric",0.46899999999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",494285.06,"Numeric",0.49948999999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.37380400000000003,508,1359,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.46899999999999997,null,0.49948999999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DSRIP base population selection criteria for all metrics: all community care clinic patients, who had at least one office visit during one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the clinics based on their most recent visit location.  Numerator: Patients from the denominator set with all of the following completed: (1) Documented BMI (HDID: 2788), (2) Documented Nutrition counseling (HDID: 156251), (3) Documented healthy eating education/counseling or Being active education/counseling (HDIDs: 410705, 410707). Denominator: All DSRIP patients 18 to 74 diagnosed with:\nDM (ICD code 250). CHF (ICD code 428). COPD (ICD code 496). Asthma (ICD code 493). Patients with 2 or more chronic diseases were counted only once for the metric. Patients excluded if: (a)  Height and/or  Weight associated with a BMI value are missing. (b) Pregnant (HDID: 21347) (c)  Medical or personal reason not to have BMI (HDIDs:  163350, 108116 410650, 407468, 407469).\n\n\n","During DY3 (4/01/2013- 9/30/2014), of those eligible adult, Uninsured/Medicaid clinic patients with a diagnosis of diabetes/CHF/COPD/Asthma, 37% of patients had a BMI screening and treatment plan completed. ","Adult Body Mass Index (BMI) Assessment ","both",null,"Patients with BMI calculated within the past six months or during the current visit and a follow-up plan is documented within the last six months or during the current visit if the BMI is outside of normal parameters.\n\nDefinitions:\n\nBMI – Body mass index (BMI) is expressed as weight/height (BMI; kg/m2) and is commonly used to classify weight categories.\n\nCalculated BMI – Requires an eligible professional or their staff to measure both the height and weight. Self-reported values cannot be used. BMI is calculated either as weight in pounds divided by height in inches squared multiplied by 703, or as weight in kilograms divided by height in meters squared.\n\nFollow-up Plan – Proposed outline of treatment to be conducted as a result of a BMI out of normal parameters. Such follow-up may include but is not limited to: documentation of a future appointment, education, referral (such as, a registered dietician, nutritionist, occupational therapist, physical therapist, primary care provider, exercise physiologist, mental health professional or surgeon), pharmacological interventions, dietary supplements, exercise counseling or nutrition counseling.\n","Patients age 18 years as of the first day of the 12-month period prior to the measurement period to 74 years as of last day of the measurement period who had an outpatient visit during the measurement period or the 12-month period prior to the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.2 ","","Adult Body Mass Index (BMI) Assessment ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 9_139485012.2.1","RHP 9_139485012.3.201","RHP 9_139485012.2.1_139485012.3.201",{"$f":"COUNTIFS($FI$4:$FI2120,FI2120)","v":1},"RHP 9_139485012.2.1_1",null,2,1,1,"RHP 9_139485012",{"$f":"COUNTIFS($FR$4:$FR2120,FR2120)","v":6},"RHP 9_139485012_6"]
["RHP 9","139485012","Baylor University Medical Center","139485012.2.1","139485012.3.9","IT-1.10","Diabetes care: HbA1c poor control (>9.0%) ","Baseline Approved","Eligible to Report in October DY4","The project purpose is to provide focused education and point of care testing for underserved patients who have diabetes, CVD and/or Respiratory disease that are in need of education, clinical management and training within a primary care setting. We will co‐locate primary care and chronic disease management services to improve clinical outcomes. This project is new because it will provide CHF and Asthma education and point of care testing, all which have not been done before. We have had some Diabetes education in our Clinics but not a formal and focused program for the Medicaid/Uninsured population.","Diabetes care: HbA1c poor control (>9.0%) ","In DY4 and DY5 provider will reduce the percentage of individuals whose most recent A1c level was >9% or missing during the measurement year out of all individuals 18-75 years of age with diabetes, insured by Medicaid or are uninsured and are receiving services at the PCMH clinic. ","Facility, Payer ","Ambulatory Setting- Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",64406.925000000003,"Yes/No","RHP 9_139485012.3.9_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",64406.925000000003,"Yes/No","RHP 9_139485012.3.9_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",103350.515,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",103350.515,"Numeric",0.2631405,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",494285.06,"Numeric",0.24929100000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.27699000000000001,508,1834,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.2631405,null,0.24929100000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DSRIP base population selection criteria for all metrics: all community care clinic patients, who had at least one office visit during one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the clinics based on their most recent visit location.  Numerator: Patients with last HgA1c measurement <= 9.0 within reporting period. Denominator: Include: ICD-9 code 250.*, Patient age btw 18-75 Exclude: ICD-9 codes 256.4, 648.8, 251.8, 962.0. Note: Missing HgA1C values are treated as ‘Not Controlled’.\n\n","During DY3 (10/01/2013- 9/30/2014), of those adult, Uninsured/Medicaid clinic patients with a diagnosis of Type I or Type II diabetes, 27% of patients had an uncontrolled A1c (A1c > 9).       ","Diabetes care: HbA1c poor control (>9.0%) ","ambulatory",null,"Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.2 ","","Diabetes care: HbA1c poor control (>9.0%) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 9_139485012.2.1","RHP 9_139485012.3.9","RHP 9_139485012.2.1_139485012.3.9",{"$f":"COUNTIFS($FI$4:$FI2121,FI2121)","v":2},"RHP 9_139485012.2.1_2",null,2,1,1,"RHP 9_139485012",{"$f":"COUNTIFS($FR$4:$FR2121,FR2121)","v":7},"RHP 9_139485012_7"]
["RHP 9","139485012","Baylor University Medical Center","139485012.2.2","139485012.3.12","IT-1.8","Screening and Treatment Plan for Clinical Depression ","Baseline Approved","Eligible to Report in October DY4","This project will co-locate and integrate outpatient behavioral health services using an LCSW to provide counseling services. Screenings for depression, substance abuse and anxiety will also be an integral part of the program. This is a new project that has not been done before. It will help to serve the less severe behavioral health needs of the Uninsured/Medicaid population","Depression management: Screening and Treatment Plan for Clinical Depression ","In DY4 and DY5 provider will increase the percentage of individuals 18 years and older with Medicaid or who are uninsured receiving services at the ambulatory clinic that have received depression screening and a follow-up plan is documented. ","Facility, Payer ","Ambulatory Setting- Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",41376.57,"Yes/No","RHP 9_139485012.3.12_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",41376.57,"Yes/No","RHP 9_139485012.3.12_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",66394.875,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",66394.880000000005,"Numeric",0.20317705,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",317540.7,"Numeric",0.2451151,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.16123899999999999,307,1904,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.20317705,null,0.2451151,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"We received additional guidance and approval from HHSC on 1/21/14 to add a comorbid condition subset “Depression screening with PHQ-2”. Since we feel that providers are not actively diagnosing depression (and other behavioral health issues) in our E.H.R, using the PHQ2 (which is done on every primary care clinic patient) is a better representative denominator of patients with depression. It is possible that in latter years that pulling ICD-9 codes to determine the prevalence of depression will be a better proxy, however, because this program is new, providers are still getting acclimated to diagnosing and treating behavioral health issues. The denominator subset is still larger than the actual intervention population. ","DSRIP base population selection criteria for all metrics: all community care clinic patients, who had at least one office visit during one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the clinics based on their most recent visit location.  Numerator: PHQ9 score observations and documented follow-up plan. Denominator: DSRIP patients >= 18 with documented depression based on completion of PHQ2. Based on communication with HHSC regarding the calculation of this metric, we received approval on 10/21/14 to add a comorbid condition subset “Depression screening with PHQ-2”. \n","During DY3 (04/01/2013- 9/30/2014), of those eligible adult, Uninsured/Medicaid clinic patients who were screened for depression using a PHQ2, 16% of patients received a depression screening (PHQ9) and documented treatment plan.","Screening and Treatment Plan for Clinical Depression ","Multiple",null,"Patient’s screening for clinical depression using a standardized tool AND follow-up plan is documented","All patients aged 18 years and older",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.19.1","","Screening and Treatment Plan for Clinical Depression ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 9_139485012.2.2","RHP 9_139485012.3.12","RHP 9_139485012.2.2_139485012.3.12",{"$f":"COUNTIFS($FI$4:$FI2122,FI2122)","v":1},"RHP 9_139485012.2.2_1",null,2,1,1,"RHP 9_139485012",{"$f":"COUNTIFS($FR$4:$FR2122,FR2122)","v":8},"RHP 9_139485012_8"]
["RHP 9","139485012","Baylor University Medical Center","139485012.2.2","139485012.3.202","IT-11.7","Initiation of Depression Treatment","Baseline Approved","Eligible to Report in October DY4","This project will co-locate and integrate outpatient behavioral health services using an LCSW to provide counseling services. Screenings for depression, substance abuse and anxiety will also be an integral part of the program. This is a new project that has not been done before. It will help to serve the less severe behavioral health needs of the Uninsured/Medicaid population","Initiation of Depression Treatment","In DY4 and DY5 provider will increase the percent of individuals (18-75 years) with major depression with Medicaid or who are uninsured receiving services at the ambulatory clinic that have filled at least one prescription for an antidepressant or had a least three psychotherapy visits during the 5 months following diagnosis. ","Facility, Payer ","Ambulatory Setting- Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",41376.57,"Yes/No","RHP 9_139485012.3.202_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",41376.57,"Yes/No","RHP 9_139485012.3.202_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",66394.875,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",66394.880000000005,"Numeric",8.8081602999999994E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",317540.7,"Numeric",0.13607730800000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",4.0085999999999997E-2,56,1397,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,8.8081602999999994E-2,null,0.13607730800000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"We received additional guidance and approval from HHSC on 1/21/14 to add a comorbid condition subset “Depression screening with PHQ-2”. Since we feel that providers are not actively diagnosing depression (and other behavioral health issues) in our E.H.R, using the PHQ2 (which is done on every primary care clinic patient) is a better representative denominator of patients with depression. It is possible that in latter years that pulling ICD-9 codes to determine the prevalence of depression will be a better proxy, however, because this program is new, providers are still getting acclimated to diagnosing and treating behavioral health issues. The denominator subset is still larger than the actual intervention population. ","DSRIP base population selection criteria for all metrics: all community care clinic patients, who had at least one office visit during one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the clinics. Numerator: Number of patients 18 to 75 who:\n(a)  filled at least one antidepressant prescription (HDID: 410740) during the 5-month period after diagnosis of depression.; or (b)  Completed 3 psychotherapy visits (HDID’s: 410735, 410737, 410738) during the 5-month period after diagnosis of depression. Denominator: Total number of DSRIP patients 18 to 75 who had major depression based on completion of PHQ2. We received approval from HHSC on 10/21/14 to use PHQ2 as an additional co-morbid subset. \n","During DY3 (4/01/2013- 9/30/2014), of those adult, Uninsured/Medicaid clinic patients with a diagnosis of major depression per a structured assessment, 4% of patients had filled an antidepressant prescription or had 3 psychotherapy visits within 5 months of diagnosis.","Initiation of Depression Treatment","Ambulatory/Inpatient",null,"Patients in the denominator who filled at least one antidepressant prescription or had at least three psychotherapy visits during the 5-month period after diagnosis.","All patients seen in primary care during a specified period who had major depression based on a structured assessment administered independent of the clinical visit.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.19.1","","Initiation of Depression Treatment",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 9_139485012.2.2","RHP 9_139485012.3.202","RHP 9_139485012.2.2_139485012.3.202",{"$f":"COUNTIFS($FI$4:$FI2123,FI2123)","v":2},"RHP 9_139485012.2.2_2",null,2,1,1,"RHP 9_139485012",{"$f":"COUNTIFS($FR$4:$FR2123,FR2123)","v":9},"RHP 9_139485012_9"]
["RHP 9","139485012","Baylor University Medical Center","139485012.2.2","139485012.3.203","IT-11.9","Care Planning for Dual Diagnosis","Baseline Approved","Eligible to Report in October DY4","This project will co-locate and integrate outpatient behavioral health services using an LCSW to provide counseling services. Screenings for depression, substance abuse and anxiety will also be an integral part of the program. This is a new project that has not been done before. It will help to serve the less severe behavioral health needs of the Uninsured/Medicaid population","Care Planning for Dual Diagnosis","In DY4 and DY5 provider will increase the percent of individuals (18-75 years) with a documented comprehensive care plan for individuals  that are dually diagnosed with a substance abuse and mental disorder with Medicaid or who are uninsured and are receiving services at the ambulatory clinic","Facility, Payer ","Ambulatory Setting- Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",41376.57,"Yes/No","RHP 9_139485012.3.203_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",41376.57,"Yes/No","RHP 9_139485012.3.203_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",66394.875,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",66394.880000000005,"Numeric",0.59557234000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",317540.7,"Numeric",0.63795319100000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.55319099999999999,26,47,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.59557234000000003,null,0.63795319100000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DSRIP base population selection criteria for all metrics: all community care clinic patients, who had at least one office visit during one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the clinics based on their most recent visit location. Numerator: Number patients 18 to 75 from the denominator for whom a case manager has documented a plan of care (HDID: 410744) that addresses a need for treatment of both a mental disorder and a substance abuse disorder. Denominator:  Number of DSRIP patients 18 to 75 who were diagnosed with both a mental disorder and a substance abuse disorder by either (a) Documented Dual Diagnosis (HDID: 410743); or (b) ICD-9 diagnosis of mental disorder  and an ICD-9 diagnosis of substance abuse disorder\n","During DY3 (4/01/2013- 9/30/2014), of those adult, Uninsured/Medicaid clinic patients with a  dual diagnosis of, 55% of patients received a treatment plan.  ","Care Planning for Dual Diagnosis","Ambulatory/Inpatient",null,"Those individuals from the denominator for whom a case manager has documented a plan of care that addresses the consumer's need for treatment of both conditions.","The number of individuals participating in a case management program who are dually diagnosed with a mental disorder and a substance abuse disorder ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.19.1","","Care Planning for Dual Diagnosis",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 9_139485012.2.2","RHP 9_139485012.3.203","RHP 9_139485012.2.2_139485012.3.203",{"$f":"COUNTIFS($FI$4:$FI2124,FI2124)","v":3},"RHP 9_139485012.2.2_3",null,2,1,1,"RHP 9_139485012",{"$f":"COUNTIFS($FR$4:$FR2124,FR2124)","v":10},"RHP 9_139485012_10"]
["RHP 9","139485012","Baylor University Medical Center","139485012.2.3","139485012.3.204","IT-9.8","Care Transition: Transition Record with Specified Elements Received by ED Discharged Patients","Baseline Approved","Eligible to Report in April DY4","This project will identify and connect underserved patients in the hospital to a PCP/PCMH, create a multi‐disciplinary care plan for frequently admitted patients and provide comprehensive follow up calls to patients to ensure they have an appointment and transportation to get to it.","Care Transition: Transition Record with Specified Elements Received by Discharged Patients (Emergency Department Discharges to Ambulatory Care [Home/Self Care] or Home Health Care)","In DY4 and DY5, the provider will improve the percentage of Medicaid/uninsured patients with ACSC, 18-75 years old, discharged from an emergency department (ED) to ambulatory care or home health care, or their caregiver(s), who received a transition record at the time of ED discharge including, at a minimum, all of the specified elements","Comorbid Condition, Payer, Age, ","Medicaid/uninsured patients age 18-75 years with ACSC","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",58942.095000000001,"Yes/No","RHP 9_139485012.3.204_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",58942.095000000001,"Yes/No","RHP 9_139485012.3.204_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",94581.38,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",94581.38,"Numeric",8.2670262999999994E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",452345.72,"Numeric",0.13095100000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",3.4389999999999997E-2,204,5932,"DY2: Oct 1st, 2012 - Sept 30th, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,8.2670262999999994E-2,null,0.13095100000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"We received communication and approval from HHSC on 1/21/14 to change our co-morbid subset from Diabetes to ACSC in order to capture a larger denominator for this metric. Upon preliminary data collection, we did not have a large enough sample just using diabetic patients to make an impact on this subset of the population. The way we calculated this baseline was using an annualized number for the numerator to determine our baseline. The numerator used 2 months of data, but we felt b/c ACSCs do not have seasonality (vs. Diabetes or CHF) that this was an accurate way to determine our baseline. For the denominator, we were able to use a full year of data of patients who were admitted to the ED with an ACSC condition. We also made this change because only identifying diabetic patients was a challenge as this condition does not show up as a primary or secondary condition in most patient cases. ACSC allows for a greater number of patients to be found and screened.","Numerator: Patients who received a transition record upon discharge from the ED. Denominator: Any ED visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period:  Grand mal status and other epileptic convulsions: 345 Chronic obstructive pulmonary diseases: 466.0 (only with secondary diagnosis of 491, 492, 494, 496), 491, 492, 494, 496  Asthma: 493 Heart failure and pulmonary edema: 402.01, 402.11, 402.91, 428, 518.4 Hypertension: 401.0, 401.9, 402.00, 402.10,  402.90 Angina:  411.1, 411.8, 413 Diabetes: 250.0, 250.1, 250.2, 250.3,250.8, 250.9. Exclusions: Grand mal status and other epileptic convulsions: None\nChronic obstructive pulmonary diseases: None\nAsthma: None\nHeart failure and pulmonary edema: Procedure codes 36.01, 36.02, 36.05, 36.1, 37.5, or 37.7\nHypertension: procedures: Procedure codes 36.01, 36.02, 36.05, 36.1, 37.5, or 37.7\nAngina: Procedure codes 01-86.99\nDiabetes: Diabetes with renal manifestations [250.4], diabetes with ophthalmic manifestations [250.5], diabetes with neurological manifestations [250.6] and diabetes with peripheral circulatory disorders [250.7]\n\n","During DY2 (10/01/2012- 9/30/2013), of those eligible adult, Uninsured/Medicaid patients with an ACSC condition that was admitted to the ED, 3.4% of patients received a transition record. ","Care Transition: Transition Record with Specified Elements Received by ED Discharged Patients","ED/Ambulatory",null,"Patients or their caregiver(s) who received a transition record at the time of emergency department (ED) discharge including, at a minimum, all of the following elements:\n•Summary of major procedures and tests performed during ED visit, AND \n•Principal clinical diagnosis at discharge which may include the presenting chief complaint, AND \n•Patient instructions, AND \n•Plan for follow-up care (OR statement that none required), including primary physician, other health care professional, or site designated for follow-up care, AND \n•List of new medications and changes to continued medications that patient should take after ED discharge, with quantity prescribed and/or dispensed (OR intended duration) and instructions for each\n\n","All patients, regardless of age, discharged from an emergency department (ED) to ambulatory care (home/self-care) or home health care",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1 ","","Care Transition: Transition Record with Specified Elements Received by ED Discharged Patients",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 9_139485012.2.3","RHP 9_139485012.3.204","RHP 9_139485012.2.3_139485012.3.204",{"$f":"COUNTIFS($FI$4:$FI2125,FI2125)","v":1},"RHP 9_139485012.2.3_1",null,2,1,1,"RHP 9_139485012",{"$f":"COUNTIFS($FR$4:$FR2125,FR2125)","v":11},"RHP 9_139485012_11"]
["RHP 9","139485012","Baylor University Medical Center","139485012.2.3","139485012.3.205","IT-9.4.b","Reduce Emergency Department visits for Diabetes","Baseline Approved","Eligible to Report in April DY4","This project will identify and connect underserved patients in the hospital to a PCP/PCMH, create a multi‐disciplinary care plan for frequently admitted patients and provide comprehensive follow up calls to patients to ensure they have an appointment and transportation to get to it.","Reduce Emergency Department visits for Diabetes","In DY4 and DY5, the provider will improve the rate of ED Visits with a primary or secondary diagnosis of diabetes for any individual 18 years and older during the measurement period over all ED visits for Medicaid/uninsured individuals 18 years or older during the measurement period","Payer ","Population subset will be focused on Medicaid and Uninsured patients only ","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",58942.095000000001,"Yes/No","RHP 9_139485012.3.205_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",58942.095000000001,"Yes/No","RHP 9_139485012.3.205_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",94581.38,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",94581.38,"Numeric",2.6330584000000001E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",452345.72,"Numeric",2.4944999999999998E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",2.7716000000000001E-2,1129,40734,"DY2: Oct 1st, 2012 - Sept 30th, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,2.6330584000000001E-2,null,2.4944999999999998E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator: Preventable diabetes conditions as those associated with the Diabetes ACSC diagnostic codes: 250.0, 250.1, 250.2, 250.3, 250.8, 250.9. Denominator: Total number of ED visits for individuals 18 years or older during the measurement period that are Medicaid/Uninsured","The ED utilization of rate of adult, diabetic Medicaid/Uninsured patients is 2.8%","Reduce Emergency Department visits for Diabetes","ED",null,"Total number of ED Visits with a primary or secondary diagnosis of diabetes for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1 ","","Reduce Emergency Department visits for Diabetes",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 9_139485012.2.3","RHP 9_139485012.3.205","RHP 9_139485012.2.3_139485012.3.205",{"$f":"COUNTIFS($FI$4:$FI2126,FI2126)","v":2},"RHP 9_139485012.2.3_2",null,2,1,1,"RHP 9_139485012",{"$f":"COUNTIFS($FR$4:$FR2126,FR2126)","v":12},"RHP 9_139485012_12"]
["RHP 9","139485012","Baylor University Medical Center","139485012.2.4","139485012.3.206","IT-1.2","Annual monitoring for patients on persistent medications - ACE/ARBs","Baseline Approved","Eligible to Report in October DY4","This project will provide in-home visits to the highest risk uninsured and Medicaid  patients. Risk is defined by patient propensity of complications, (re)admissions, downstream healthcare utilization and costs within the parameters of socioeconomic and clinical risk indicators. The team will be led by an APRN overseen by a Medical Director and augmented with a Social Worker, LVN and Care Coordinator who will have overall oversight and responsibility of continuity of care for the patients in the program. Services such as examinations and clinical decision making to changing urinary catheters, labs, vaccinations and medication reconciliation, management and education will be available in the patient’s home.  This project is an expansion of the Vulnerable Patient Network at Baylor University Medical Center. New components include an expanded care team, risk stratification and identification of high risk patients, complete oversight and management of program patients and increased contact encounters with patients in their homes. ","Annual monitoring for patients on persistent medications - Angiotensin Converting Enzyme (ACE) inhibitors or Angiotensin Receptor Blockers (ARBs) ","In DY4 and DY5 provider will increase the percentage of uninsured/Medicaid individuals (18-75 years) receiving home based primary care services with a positive history for ACE/ARBs for at least 180 treatment days the receive a potassium and either a BUN or Creat test during the measurement year.","Facility, Payer ","Homebound (Home Visit) Patients; Uninsured/Medicaid","P4R","SA3","PM-8","Submission of Category 3 DY3 Status Report",28885.53,"Yes/No","RHP 9_139485012.3.206_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",28885.53,"Yes/No","RHP 9_139485012.3.206_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",92702.279999999984,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",110839.67999999999,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",110839.67999999999,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.77777777777777779,14,18,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"This metric is in line with the denominator specifications- however because our QPI for this project is n<3, our denominator for this metric is less than 3. This was communicated to HHSC on 1/6/214","DSRIP base population selection criteria for all metrics: all homebound patients part of the home visit program, who had at least one home visit during or one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the home visit program based on their most recent visit location.  Numerator: Patients from denominator group with at least one serum K measurement and BUN or creatinine measurement during reporting period. Denominator: Include: Homebound program patients, Patients aged 18 and above with at least 180 day ACE Inhibitors/ARBs treatment during report year. Medication GPI codes selected according to the medications list.","During DY3 (10/01/2013- 9/30/2014), of those eligible adult, homebound-Uninsured/Medicaid clinic patients, 77.8% of patients received one serum K measurement and BUN or creatinine measurement to verify medication appropriateness.","Annual monitoring for patients on persistent medications - ACE/ARBs","ambulatory",null,"Patients from the denominator with at least one serum potassium and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test in the measurement year ","Patients 18 years of age and older as of the last day of the measurement year on persistent angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) -- defined as patients who received at least 180 treatment days of ambulatory medication during the measurement year ",null,null,null,null,null,null,null,null,null,null,"Stretch Activity status not reported in DY3",null,null,"2.12.2","","ACE/ARB",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 9_139485012.2.4","RHP 9_139485012.3.206","RHP 9_139485012.2.4_139485012.3.206",{"$f":"COUNTIFS($FI$4:$FI2127,FI2127)","v":1},"RHP 9_139485012.2.4_1",null,2,1,1,"RHP 9_139485012",{"$f":"COUNTIFS($FR$4:$FR2127,FR2127)","v":13},"RHP 9_139485012_13"]
["RHP 9","139485012","Baylor University Medical Center","139485012.2.4","139485012.3.207","IT-1.8","Screening and Treatment Plan for Clinical Depression ","Baseline Approved","Eligible to Report in October DY4","This project will provide in-home visits to the highest risk uninsured and Medicaid  patients. Risk is defined by patient propensity of complications, (re)admissions, downstream healthcare utilization and costs within the parameters of socioeconomic and clinical risk indicators. The team will be led by an APRN overseen by a Medical Director and augmented with a Social Worker, LVN and Care Coordinator who will have overall oversight and responsibility of continuity of care for the patients in the program. Services such as examinations and clinical decision making to changing urinary catheters, labs, vaccinations and medication reconciliation, management and education will be available in the patient’s home.  This project is an expansion of the Vulnerable Patient Network at Baylor University Medical Center. New components include an expanded care team, risk stratification and identification of high risk patients, complete oversight and management of program patients and increased contact encounters with patients in their homes. ","Depression management: Screening and Treatment Plan for Clinical Depression ","In DY4 and DY5 providers will increase the percentage of Medicaid/uninsured individuals (18-75 years) receiving home based primary care services that have received a screening for depression and, if positive, have a documented treatment plan in the measurement year. ","Facility, Payer, Comorbid condition ","Homebound (Home Visit) Patients; Uninsured/Medicaid; PHQ-2 positive screen","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",28885.53,"Yes/No","RHP 9_139485012.3.207_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",28885.53,"Yes/No","RHP 9_139485012.3.207_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",46351.14,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",46351.14,"Numeric",0.71499999999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",221679.35999999999,"Numeric",0.73,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.7,14,20,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.71499999999999997,null,0.73,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"We received additional guidance and approval from HHSC on 1/21/14 to add a comorbid condition subset “Depression screening with PHQ-2”. Since we feel that providers are not actively diagnosing depression (and other behavioral health issues) in our E.H.R, using the PHQ2 (which is done on every primary care clinic patient) is a better representative denominator of patients with depression. It is possible that in latter years that pulling ICD-9 codes to determine the prevalence of depression will be a better proxy, however, because this program is new, providers are still getting acclimated to diagnosing and treating behavioral health issues. Additionally, per communication with HHSC on 1/6- our denominator for this metric will be less than 3 because the overall QPI for this metric is n<3. \n\n","DSRIP base population selection criteria for all metrics: all homebound patients part of the home visit program, who had at least one home visit during or one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the home visit program based on their most recent visit location.  \nNumerator: Patients from denominator group with a PHQ9 and documented follow-up plan completed. Denominator: Include: Homebound program patients, Patients aged 18 and above with a PHQ2 completed and positive result indicated. ","During DY3 (1/1/14-9/30/14), of those eligible adult, homebound-Uninsured/Medicaid clinic patients, 70% of patients received that screened positive for depression using the PHQ2 received a PHQ9 and follow-up plan. ","Screening and Treatment Plan for Clinical Depression ","Multiple",null,"Patient’s screening for clinical depression using a standardized tool AND follow-up plan is documented","All patients aged 18 years and older",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.12.2","","Screening and Treatment Plan for Clinical Depression ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 9_139485012.2.4","RHP 9_139485012.3.207","RHP 9_139485012.2.4_139485012.3.207",{"$f":"COUNTIFS($FI$4:$FI2128,FI2128)","v":2},"RHP 9_139485012.2.4_2",null,2,1,1,"RHP 9_139485012",{"$f":"COUNTIFS($FR$4:$FR2128,FR2128)","v":14},"RHP 9_139485012_14"]
["RHP 9","139485012","Baylor University Medical Center","139485012.2.4","139485012.3.208","IT-12.6","Influenza Immunization -- Ambulatory","Baseline Approved","Eligible to Report in October DY4","This project will provide in-home visits to the highest risk uninsured and Medicaid  patients. Risk is defined by patient propensity of complications, (re)admissions, downstream healthcare utilization and costs within the parameters of socioeconomic and clinical risk indicators. The team will be led by an APRN overseen by a Medical Director and augmented with a Social Worker, LVN and Care Coordinator who will have overall oversight and responsibility of continuity of care for the patients in the program. Services such as examinations and clinical decision making to changing urinary catheters, labs, vaccinations and medication reconciliation, management and education will be available in the patient’s home.  This project is an expansion of the Vulnerable Patient Network at Baylor University Medical Center. New components include an expanded care team, risk stratification and identification of high risk patients, complete oversight and management of program patients and increased contact encounters with patients in their homes. ","Influenza Immunization -- Ambulatory","In DY4 and DY5 provider will increase the percentage of Medicaid/uninsured individuals (18-75 years) receiving home based primary care services between October and March that were administered a flu vaccine or have a documented history of previously receiving the vaccine. ","Facility, Payer ","Homebound (Home Visit) Patients; Uninsured/Medicaid","P4R","SA3","PM-8","Submission of Category 3 DY3 Status Report",28885.53,"Yes/No","RHP 9_139485012.3.208_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",28885.53,"Yes/No","RHP 9_139485012.3.208_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",92702.279999999984,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",110839.67999999999,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",110839.67999999999,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.625,5,8,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"The denominator population does align with the approved denominator, however we wanted to note that on 1/6/14 communication went to HHSC about our sample size- it will be less than 3 for this denominator because the QPI has an n<3","DSRIP base population selection criteria for all metrics: all homebound patients part of the home visit program, who had at least one home visit during or one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the home visit program based on their most recent visit location.  Numerator: Patients from denominator group 18 and older that were administered a flu vaccine or have a documented history of previously receiving the vaccine. Denominator: Include: Homebound program patients, Patients aged 18 and above \n\n","During DY3 (10/01/2013- 9/30/2014), of those eligible homebound, adult, Uninsured/Medicaid clinic patients, 62.5% of patients received an influenza vaccine.","Influenza Immunization -- Ambulatory","ambulatory",null,"Patients who received an influenza immunization OR who reported previous receipt* of influenza immunization","All patients aged 6 months and older seen for a visit between October 1 and March 31.",null,null,null,null,null,null,null,null,null,null,"Stretch Activity status not reported in DY3",null,null,"2.12.2","","Influenza Immunization -- Ambulatory",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 9_139485012.2.4","RHP 9_139485012.3.208","RHP 9_139485012.2.4_139485012.3.208",{"$f":"COUNTIFS($FI$4:$FI2129,FI2129)","v":3},"RHP 9_139485012.2.4_3",null,2,1,1,"RHP 9_139485012",{"$f":"COUNTIFS($FR$4:$FR2129,FR2129)","v":15},"RHP 9_139485012_15"]
["RHP 9","139485012","Baylor University Medical Center","139485012.2.5","139485012.3.18","IT-1.2","Annual monitoring for patients on persistent medications - ACE/ARBs","Baseline Approved","Eligible to Report in October DY4","This project will provide medication management and reconciliation services to uninsured and Medicaid patients at the Baylor Clinic on the Baylor University Medical Center campus. Patients who are 150% or below the FPL and/or have chronic illnesses can qualify for prescription assistance. A clinical pharmacist will be responsible for oversight of prescriptions, educate patients about how and why to take their medications and review utilization, appropriateness and efficacy of medications that patients have been prescribed. This project is a new initiative and contributes to creating a complete PCMH for underserved patients. ","Annual monitoring for patients on persistent medications - Angiotensin Converting Enzyme (ACE) inhibitors or Angiotensin Receptor Blockers (ARBs) ","In DY4 and DY5 provider will increase the percentage of individuals with Medicaid or are Uninsured receiving care at a Baylor primary care clinic with a positive history for ACE/ARBs for at least 180 treatment days the receive a potassium and either a BUN or Creat test during the measurement year.","Facility, Payer ","Ambulatory Setting- Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",19517.25,"Yes/No","RHP 9_139485012.3.18_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",19517.25,"Yes/No","RHP 9_139485012.3.18_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",31318.34,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",31318.34,"Numeric",0.88065236000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",149783.35,"Numeric",0.88424700000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.877058,1598,1822,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.88065236000000002,null,0.88424700000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DSRIP base population selection criteria for all metrics: all community care clinic patients, who had at least one office visit during one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the clinics based on their most recent visit location.  Numerator: Patients from denominator group with at least one serum K measurement and BUN or creatinine measurement during reporting period. Denominator: Include: Patients aged 18 and above with at least 180 day ACE Inhibitors/ARBs treatment during report year. Medication GPI codes selected according to the medications list.","During DY3 (10/01/2013- 9/30/2014), of those eligible adult, Uninsured/Medicaid clinic patients, 87% of patients received one serum K measurement and BUN or creatinine measurement to verify medication appropriateness. ","Annual monitoring for patients on persistent medications - ACE/ARBs","ambulatory",null,"Patients from the denominator with at least one serum potassium and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test in the measurement year ","Patients 18 years of age and older as of the last day of the measurement year on persistent angiotensin converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) -- defined as patients who received at least 180 treatment days of ambulatory medication during the measurement year ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.11.3","","ACE/ARB",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 9_139485012.2.5","RHP 9_139485012.3.18","RHP 9_139485012.2.5_139485012.3.18",{"$f":"COUNTIFS($FI$4:$FI2130,FI2130)","v":1},"RHP 9_139485012.2.5_1",null,2,1,1,"RHP 9_139485012",{"$f":"COUNTIFS($FR$4:$FR2130,FR2130)","v":16},"RHP 9_139485012_16"]
["RHP 9","139485012","Baylor University Medical Center","139485012.2.5","139485012.3.19","IT-1.4","Annual monitoring for patients on persistent medications- Diuretic ","Baseline Approved","Eligible to Report in October DY4","This project will provide medication management and reconciliation services to uninsured and Medicaid patients at the Baylor Clinic on the Baylor University Medical Center campus. Patients who are 150% or below the FPL and/or have chronic illnesses can qualify for prescription assistance. A clinical pharmacist will be responsible for oversight of prescriptions, educate patients about how and why to take their medications and review utilization, appropriateness and efficacy of medications that patients have been prescribed. This project is a new initiative and contributes to creating a complete PCMH for underserved patients. ","Annual monitoring for patients on persistent medications- Diuretic ","In DY4 and DY5 provider will increase the percentage of individuals (18-75 years) with Medicaid or are Uninsured receiving care at a Baylor primary care clinic with a positive history for diuretics for at least 180 treatment days the receive a potassium and either a BUN or Creat test during the measurement year.","Facility, Payer ","Ambulatory Setting- Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",19517.25,"Yes/No","RHP 9_139485012.3.19_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",19517.25,"Yes/No","RHP 9_139485012.3.19_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",31318.34,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",31318.34,"Numeric",0.86506237699999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",149783.35,"Numeric",0.87038899999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.85973599999999994,521,606,"DY3: Oct 1st, 2013- Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.86506237699999999,null,0.87038899999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"DSRIP base population selection criteria for all metrics: all community care clinic patients, who had at least one office visit during one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the clinics based on their most recent visit location.  Numerator: Patients from denominator group with at least one serum K measurement and BUN or creatinine measurement during reporting period. Denominator: Include: Patients aged 18 and above with at least 180 day diuretics treatment during report year. . Medication GPI codes selected according to the medications list.","During DY3 (10/01/2013- 9/30/2014), of those eligible adult, Uninsured/Medicaid clinic patients, 86% of patients received one serum K measurement and BUN or creatinine measurement to verify medication appropriateness.","Annual monitoring for patients on persistent medications- Diuretic ","ambulatory",null,"Patients from the denominator with at least one serum potassium and either a serum creatinine or a blood urea nitrogen therapeutic monitoring test in the measurement year ","Patients* 18 years of age and older as of the last day of the measurement year on persistent diuretics**-- defined as patients who received at least 180 treatment days*** of ambulatory medication during the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.11.3","","Diuretic",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2013-10-01","2014-09-30",null,null,"RHP 9_139485012.2.5","RHP 9_139485012.3.19","RHP 9_139485012.2.5_139485012.3.19",{"$f":"COUNTIFS($FI$4:$FI2131,FI2131)","v":2},"RHP 9_139485012.2.5_2",null,2,1,1,"RHP 9_139485012",{"$f":"COUNTIFS($FR$4:$FR2131,FR2131)","v":17},"RHP 9_139485012_17"]
["RHP 9","139485012","Baylor University Medical Center","139485012.2.5","139485012.3.209","IT-1.33","Medical Assistance With Smoking and Tobacco Use Cessation","Baseline Approved","Eligible to Report in October DY4","This project will provide medication management and reconciliation services to uninsured and Medicaid patients at the Baylor Clinic on the Baylor University Medical Center campus. Patients who are 150% or below the FPL and/or have chronic illnesses can qualify for prescription assistance. A clinical pharmacist will be responsible for oversight of prescriptions, educate patients about how and why to take their medications and review utilization, appropriateness and efficacy of medications that patients have been prescribed. This project is a new initiative and contributes to creating a complete PCMH for underserved patients. ","Medical Assistance With Smoking and Tobacco Use Cessation","In DY4 and DY5 provider will increase the number of individuals who were advised to quit, were counseled on cessation medications and cessation strategies out of all individuals that indicated tobacco use that receive services at the Baylor primary care clinic with Medicaid or are Uninsured over the age of 18 with any of the following chronic conditions: Diabetes, CHF, COPD, Asthma.","Facility, Payer, Comorbid Condition, ","Ambulatory Setting- Clinic, include Payer subset (Medicaid and Uninsured) and Co-morbid condition subset (Diabetes, CHF, COPD/Asthma)","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",19517.25,"Yes/No","RHP 9_139485012.3.209_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",19517.25,"Yes/No","RHP 9_139485012.3.209_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",31318.34,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal- Medical advice to quit",10439.446666666667,"Numeric",0.71430000000000005,"AM-1.2","Achievement of DY4 performance goal- Cessation Medications",10439.446666666667,"Numeric",0.34089999999999998,"AM-1.3","Achievement of DY4 performance goal- Cessation Methods/Strategies",10439.446666666667,"Numeric",0.37459999999999999,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal- Medical advice to quit",49927.783333333333,"Numeric",0.72423000000000004,"AM-2.2","Achievement of DY5 performance goal- Cessation Medications",49927.783333333333,"Numeric",0.35747000000000001,"AM-2.3","Achievement of DY5 performance goal- Cessation Methods/Strategies",49927.783333333333,"Numeric",0.39376,null,null,null,null,null,null,null,null,null,null,3,"%",0.15032679738562091,23,153,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",0.1111111111111111,17,153,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",0.1437908496732026,22,153,"DY3 (2): April 1st, 2014 - Sept 30th, 2014",null,0,0,null,null,0,0,null,null,0.71430000000000005,null,0.72423000000000004,null,0.34089999999999998,null,0.35747000000000001,null,0.37459999999999999,null,0.39376,null,null,null,null,null,null,null,null,null,null,null,"DSRIP base population selection criteria for all metrics: all community care clinic patients, who had at least one office visit during one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the clinics based on their most recent visit location.  Numerator: Smoking cessation program observations. HDID values: 410727 – Advise, 410728 – Strategy, 410729 – Medication. Denominator: DSRIP patients with chronic disease intake form observation (HDID=410650) and following smoking status observation (HDID=300015) values: (‘smoker’, ‘current smoker’, ‘current’, ‘current every day smoker’, ‘current some day smoker’). \n","During DY3 (04/01/2014- 9/30/2014), of those eligible adult, Uninsured/Medicaid clinic patients with CHF/Diabetes/Asthma/COPD who are identified smokers- 11% of patients were advised on medications to help with smoking cessation, 14% were counseled on strategies to help with tobacco cessation and 15% were advised on tobacco cessation.","Medical Assistance With Smoking and Tobacco Use Cessation","ambulatory",null,"The number of patients in the denominator who indicated that they had received advice to quit from a doctor or other health provider: Advising to Quit\n","The number of eligible patients who responded to the survey and indicated that they were current smokers or tobacco users","The number of patients in the denominator who indicated that they had received advice to quit from a doctor or other health provider: Discussing Strategies\n","The number of eligible patients who responded to the survey and indicated that they were current smokers or tobacco users","The number of patients in the denominator who indicated that they had received advice to quit from a doctor or other health provider: Discussing Medications\n","The number of eligible patients who responded to the survey and indicated that they were current smokers or tobacco users",null,null,null,null,null,null,null,null,null,"2.11.3","","Advising to Quit","Discussing Strategies","Discussion Medications",null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-04-01","2014-09-30",null,null,"RHP 9_139485012.2.5","RHP 9_139485012.3.209","RHP 9_139485012.2.5_139485012.3.209",{"$f":"COUNTIFS($FI$4:$FI2132,FI2132)","v":3},"RHP 9_139485012.2.5_3",null,4,3,1,"RHP 9_139485012",{"$f":"COUNTIFS($FR$4:$FR2132,FR2132)","v":18},"RHP 9_139485012_18"]
["RHP 9","175287501","University of Texas Southwestern St Paul Universit","175287501.2.1","175287501.3.2","IT-9.2","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","Baseline Approved","Eligible to Report in April DY4","This project will establish an emergency department navigator system for patients without a known primary care physician. At first this project will cover 5 days per week but expand hours according to target population needs","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","In DY4 and DY5, the provider will improve the rate of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period over all ED visits for individuals 18 years or older during the measurement period",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",112059.83500000001,"Yes/No","RHP 9_175287501.3.2_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",112059.83500000001,"Yes/No","RHP 9_175287501.3.2_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",179816.66500000001,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",179816.67,"Numeric",6.1067813999999998E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",859992.33,"Numeric",5.7854000000000003E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",6.4282000000000006E-2,2293,35671,"DY3 (1): Oct 1st, 2013 - March 31st, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,6.1067813999999998E-2,null,5.7854000000000003E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Number of ED Visits for Composite of all Seven ACSC = 2,293 /Total number of ED visits for individuals 18 years or older during the measurement period = 35,671.  Composite rate per 100,000 = 6,428 ","Composite rate per 100,000 ED visits = 6428, which establishes the DY3 baseline rate for the seven ACSC for DY3 at 6.43%","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","ED",null,"Total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1 ","","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ",null,null,null,null,null,"2014-04-01","2015-03-31","2015-04-01","2016-03-31","2013-10-01","2014-03-31",null,null,"RHP 9_175287501.2.1","RHP 9_175287501.3.2","RHP 9_175287501.2.1_175287501.3.2",{"$f":"COUNTIFS($FI$4:$FI2133,FI2133)","v":1},"RHP 9_175287501.2.1_1",null,2,1,1,"RHP 9_175287501",{"$f":"COUNTIFS($FR$4:$FR2133,FR2133)","v":1},"RHP 9_175287501_1"]
["RHP 9","175287501","University of Texas Southwestern St Paul Universit","175287501.2.2","175287501.3.3","IT-13.1","Hospice and Palliative Care – Pain assessment ","Baseline Approved","Eligible to Report in April DY4","This project will expand the palliative care service to provide comprehensive palliative care services to all patients of the UT Southwestern Health System.","Hospice and Palliative Care – Pain assessment ","In DY4 and DY5 provider will increase the percentage of patients enrolled in hospice or receiving palliative care that received a comprehensive pain assessment within 24 hours of screening. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",37353.279999999999,"Yes/No","RHP 9_175287501.3.3_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",37353.279999999999,"Yes/No","RHP 9_175287501.3.3_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",59938.89,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",59938.89,"Numeric",0.68540983600000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",286664.11,"Numeric",0.70196700000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.668852,204,305,"DY3 (1): Oct 1st, 2013 - March 31st, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.68540983600000005,null,0.70196700000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Number of patients who received a clinical pain assessment within 24 hours of initial pain screening. / Number of unique encounters for Palliative Care with LOS >=1 who received an initial pain assessment with a score of >4 or verbal rating of moderate/high. ","Numerator divided by denominator as described above, determines the rate/percentage of palliative patients who recieved a clinical pain assessment within 24 hours of initial pain screening.  ","Hospice and Palliative Care – Pain assessment ","Ambulatory/Inpatient",null,"Patients who received a comprehensive clinical assessment to determine the severity, etiology, and impact of their pain within 24 hours of screening positive for pain","Patients enrolled in hospice or receiving palliative care who report pain when pain screening is done on the admission evaluation/initial encounter",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.10.1","","Hospice and Palliative Care – Pain assessment ",null,null,null,null,null,"2014-04-01","2015-03-31","2015-04-01","2016-03-31","2013-10-01","2014-03-31",null,null,"RHP 9_175287501.2.2","RHP 9_175287501.3.3","RHP 9_175287501.2.2_175287501.3.3",{"$f":"COUNTIFS($FI$4:$FI2134,FI2134)","v":1},"RHP 9_175287501.2.2_1",null,2,1,1,"RHP 9_175287501",{"$f":"COUNTIFS($FR$4:$FR2134,FR2134)","v":2},"RHP 9_175287501_2"]
["RHP 9","175287501","University of Texas Southwestern St Paul Universit","175287501.2.2","175287501.3.4","IT-13.2","Hospice and Palliative Care – Treatment Preferences ","Baseline Approved","Eligible to Report in April DY4","This project will expand the palliative care service to provide comprehensive palliative care services to all patients of the UT Southwestern Health System.","Hospice and Palliative Care – Treatment Preferences ","In DY4 and DY5 provider will increase the percentage of patients enrolled in hospice or receiving palliative care with preferences for life sustaining treatment documented. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",37353.279999999999,"Yes/No","RHP 9_175287501.3.4_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",37353.279999999999,"Yes/No","RHP 9_175287501.3.4_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",59938.89,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",59938.89,"Numeric",0.27964376600000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",286664.11,"Numeric",0.31755699999999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.24173,95,393,"DY3 (1): Oct 1st, 2013 - March 31st, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.27964376600000002,null,0.31755699999999998,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator: Patients whose medical record includes documentation of life sustaining preferences (ig: Advance Directives.). / Denominator:  Seriously ill patients enrolled in hospice OR receiving palliative care in an acute hospital setting.","Number of unique patienst that have documeented end of life treatment preferences . Divided by Number of unique patients in palliative care with LOS >=1.   Equals the percentage fo palliative care patients with documented end of lifetreatment preferences.","Hospice and Palliative Care – Treatment Preferences ","Ambulatory/Inpatient",null,"Patients whose medical record includes documentation of life sustaining preferences","Seriously ill patients enrolled in hospice OR receiving palliative care in an acute hospital setting",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.10.1","","Hospice and Palliative Care – Treatment Preferences ",null,null,null,null,null,"2014-04-01","2015-03-31","2015-04-01","2016-03-31","2013-10-01","2014-03-31",null,null,"RHP 9_175287501.2.2","RHP 9_175287501.3.4","RHP 9_175287501.2.2_175287501.3.4",{"$f":"COUNTIFS($FI$4:$FI2135,FI2135)","v":2},"RHP 9_175287501.2.2_2",null,2,1,1,"RHP 9_175287501",{"$f":"COUNTIFS($FR$4:$FR2135,FR2135)","v":3},"RHP 9_175287501_3"]
["RHP 9","175287501","University of Texas Southwestern St Paul Universit","175287501.2.2","175287501.3.5","IT-13.5","Hospice and Palliative Care – documentation of spiritual/religions concerns ","Baseline Approved","Eligible to Report in April DY4","This project will expand the palliative care service to provide comprehensive palliative care services to all patients of the UT Southwestern Health System.","Hospice and Palliative Care – Percentage of patients receiving hospice or palliative care services with documentation in the clinical record of a discussion of spiritual/religions concerns or documentation that the patient/caregiver did not want to discuss ","In DY4 and DY5 provider will increase the percentage of patients with documentation of spiritual/religions concerns out of the total number of individuals discharged from hospice care. ",null,null,"P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",37353.279999999999,"Yes/No","RHP 9_175287501.3.5_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",37353.279999999999,"Yes/No","RHP 9_175287501.3.5_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",59938.89,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",59938.89,"Numeric",0.13995381100000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",286664.11,"Numeric",0.18521899999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",9.4687999999999994E-2,41,433,"DY3 (1): Oct 1st, 2013 - March 31st, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.13995381100000001,null,0.18521899999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Number of palliative care consults (Unique Encounters). / Number of spiritual/religious care consults (Unique Patients) = Equals the Percentage of palliative care patients with documentation of spiritual/religious consults documentation","Numerator divided by the denominator equals: Percentage of palliative care patients with documentation of spiritual/religious consults documentation","Hospice and Palliative Care – documentation of spiritual/religions concerns ","Ambulatory/Inpatient",null,"Number of patient with clinical record documentation of spiritual/religious concerns or documentation that the patient/family did not want to discuss","Total number of patient’s discharged from hospice care and/or palliative care during the designated reporting period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.10.1","","Hospice and Palliative Care – documentation of spiritual/religions concerns ",null,null,null,null,null,"2014-04-01","2015-03-31","2015-04-01","2016-03-31","2013-10-01","2014-03-31",null,null,"RHP 9_175287501.2.2","RHP 9_175287501.3.5","RHP 9_175287501.2.2_175287501.3.5",{"$f":"COUNTIFS($FI$4:$FI2136,FI2136)","v":3},"RHP 9_175287501.2.2_3",null,2,1,1,"RHP 9_175287501",{"$f":"COUNTIFS($FR$4:$FR2136,FR2136)","v":4},"RHP 9_175287501_4"]
["RHP 9","175287501","University of Texas Southwestern St Paul Universit","175287501.2.3","175287501.3.500","IT-3.27","Cancer Related 30-day Readmission Rate ","Baseline Approved","Eligible to Report in April DY4","Expand the Transitional Care Program for Cancer Surgery Patients that it started over one year ago. We currently provide transitional care services only for Hematology-Oncology and Gynecologic Oncology patients. With additional resources from this project, the program will be expanded to include Surgical Oncology, Thoracic Surgery, Neuro-Surgery and Breast Surgery patients.","Cancer Related 30-day Readmission Rate ","In DY4 and DY5, the provider will report the rate of readmissions (for patients 18 years and older), for any cause, within 30 days of discharge from the index cancer-related admission over all admissions (for patients 18 years and older), for patients discharged from the hospital with a principle diagnosis of cancer. In DY5, the provider will demonstrate improvement by validating the P4R outcome (SA.1).",null,null,"P4R","SA1","PM-8","Submission of Category 3 DY3 Status Report",56029.917500000003,"Yes/No","RHP 9_175287501.3.500_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",56029.917500000003,"Yes/No","RHP 9_175287501.3.500_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",179816.66500000001,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"PM-10","Successful reporting to approved measure specifications",214998.08249999999,"Yes/No","NA","PM-11","Successful Achievment of Stretch Activity",214998.08249999999,"Yes/No","NA",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.14127799999999999,294,2081,"DY3 (1): Oct 1st, 2013 - March 31st, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,"P4R",null,"P4R",null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"We understood this meassurement as:   A readmission is a subsequent hospital admission in the same or a different hospital within 30 days following an original admission (or index stay). The discharge date for the index stay must occur within 11 months from the  beginning of the measurement year the readmissions are calculated to allow a 30-day follow-up period for all index stays.  Numerator: Total number of admissions (index stay) with at least one subsequent readmission (hospital stay) for any reason within 30 days during the measurement year.  Denominator: The total number of hospital stays for Cancer during the measurement year.","Percentage of hospital admissions (stays) for Cancer that had at least one subsequent readmission (hospital stay) within 30 days of discharge for patients 18 years of age and older.  Our understanding is that our Cancer 30-day Readmission Rate = 14% in DY3.","Cancer Related 30-day Readmission Rate ","inpatient",null,"Total number of admissions (index stay) with at least one subsequent readmission (hospital stay) for any reason within 30 days during the measurement year.","The total number of hospital stays for Cancer during the measurement year for patients 18 years of age and older.",null,null,null,null,null,null,null,null,null,null,"We have two Cat3 Measures for this project which we understand counts as a stretch activity.  Our two outcome measures include HCAHPS for Discharging Information and Cancer 30-day Readmission Rate.",null,null,"2.12.2","","Cancer Related 30-day Readmission Rate ",null,null,null,null,null,"2014-04-01","2015-03-31","2015-04-01","2016-03-31","2013-10-01","2014-03-31",null,null,"RHP 9_175287501.2.3","RHP 9_175287501.3.500","RHP 9_175287501.2.3_175287501.3.500",{"$f":"COUNTIFS($FI$4:$FI2137,FI2137)","v":1},"RHP 9_175287501.2.3_1",null,2,1,1,"RHP 9_175287501",{"$f":"COUNTIFS($FR$4:$FR2137,FR2137)","v":5},"RHP 9_175287501_5"]
["RHP 9","175287501","University of Texas Southwestern St Paul Universit","175287501.2.3","175287501.3.6","IT-6.1.a.viii","HCAHPS Discharging Information","Baseline Approved","Eligible to Report in April DY4","Cancer surgery patients are one of many inpatient diagnostic categories that have very complex needs during the hospital stay and during their navigation of post-discharge continuum of care.  The Transitional Care Services program greatly enhances collaboration and communication between inpatient care givers and the myriad outpatient, post-acute care, home and physician office providers.  The process improves patient satisfaction, assures a tighter continuum of care for better overall outcomes, reduces the chance of re-admissions because fewer missteps are taken with nutrition, medication management, adherence to discharge instructions, physician office visit scheduling, and the patients ability to cope with everything going on with their care.","HCAHPS Discharging Information","In DY4 and DY5 provider will improve patient satisfaction for individuals with a diagnosis of Cancer that are discharged from Hematology-Oncology, Gynecologic Oncology, Surgical Oncology, Thoracic Surgery, Neuro-Surgery and Breast Surgery as demonstrated by increased \"top box\" scores in HCAHPS- Discharge information.  ","Facility,Comorbid Condition ","Patients with a diagnosis of Cancer that are discharged from Hematology-Oncology, Gynecologic Oncology, Surgical Oncology, Thoracic Surgery, Neuro-Surgery and Breast Surgery.  ","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",56029.917500000003,"Yes/No","RHP 9_175287501.3.6_PM-8","Metric Achieved in October DY3","PM-9","Validation and submission of baseline performance",56029.917500000003,"Yes/No","RHP 9_175287501.3.6_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",89908.335000000006,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",89908.33,"Numeric",0.87531578899999996,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",429996.17,"Numeric",0.87694736799999995,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.87368400000000002,249,285,"DY3 (1): Oct 1st, 2013 - March 31st, 2014",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.87531578899999996,null,0.87694736799999995,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"Numerator: The PatientKey of patients diagnosed with cancer and discharged between 10-01-2013 and 03-31-2014 are crosschecked against returned HCAHPS surveys stored in HealthSystemDWApproved.dbo.FACT_PressGaney_HCAHPS. For those patients that returned surveys between 10-01-2013 and 03-31-2014, the patient's response to the HCAHPS discharge information question, PG_Measure_HCAHPSKey = 13, is evaluated. A response of 'Yes' discharge information was receieved is stored as '20' and a response of 'No' discharge information was not receieved is stored as '21' in the PG_ResponseType_HCAHPSKey field. / Denominator: Patients that were diagnosed and discharged with cancer between 10-01-2013 and 03-31-2014 and returned a response to the HCAHPS Discharging Information question between 10-01-2013 and 03-31-2014. Discharged date range: 10-01-2013 through 03-31-2014. All financial classes grouped by name. Admitted with diagnosis of cancer.","Percentage of the surveyed Target Population that received the HCAHPS survey and responded 'Yes' to the Discharging Information question.  ","HCAHPS Discharging Information","Inpatient",null,"Patient-mix and survey mode adjusted percent \"top box\" score for a given subdomain as provided by your survey administrator, multiplied by the number of completed surveys represented in the \"top box\" score.","The number of HCAHPS surveys completed during the measurement period as reported by your survey administrator. The denominator should be the same as the multiplier used in the numerator. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.12.2","","HCAHPS Discharging Information",null,null,null,null,null,"2014-04-01","2015-03-31","2015-04-01","2016-03-31","2013-10-01","2014-03-31",null,null,"RHP 9_175287501.2.3","RHP 9_175287501.3.6","RHP 9_175287501.2.3_175287501.3.6",{"$f":"COUNTIFS($FI$4:$FI2138,FI2138)","v":2},"RHP 9_175287501.2.3_2",null,2,1,1,"RHP 9_175287501",{"$f":"COUNTIFS($FR$4:$FR2138,FR2138)","v":6},"RHP 9_175287501_6"]
["RHP 9","195018001","Trinity Medical Center","195018001.1.1","195018001.3.1","IT-1.7","Controlling high blood pressure ","Baseline Approved","Eligible to Report in October DY4","Establish a new clinic for the underserved (including Medicaid/Uninsured) population on the Baylor Medical Center at Carrollton campus.","Controlling high blood pressure ","In DY4 and DY5, the provider will improve the percentage of patients in the denominator whose most recent BP is adequately controlled during the measurement year (For a patient’s BP to be controlled, both the systolic and diastolic BP must be <140/90 (adequate control). To determine if a patient’s BP is adequately controlled, the representative BP must be identified) over all Medicaid/Uninsured patients treated at the new primary care clinic 18 to 85 years of age by the end of the measurement year who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year.","Facility , Payer ","Ambulatory Setting- Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",6427.54,"Yes/No","RHP 9_195018001.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",6427.54,"Yes/No","RHP 9_195018001.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",10313.700000000001,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",10313.700000000001,"Numeric",0.54279421000000005,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",49328.03,"Numeric",0.55927300000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.52631600000000001,40,76,"06/02/14 - 09/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"short",0.54279421000000005,null,0.55927300000000002,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"We received approval via email from HHSC on 1/16/14 that a 4 month baseline period would be adequate for the baselines we are submitting. Our lead physician also felt that the results are in line with other clinics and baseline numbers and imporvement thresholds are attainable. ","DSRIP base population selection criteria for all metrics: all community care clinic patients, who had at least one office visit during one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the clinics based on their most recent visit location. Numerator: Patients with last SBP < 140 and DBP < 90 within reporting period, Denominator: Patients with HT: ICD-9 401.*-405.* and age between 18 and 85. Note: Includes only those patients with recorded BP measurement.","During DY3 (06/02/2014- 9/30/2014), of those adult, Uninsured/Medicaid clinic patients with a diagnosis of hypertension, 73% of patients had controlled hypertension (BP less than 140/90). ","Controlling high blood pressure ","ambulatory",null,"The number of patients in the denominator whose most recent BP is adequately controlled during the measurement year. For a patient’s BP to be controlled, both the systolic and diastolic BP must be <140/90 (adequate control). To determine if a patient’s BP is adequately controlled, the representative BP must be identified.\n","Patients 18 to 85 years of age by the end of the measurement year who had at least one outpatient encounter with a diagnosis of hypertension (HTN) during the first six months of the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1 ","","Controlling high blood pressure ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-06-02","2014-09-30",null,null,"RHP 9_195018001.1.1","RHP 9_195018001.3.1","RHP 9_195018001.1.1_195018001.3.1",{"$f":"COUNTIFS($FI$4:$FI2139,FI2139)","v":1},"RHP 9_195018001.1.1_1",null,2,1,1,"RHP 9_195018001",{"$f":"COUNTIFS($FR$4:$FR2139,FR2139)","v":1},"RHP 9_195018001_1"]
["RHP 9","195018001","Trinity Medical Center","195018001.1.1","195018001.3.200","IT-12.3","Colorectal Cancer Screening ","Baseline Approved","Eligible to Report in October DY4","Establish a new clinic for the underserved (including Medicaid/Uninsured) population on the Baylor Medical Center at Carrollton campus.","Colorectal Cancer Screening ","In DY4 and DY5, the provider will improve the percentage of patients who have had one or more screenings for colorectal cancer over all Medicaid/uninsured patients receiving services at the new primary care clinic 51–75 years of age as of December 31 of the measurement year.","Facility , Payer ","Ambulatory Setting- Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",6427.54,"Yes/No","RHP 9_195018001.3.200_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",6427.54,"Yes/No","RHP 9_195018001.3.200_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",10313.700000000001,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",10313.700000000001,"Numeric",0.51,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",49328.03,"Numeric",0.53300000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.23880599999999999,16,67,"06/02/14 - 09/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"short",0.51,null,0.53300000000000003,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"We received approval via email from HHSC on 1/16/14 that a 4 month baseline period would be adequate for the baselines we are submitting. Our lead physician also felt that the results are in line with other clinics and baseline numbers and imporvement thresholds are attainable. ","DSRIP base population selection criteria for all metrics: all community care clinic patients, who had at least one office visit during one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the clinics based on their most recent visit location. Numerator: Adults aged 51-75 and at least one colonoscopy observation within 10 years or one FOBT within 1 year prior to the report date. HDIDs: (27, 2323)\n","During DY3 (06/02/2014- 9/30/2014), of those eligble adult, Uninsured/Medicaid clinic patients between the ages of 51-75, 24% of patients received a colorectal cancer screening- most likely an FOBT based on the ambulatory setting criteria. ","Colorectal Cancer Screening ","ambulatory",null,"One or more screenings for colorectal cancer. Any of the following meet the criteria: \n\n• Fecal occult blood test (FOBT) during the measurement year. For administrative data, assume the required number of samples were returned regardless of FOBT type.\n• Flexible sigmoidoscopy during the measurement year or the four years prior to the measurement year.\n• Colonoscopy during the measurement year or the nine years prior to the measurement year.\n","Patients 51–75 years of age as of the end of the measurement year.",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1 ","","Colorectal Cancer Screening ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-06-02","2014-09-30",null,null,"RHP 9_195018001.1.1","RHP 9_195018001.3.200","RHP 9_195018001.1.1_195018001.3.200",{"$f":"COUNTIFS($FI$4:$FI2140,FI2140)","v":2},"RHP 9_195018001.1.1_2",null,2,1,1,"RHP 9_195018001",{"$f":"COUNTIFS($FR$4:$FR2140,FR2140)","v":2},"RHP 9_195018001_2"]
["RHP 9","195018001","Trinity Medical Center","195018001.1.1","195018001.3.4","IT-12.1","Breast Cancer Screening","Baseline Approved","Eligible to Report in October DY4","Establish a new clinic for the underserved (including Medicaid/Uninsured) population on the Baylor Medical Center at Carrollton campus.","Breast Cancer Screening","In DY4 and DY5, the provider will improve the percentage of women who had mammogram during the measurement year or the 18 months prior to the measurement year over all Medicaid/uninsured women receiving primary care services at the new clinic 50-74 years old as of the measurement year who had at least one (1) outpatient encounter in the prior 12-month period. ","Facility , Payer ","Ambulatory Setting- Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",6427.54,"Yes/No","RHP 9_195018001.3.4_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",6427.54,"Yes/No","RHP 9_195018001.3.4_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",10313.700000000001,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",10313.700000000001,"Numeric",0.44819999999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",49328.03,"Numeric",0.46614,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",6.8182000000000006E-2,3,44,"06/02/14 - 09/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"short",0.44819999999999999,null,0.46614,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"We received approval via email from HHSC on 1/16/14 that a 4 month baseline period would be adequate for the baselines we are submitting. Our lead physician also felt that the results are in line with other clinics and baseline numbers and imporvement thresholds are attainable. ","DSRIP base population selection criteria for all metrics: all community care clinic patients, who had at least one office visit during one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the clinics based on their most recent visit location. Numerator: Females aged 50-74 and at least one ‘MAMMOGRAM’ observation record within reporting period HDID=71. Denominator: Include: females aged 50-74 Exclude: Hx of bilateral mastectomy - ICD-V45.71, CPT-19303. Notes: none\n","During DY3 (06/02/2014- 9/30/2014), of those female adult, Uninsured/Medicaid clinic patients between the ages of 50-74 without a history of a mastectomy, 7% of eligible patients received a mammogram. ","Breast Cancer Screening","ambulatory",null,"Women who had mammogram during the measurement year or the 18 months prior to the measurement year.","Women 50-74 years old as of the measurement year who had at least one (1) outpatient encounter in the prior 12-month period. ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.1.1 ","","Breast Cancer Screening",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-06-02","2014-09-30",null,null,"RHP 9_195018001.1.1","RHP 9_195018001.3.4","RHP 9_195018001.1.1_195018001.3.4",{"$f":"COUNTIFS($FI$4:$FI2141,FI2141)","v":3},"RHP 9_195018001.1.1_3",null,2,1,1,"RHP 9_195018001",{"$f":"COUNTIFS($FR$4:$FR2141,FR2141)","v":3},"RHP 9_195018001_3"]
["RHP 9","195018001","Trinity Medical Center","195018001.1.2","195018001.3.202","IT-1.22","Asthma Percent of Opportunity Achieved","Baseline Approved","Eligible to Report in October DY4","Increase access to needed specialty care services (i.e. outpatient visits with specialty physicians, hospital-based procedures) for uninsured patients under the care of the new Baylor Clinic in Carrollton.","Asthma Percent of Opportunity Achieved","In DY4 and DY5, the provider will improve the percentage of 18-75 year old asthma opportunities completed/fulfilled:  1.) documentation of Action/Mgmt. Plan, 2.) Severity Assessment, 3.) Controller Therapy for those who are eligible, and 4.) Spirometry within last two years over all asthma appropriate opportunities x number of Medicaid/uninsured asthma patients receiving services at the facility","Facility , Age ","Patients aged 18-75 years","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",3265.605,"Yes/No","RHP 9_195018001.3.202_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",3265.605,"Yes/No","RHP 9_195018001.3.202_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",5240.0249999999996,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",5240.03,"Numeric",0.43,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",25061.82,"Numeric",0.46,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.4,16,40,"06/02/14 - 09/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"short",0.43,null,0.46,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"We received approval via email from HHSC on 1/16/14 that a 4 month baseline period would be adequate for the baselines we are submitting. Our lead physician also felt that the results are in line with other clinics and baseline numbers and imporvement thresholds are attainable. ","DSRIP base population selection criteria for all metrics: all community care clinic patients, who had at least one office visit during one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the clinics based on their most recent visit location. Numerator:  Number of times each of the asthma opportunities was met for patients 18 to 65 with Asthma (ICD code 493). Observed Asthma Opportunities are derived from:\na) Symptom Assessment using OBS term ASTHSEV1 (HDID: 30785) or OBS term ASTHSEV2 (HDID: 30786). If assessment date within 1 year of last visit. b) Action Management Plan using variable ASTHGUIACTPL (HDID: 36409). If plan is within 1 year of last visit. c) Controller Therapy using variable ASTHSERVERITY (HDID: 13800218) along with appropriate controller medication per generic list with start date prior to end of audit period. If therapy is begun prior to the end of the report period. d) Spirometry Measures using OBS term FEV1/FVC ( HDID: 95) or OBS term PREFEV1/FVC (HDID: 25296) or OBS term PULM FNC TST (HDID: 4636) that are current or within the past two years of last visit date within audit period. Denominator: Total number of asthma opportunities (3 or 4 opportunities) that should have been completed (expected) during the measurement period for patients 18 to 65 with Asthma (ICD code 493). Expected Asthma Opportunities: a) Symptom Assessment. b) Action Management Plan. c) Controller Therapy (not counted if patient did not require medication). d) Spirometry Measures. Note: Achievement Value, (expressed in percentage) is calculated by dividing the numerator count by the denominator count.\n\n","During DY3 (06/02/2014- 9/30/2014), of those adult, Uninsured/Medicaid clinic patients with a diagnosis of asthma , 40% of patients had the asthma percent of opportunities fulfilled.       ","Asthma Percent of Opportunity Achieved","ambulatory",null,"The number of times that each of the asthma opportunities (processes) listed below were completed/fulfilled at least once during the measurement year for all individuals with asthma (any age) :  \n1.) Documentation of Action/Management Plan, \n2.) Severity Assessment\n3.) Controller Therapy for those who are eligible, and \n4.) Documentation of spirometry assessment completed within last two years.\n","The total number of opportunities can be calculated in the following manner-\nFor each individual with an asthma diagnosis assign a count one for each of the four processes that should have been completed (should be 3-4 counts per patient) at least once during the measurement period. \n",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2 ","","Asthma Percent of Opportunity Achieved",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-06-02","2014-09-30",null,null,"RHP 9_195018001.1.2","RHP 9_195018001.3.202","RHP 9_195018001.1.2_195018001.3.202",{"$f":"COUNTIFS($FI$4:$FI2142,FI2142)","v":1},"RHP 9_195018001.1.2_1",null,2,1,1,"RHP 9_195018001",{"$f":"COUNTIFS($FR$4:$FR2142,FR2142)","v":4},"RHP 9_195018001_4"]
["RHP 9","195018001","Trinity Medical Center","195018001.1.2","195018001.3.6","IT-12.2","Cervical Cancer Screening ","Baseline Approved","Eligible to Report in October DY4","Increase access to needed specialty care services (i.e. outpatient visits with specialty physicians, hospital-based procedures) for uninsured patients under the care of the new Baylor Clinic in Carrollton.","Cervical Cancer Screening ","In DY4 and DY5, the provider will improve the percentage of women who were screened for cervical cancer over all Medicaid/uninsured women receiving services at the facility 24-64 years of age as of the end of the measurement year.","Facility , Payer ","Ambulatory Setting- Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",3265.605,"Yes/No","RHP 9_195018001.3.6_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",3265.605,"Yes/No","RHP 9_195018001.3.6_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",5240.0249999999996,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",5240.03,"Numeric",0.68369999999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",25061.82,"Numeric",0.69384000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.290076,38,131,"06/02/14 - 09/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"short",0.68369999999999997,null,0.69384000000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"We received approval via email from HHSC on 1/16/14 that a 4 month baseline period would be adequate for the baselines we are submitting. Our lead physician also felt that the results are in line with other clinics and baseline numbers and imporvement thresholds are attainable. ","DSRIP base population selection criteria for all metrics: all community care clinic patients, who had at least one office visit during one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the clinics based on their most recent visit location. Numerator: Females aged 21-64 and at least one ‘PAP’ observation record within reporting period HDIDs: (73,6759,16048,11438). Denominator: Include: females aged 21-64 Exclude: Hx of radical hysterectomy – ICD Procedure codes: 68.4, 68.6, 68.7. \n","During DY3 (06/02/2014- 9/30/2014), of those eligible female adult, Uninsured/Medicaid clinic patients between the ages of 21-64, 51% of patients had a cervical cancer screen completed. ","Cervical Cancer Screening ","ambulatory",null,"The number of women who were screened for cervical cancer during the measurement year or the two years prior to the measurement year.","Women 24-64 years of age as of the end of the measurement year ",null,null,null,null,null,null,null,null,null,null,null,null,null,"1.9.2 ","","Cervical Cancer Screening ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-06-02","2014-09-30",null,null,"RHP 9_195018001.1.2","RHP 9_195018001.3.6","RHP 9_195018001.1.2_195018001.3.6",{"$f":"COUNTIFS($FI$4:$FI2143,FI2143)","v":2},"RHP 9_195018001.1.2_2",null,2,1,1,"RHP 9_195018001",{"$f":"COUNTIFS($FR$4:$FR2143,FR2143)","v":5},"RHP 9_195018001_5"]
["RHP 9","195018001","Trinity Medical Center","195018001.2.1","195018001.3.201","IT-1.21","Adult Body Mass Index (BMI) Assessment ","Baseline Approved","Eligible to Report in October DY4","Provide focused education and point of care testing for underserved patients who have diabetes, CVD and/or Respiratory disease that are in need of education, clinical management and training within a primary care setting. We will co-locate primary care and chronic disease management services to improve clinical outcomes. ","Adult Body Mass Index (BMI) Assessment ","In DY4 and DY5, the provider will improve the percentage of Medicaid/uninsured patients with diabetes, COPD/Asthma, and/or CHF receiving services at the facility 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. ","Facility , Comorbid Condition, Payer, ","Diabetes, CHF, Asthma, COPD Medicaid/Uninsured patients served by the clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",2643.585,"Yes/No","RHP 9_195018001.3.201_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",2643.585,"Yes/No","RHP 9_195018001.3.201_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",4241.9250000000002,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",4241.93,"Numeric",0.46899999999999997,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",20288.14,"Numeric",0.49948999999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.42372900000000002,25,59,"06/02/14 - 09/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"short",0.46899999999999997,null,0.49948999999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"We received approval via email from HHSC on 1/16/14 that a 4 month baseline period would be adequate for the baselines we are submitting. Our lead physician also felt that the results are in line with other clinics and baseline numbers and imporvement thresholds are attainable. ","DSRIP base population selection criteria for all metrics: all community care clinic patients, who had at least one office visit during one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the clinics based on their most recent visit location.  Numerator: Patients from the denominator set with all of the following completed: (1) Documented BMI (HDID: 2788), (2) Documented Nutrition counseling (HDID: 156251), (3) Documented healthy eating education/counseling or Being active education/counseling (HDIDs: 410705, 410707). Denominator: All DSRIP patients 18 to 74 diagnosed with:\nDM (ICD code 250). CHF (ICD code 428). COPD (ICD code 496). Asthma (ICD code 493). Patients with 2 or more chronic diseases were counted only once for the metric. Patients excluded if: (a)  Height and/or  Weight associated with a BMI value are missing. (b) Pregnant (HDID: 21347) (c)  Medical or personal reason not to have BMI (HDIDs:  163350, 108116 410650, 407468, 407469).\n\n\n","During DY3 (06/02/2014- 9/30/2014), of those eligible adult, Uninsured/Medicaid clinic patients with a diagnosis of diabetes/CHF/COPD/Asthma, 48% of patients had a BMI screening and treatment plan completed. ","Adult Body Mass Index (BMI) Assessment ","both",null,"Patients with BMI calculated within the past six months or during the current visit and a follow-up plan is documented within the last six months or during the current visit if the BMI is outside of normal parameters.\n\nDefinitions:\n\nBMI – Body mass index (BMI) is expressed as weight/height (BMI; kg/m2) and is commonly used to classify weight categories.\n\nCalculated BMI – Requires an eligible professional or their staff to measure both the height and weight. Self-reported values cannot be used. BMI is calculated either as weight in pounds divided by height in inches squared multiplied by 703, or as weight in kilograms divided by height in meters squared.\n\nFollow-up Plan – Proposed outline of treatment to be conducted as a result of a BMI out of normal parameters. Such follow-up may include but is not limited to: documentation of a future appointment, education, referral (such as, a registered dietician, nutritionist, occupational therapist, physical therapist, primary care provider, exercise physiologist, mental health professional or surgeon), pharmacological interventions, dietary supplements, exercise counseling or nutrition counseling.\n","Patients age 18 years as of the first day of the 12-month period prior to the measurement period to 74 years as of last day of the measurement period who had an outpatient visit during the measurement period or the 12-month period prior to the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.2 ","","Adult Body Mass Index (BMI) Assessment ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-06-02","2014-09-30",null,null,"RHP 9_195018001.2.1","RHP 9_195018001.3.201","RHP 9_195018001.2.1_195018001.3.201",{"$f":"COUNTIFS($FI$4:$FI2144,FI2144)","v":1},"RHP 9_195018001.2.1_1",null,2,1,1,"RHP 9_195018001",{"$f":"COUNTIFS($FR$4:$FR2144,FR2144)","v":6},"RHP 9_195018001_6"]
["RHP 9","195018001","Trinity Medical Center","195018001.2.1","195018001.3.8","IT-1.10","Diabetes care: HbA1c poor control (>9.0%) ","Baseline Approved","Eligible to Report in October DY4","Provide focused education and point of care testing for underserved patients who have diabetes, CVD and/or Respiratory disease that are in need of education, clinical management and training within a primary care setting. We will co-locate primary care and chronic disease management services to improve clinical outcomes. ","Diabetes care: HbA1c poor control (>9.0%) ","In DY4 and DY5, the provider will improve the percentage of patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year over all Medicaid/uninsured patients served at the facility 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.","Facility , Payer ","Ambulatory Setting- Clinic","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",2643.585,"Yes/No","RHP 9_195018001.3.8_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",2643.585,"Yes/No","RHP 9_195018001.3.8_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",4241.9250000000002,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",4241.9250000000002,"Numeric",0.27142830000000001,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",20288.14,"Numeric",0.2571426,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.28571400000000002,12,42,"06/02/14 - 09/30/14",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,"short",0.27142830000000001,null,0.2571426,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"We received approval via email from HHSC on 1/16/14 that a 4 month baseline period would be adequate for the baselines we are submitting. Our lead physician also felt that the results are in line with other clinics and baseline numbers and imporvement thresholds are attainable. ","DSRIP base population selection criteria for all metrics: all community care clinic patients, who had at least one office visit during one year prior to the report date and were DSRIP eligible (Medicaid, Charity, Self-pay) during that visit. Unless specified otherwise, patients are attributed to the clinics based on their most recent visit location.  Numerator: Patients with last HgA1c measurement <= 9.0 within reporting period. Denominator: Include: ICD-9 code 250.*, Patient age btw 18-75 Exclude: ICD-9 codes 256.4, 648.8, 251.8, 962.0. Note: Missing HgA1C values are treated as ‘Not Controlled’.\n\n","During DY3 (10/01/2013- 9/30/2014), of those adult, Uninsured/Medicaid clinic patients with a diagnosis of Type I or Type II diabetes, 29% of patients had an uncontrolled A1c (A1c > 9).       ","Diabetes care: HbA1c poor control (>9.0%) ","ambulatory",null,"Patients whose most recent HbA1c level is greater than 9.0% or is missing a result, or if an HbA1c test was not done during the measurement year.","Patients 18-75 years of age by the end of the measurement year who had a diagnosis of diabetes (type 1 or type 2) during the measurement year or the year prior to the measurement year.\n",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.2 ","","Diabetes care: HbA1c poor control (>9.0%) ",null,null,null,null,null,"2014-10-01","2015-09-30","2015-10-01","2016-09-30","2014-06-02","2014-09-30",null,null,"RHP 9_195018001.2.1","RHP 9_195018001.3.8","RHP 9_195018001.2.1_195018001.3.8",{"$f":"COUNTIFS($FI$4:$FI2145,FI2145)","v":2},"RHP 9_195018001.2.1_2",null,2,1,1,"RHP 9_195018001",{"$f":"COUNTIFS($FR$4:$FR2145,FR2145)","v":7},"RHP 9_195018001_7"]
["RHP 9","209345201","Methodist Richardson Medical Center","209345201.2.1","209345201.3.1","IT-9.2","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","Baseline Approved","Eligible to Report in April DY4","To provide patient navigation services in the Emergency Department who are at high risk of disconnecting from institutionalized health care services or are identified as not having a primary care physician and/or medical home to address their needs. ","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","In DY4 and DY5, the provider will improve the rate of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period over all ED visits at Methodist Richardson Medical Center for individuals 18 years or older during the measurement period","Facility ","Methodist Richardson Medical Center","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",42838.25,"Yes/No","RHP 9_209345201.3.1_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",42838.25,"Yes/No","RHP 9_209345201.3.1_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",68740.25,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",68740.25,"Numeric",0.234583334,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",328759.5,"Numeric",0.22223699999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",0.24693000000000001,6756,27360,"DY2: Oct 1st, 2012 - Sept 30th, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,0.234583334,null,0.22223699999999999,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ED visits during the measurement period (Oct 2012 - Sept 2013)  with a primary or secondary ACSC diagnosis were extracted from the EMR based on ICD-9 diagnosis codes for patients 18 years and older and were applied to the numerator. The total number of ED visits (all diagnoses included) at Methodist Dallas were extracted from the EMR for patients 18 years or older and applied to the denominator.","Of the total Emergency Department visits between October 1, 2012 and September 30, 2013, 6756 of those visits had a primary or secondary ACSC diagnosis resulting in a rate of 24.69 ACSC visits per 100 ED visits for patients 18 years and older.","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ","ED",null,"Total number of ED Visits with a primary or secondary ACSC diagnosis for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.9.1 ","","\nReduce Emergency Department (ED) visits for Ambulatory Care Sensitive Conditions (ACSC) ",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 9_209345201.2.1","RHP 9_209345201.3.1","RHP 9_209345201.2.1_209345201.3.1",{"$f":"COUNTIFS($FI$4:$FI2146,FI2146)","v":1},"RHP 9_209345201.2.1_1",null,2,1,1,"RHP 9_209345201",{"$f":"COUNTIFS($FR$4:$FR2146,FR2146)","v":1},"RHP 9_209345201_1"]
["RHP 9","209345201","Methodist Richardson Medical Center","209345201.2.2","209345201.3.3","IT-9.4.b","Reduce Emergency Department visits for Diabetes","Baseline Approved","Eligible to Report in April DY4","Develop and implement a chronic disease management intervention geared toward improving effective management of chronic conditions and ultimately improving patient clinical indicators, health outcomes and quality, and reducing unnecessary acute and emergency care utilization.","Reduce Emergency Department visits for Diabetes","In DY4 and DY5, the provider will improve the rate of ED Visits with a primary or secondary diabetes diagnosis for any individual 18 years and older during the measurement period over all ED visits at Methodist Richardson Medical Center for individuals 18 yea","Facility ","Methodist Richardson Medical Center","P4P",null,"PM-8","Submission of Category 3 DY3 Status Report",42838.245000000003,"Yes/No","RHP 9_209345201.3.3_PM-8","Metric Achieved in April DY3","PM-9","Validation and submission of baseline performance",42838.245000000003,"Yes/No","RHP 9_209345201.3.3_PM-9","Metric Achieved in October DY3","PM-10","Successful reporting to approved measure specifications",68740.244999999995,"Yes/No","NA","AM-1.1","Achievement of DY4 performance goal",68740.244999999995,"Numeric",5.2881945E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"AM-2.1","Achievement of DY5 performance goal",328759.5,"Numeric",5.0098999999999998E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,0,"%",5.5664999999999999E-2,1523,27360,"DY2: Oct 1st, 2012 - Sept 30th, 2013",null,0,0,null,null,0,0,null,null,0,0,null,null,0,0,null,null,5.2881945E-2,null,5.0098999999999998E-2,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,null,"ED visits during the measurement period (Oct 2012 - Sept 2013)  with a primary or secondary diagnosis of diabetes were extracted from the EMR based on ICD-9 diagnosis codes 250.0, 250.1, 250.2, 250.3, 250.8, 250.9 for patients 18 years and older and were applied to the numerator. The total number of ED visits (all diagnoses included) at Methodist Dallas were extracted from the EMR for patients 18 years or older and applied to the denominator.","Of the total Emergency Department visits between October 1, 2012 and September 30, 2013,  1523 of those visits had a primary or secondary diagnosis of diabetes resulting in a rate of 5.57 diabetic visits per 100 ED visits for patients 18 years and older.","Reduce Emergency Department visits for Diabetes","ED",null,"Total number of ED Visits with a primary or secondary diagnosis of diabetes for any individual 18 years and older during the measurement period","Total number of ED visits for individuals 18 years or older during the measurement period",null,null,null,null,null,null,null,null,null,null,null,null,null,"2.2.1 ","","Reduce Emergency Department visits for Diabetes",null,null,null,null,null,"2013-10-01","2014-09-30","2014-10-01","2015-09-30","2012-10-01","2013-09-30",null,null,"RHP 9_209345201.2.2","RHP 9_209345201.3.3","RHP 9_209345201.2.2_209345201.3.3",{"$f":"COUNTIFS($FI$4:$FI2147,FI2147)","v":1},"RHP 9_209345201.2.2_1",null,2,1,1,"RHP 9_209345201",{"$f":"COUNTIFS($FR$4:$FR2147,FR2147)","v":2},"RHP 9_209345201_2"]
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{"sheet":"Providers List","index":6,"n_rows":3000,"n_cols":18,"rows_kept":3000,"cut":false,"hidden":true,"merged":[]}
["RHP","TPI w/ leading 0s","Provider name","Cat 1 or 2 project ID",null,"RHP Index",null,"RHP_TPI Number",{"$f":"\"\"&RHP&\"_TPI Index\"","v":"_TPI Index"},null,"RHP_TPI Number_Cat 1 or 2 Project ID",{"$f":"\"\"&RHP&\"_\"& TPI &\" Project Index\"","v":"_ Project Index"},null,"RHP_TPI Number_Provider Name",{"$f":"\"\"&RHP&\"_\"& TPI &\" Provider Name Index\"","v":"_ Provider Name Index"},null,"Cat 1 or 2 Index",{"$f":"H1&\"_\"&Q1","v":"RHP_TPI Number_Cat 1 or 2 Index"}]
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[{"$f":"IF('Master Data Mock'!$A5=\"\",\"\",TRIM('Master Data Mock'!$A5))","v":"RHP 1"},{"$f":"IF('Master Data Mock'!$B5=\"\",\"\",RIGHT(\"0000000000000\"&'Master Data Mock'!$B5&\"\",9))","v":"020812601"},{"$f":"IF('Master Data Mock'!$C5=\"\",\"\",TRIM('Master Data Mock'!$C5))","v":"East Texas Medical Center"},{"$f":"IF('Master Data Mock'!$D5=\"\",\"\",TRIM('Master Data Mock'!$D5))","v":"020812601.1.1"},null,{"$f":"IF(A3=\"\",\"\",IF(COUNTIF(A$2:A3,$A3)>1,F2,F2+1))","v":1},null,{"$f":"IF(A3=\"\",\"\",\"\"& $A3 &\"_\"&$B3)","v":"RHP 1_020812601"},{"$f":"IF(A3=\"\",\"\",IF($A3<>RHP,I2,IF(COUNTIF($H$2:$H3,$H3)>1,I2,I2+1)))","v":0},null,{"$f":"IF($A3=\"\",\"\",\"\"& $A3 &\"_\"&$B3&\"_\"&$D3)","v":"RHP 1_020812601_020812601.1.1"},{"$f":"IF($A3=\"\",\"\",IF(OR($A3<>RHP,$B3<>TPI),$L2,IF(COUNTIF($K$2:$K3,$K3)>1,$L2,$L2+1)))","v":0},null,{"$f":"IF(A3=\"\",\"\",\"\"&$A3&\"_\"&$B3&\"_\"&$C3)","v":"RHP 1_020812601_East Texas Medical Center"},{"$f":"IF(A3=\"\",\"\",IF(OR($A3<>RHP,$B3<>TPI),$O2,IF(COUNTIF($N$2:$N3,$N3)>1,$O2,$O2+1)))","v":0},null,{"$f":"IF(H3=\"\",\"\",COUNTIFS($H$2:$H3,$H3))","v":1},{"$f":"H3&\"_\"&Q3","v":"RHP 1_020812601_1"}]
[{"$f":"IF('Master Data Mock'!$A6=\"\",\"\",TRIM('Master Data Mock'!$A6))","v":"RHP 1"},{"$f":"IF('Master Data Mock'!$B6=\"\",\"\",RIGHT(\"0000000000000\"&'Master Data Mock'!$B6&\"\",9))","v":"020812601"},{"$f":"IF('Master Data Mock'!$C6=\"\",\"\",TRIM('Master Data Mock'!$C6))","v":"East Texas Medical Center"},{"$f":"IF('Master Data Mock'!$D6=\"\",\"\",TRIM('Master Data Mock'!$D6))","v":"020812601.1.2"},null,{"$f":"IF(A4=\"\",\"\",IF(COUNTIF(A$2:A4,$A4)>1,F3,F3+1))","v":1},null,"RHP 1_020812601",{"$f":"IF(A4=\"\",\"\",IF($A4<>RHP,I3,IF(COUNTIF($H$2:$H4,$H4)>1,I3,I3+1)))","v":0},null,"RHP 1_020812601_020812601.1.2",{"$f":"IF($A4=\"\",\"\",IF(OR($A4<>RHP,$B4<>TPI),$L3,IF(COUNTIF($K$2:$K4,$K4)>1,$L3,$L3+1)))","v":0},null,"RHP 1_020812601_East Texas Medical Center",{"$f":"IF(A4=\"\",\"\",IF(OR($A4<>RHP,$B4<>TPI),$O3,IF(COUNTIF($N$2:$N4,$N4)>1,$O3,$O3+1)))","v":0},null,{"$f":"IF(H4=\"\",\"\",COUNTIFS($H$2:$H4,$H4))","v":2},"RHP 1_020812601_2"]
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{"sheet":"Sheet1","index":7,"n_rows":1485,"n_cols":5,"rows_kept":1485,"cut":false,"hidden":true,"merged":[]}
[null,null,"RHP #","Unique Project ID","Project Option"]
[{"$f":"CONCATENATE(B2,\" \",C2,\"_\",D2)","v":"RHP 1_017624002.1.1"},"RHP",1,"017624002.1.1","1.1.2 "]
[{"$f":"CONCATENATE(B3,\" \",C3,\"_\",D3)","v":"RHP 1_020812601.1.1"},"RHP",1,"020812601.1.1","1.9.2 "]
["RHP 1_020812601.1.2","RHP",1,"020812601.1.2","1.9.2 "]
["RHP 1_020812601.1.3","RHP",1,"020812601.1.3","1.9.2 "]
["RHP 1_020812601.2.1","RHP",1,"020812601.2.1","2.9.1 "]
["RHP 1_020812601.2.2","RHP",1,"020812601.2.2","2.12.1"]
["RHP 1_020812601.2.3","RHP",1,"020812601.2.3","2.4.1 "]
["RHP 1_084434201.1.1","RHP",1,"084434201.1.1","1.11.2"]
["RHP 1_084434201.1.2","RHP",1,"084434201.1.2","1.12.2"]
["RHP 1_084434201.1.3","RHP",1,"084434201.1.3","1.12.2"]
["RHP 1_084434201.1.4","RHP",1,"084434201.1.4","1.10.3"]
["RHP 1_084434201.2.1","RHP",1,"084434201.2.1","2.19.1"]
["RHP 1_084434201.2.2","RHP",1,"084434201.2.2","2.13.1"]
["RHP 1_094095902.2.1","RHP",1,"094095902.2.1","2.9.1 "]
["RHP 1_094108002.1.1","RHP",1,"094108002.1.1","1.1.2 "]
["RHP 1_094108002.1.2","RHP",1,"094108002.1.2","1.9.2 "]
["RHP 1_094108002.1.3","RHP",1,"094108002.1.3","1.7.1 "]
["RHP 1_094108002.2.1","RHP",1,"094108002.2.1","2.1.2"]
["RHP 1_094108002.2.2","RHP",1,"094108002.2.2","2.9.1 "]
["RHP 1_094108002.2.3","RHP",1,"094108002.2.3","2.12.1"]
["RHP 1_094127002.1.1","RHP",1,"094127002.1.1","1.1.2 "]
["RHP 1_094127002.2.1","RHP",1,"094127002.2.1","2.9.1 "]
["RHP 1_094190802.1.1","RHP",1,"094190802.1.1","1.1.2 "]
["RHP 1_094190802.2.1","RHP",1,"094190802.2.1","2.9.1 "]
["RHP 1_121817401.1.1","RHP",1,"121817401.1.1","1.1.2 "]
["RHP 1_121817401.2.1","RHP",1,"121817401.2.1","2.9.1 "]
["RHP 1_121988304.1.1","RHP",1,"121988304.1.1","1.12.2"]
["RHP 1_121988304.2.1","RHP",1,"121988304.2.1","2.15.1"]
["RHP 1_121988304.2.2","RHP",1,"121988304.2.2","2.13.1"]
["RHP 1_127278302.1.1","RHP",1,"127278302.1.1","1.8.6 "]
["RHP 1_127278302.1.10","RHP",1,"127278302.1.10","1.11.1"]
["RHP 1_127278302.1.11","RHP",1,"127278302.1.11","1.1.1 "]
["RHP 1_127278302.1.12","RHP",1,"127278302.1.12","1.8.6 "]
["RHP 1_127278302.1.13","RHP",1,"127278302.1.13","1.13.1"]
["RHP 1_127278302.1.4","RHP",1,"127278302.1.4","1.2.2 "]
["RHP 1_127278302.1.8","RHP",1,"127278302.1.8","1.1.1 "]
["RHP 1_127278302.1.9","RHP",1,"127278302.1.9","1.9.2 "]
["RHP 1_127278302.2.1","RHP",1,"127278302.2.1","2.1.1 "]
["RHP 1_127278302.2.13","RHP",1,"127278302.2.13","2.7.5 "]
["RHP 1_127278302.2.14","RHP",1,"127278302.2.14","2.1.1 "]
["RHP 1_127278302.2.15","RHP",1,"127278302.2.15","2.10.1"]
["RHP 1_127278302.2.16","RHP",1,"127278302.2.16","2.2.1 "]
["RHP 1_127278302.2.17","RHP",1,"127278302.2.17","2.8.4 "]
["RHP 1_127278302.2.18","RHP",1,"127278302.2.18","2.15.1"]
["RHP 1_127278302.2.19","RHP",1,"127278302.2.19","2.9.1 "]
["RHP 1_127278302.2.20","RHP",1,"127278302.2.20","2.1.2 "]
["RHP 1_127278302.2.22","RHP",1,"127278302.2.22","2.12.2"]
["RHP 1_127278302.2.23","RHP",1,"127278302.2.23","2.13.1"]
["RHP 1_127278302.2.5","RHP",1,"127278302.2.5","2.7.1 "]
["RHP 1_130612806.1.1","RHP",1,"130612806.1.1","1.1.2 "]
["RHP 1_130612806.2.1","RHP",1,"130612806.2.1","2.9.1 "]
["RHP 1_131037704.1.1","RHP",1,"131037704.1.1","1.1.2 "]
["RHP 1_131037704.1.2","RHP",1,"131037704.1.2","1.1.2"]
["RHP 1_131037704.2.1","RHP",1,"131037704.2.1","2.5.3 "]
["RHP 1_131037704.2.2","RHP",1,"131037704.2.2","2.12.1"]
["RHP 1_131038504.1.1","RHP",1,"131038504.1.1","1.1.2 "]
["RHP 1_131038504.1.2","RHP",1,"131038504.1.2","1.7.2 "]
["RHP 1_131038504.1.3","RHP",1,"131038504.1.3","1.10.2"]
["RHP 1_131038504.2.1","RHP",1,"131038504.2.1","2.9.1 "]
["RHP 1_131038504.2.2","RHP",1,"131038504.2.2","2.12.1"]
["RHP 1_136367307.1.1","RHP",1,"136367307.1.1","1.12.2"]
["RHP 1_137319306.1.1","RHP",1,"137319306.1.1","1.1.2 "]
["RHP 1_137319306.2.1","RHP",1,"137319306.2.1","2.9.1 "]
["RHP 1_137921608.1.1","RHP",1,"137921608.1.1","1.13.1"]
["RHP 1_137921608.1.3","RHP",1,"137921608.1.3","1.9.2 "]
[{"$f":"CONCATENATE(B67,\" \",C67,\"_\",D67)","v":"RHP 1_137921608.1.4"},"RHP",1,"137921608.1.4","1.13.1"]
["RHP 1_137921608.2.1","RHP",1,"137921608.2.1","2.15.1"]
["RHP 1_138360606.2.1","RHP",1,"138360606.2.1","2.6.2 "]
["RHP 1_138374715.1.1","RHP",1,"138374715.1.1","1.9.2 "]
["RHP 1_138913209.1.1","RHP",1,"138913209.1.1","1.1.1 "]
["RHP 1_138913209.1.2","RHP",1,"138913209.1.2","1.9.2 "]
["RHP 1_138913209.1.3","RHP",1,"138913209.1.3","1.9.1"]
["RHP 1_138913209.2.1","RHP",1,"138913209.2.1","2.5.3 "]
["RHP 1_138913209.2.2","RHP",1,"138913209.2.2","2.8.1 "]
["RHP 1_139173209.1.1","RHP",1,"139173209.1.1","1.1.1 "]
["RHP 1_139173209.1.2","RHP",1,"139173209.1.2","1.1.2 "]
["RHP 1_139173209.2.1","RHP",1,"139173209.2.1","2.9.1 "]
["RHP 1_139173209.2.2","RHP",1,"139173209.2.2","2.12.1"]
["RHP 1_139173209.2.3","RHP",1,"139173209.2.3","2.4.1 "]
["RHP 1_140425362.1.1","RHP",1,"140425362.1.1","1.1.2 "]
["RHP 1_177870603.1.2","RHP",1,"177870603.1.2","1.1.2 "]
["RHP 1_177870603.2.2","RHP",1,"177870603.2.2","2.4.1 "]
["RHP 1_177870603.2.3","RHP",1,"177870603.2.3","2.13.1"]
["RHP 1_177870603.2.4","RHP",1,"177870603.2.4","2.6.2 "]
["RHP 1_208843701.1.1","RHP",1,"208843701.1.1","1.1.2 "]
["RHP 1_208843701.1.2","RHP",1,"208843701.1.2","1.9.2 "]
["RHP 1_751281410.1.1","RHP",1,"751281410.1.1","1.13.1"]
["RHP 1_751281410.2.1","RHP",1,"751281410.2.1","2.13.1"]
["RHP 1_751281410.2.2","RHP",1,"751281410.2.2","2.15.1"]
["RHP 1_751281410.2.3","RHP",1,"751281410.2.3","2.13.1"]
["RHP 2_019053001.1.1","RHP",2,"019053001.1.1","1.1.2 "]
["RHP 2_081844501.1.1","RHP",2,"081844501.1.1","1.9.2 "]
["RHP 2_094092602.1.1","RHP",2,"094092602.1.1","1.1.2 "]
["RHP 2_094092602.1.10","RHP",2,"094092602.1.10","1.9.1 "]
["RHP 2_094092602.1.2","RHP",2,"094092602.1.2","1.1.2 "]
["RHP 2_094092602.1.3","RHP",2,"094092602.1.3","1.1.2 "]
["RHP 2_094092602.1.4","RHP",2,"094092602.1.4","1.3.1 "]
["RHP 2_094092602.1.5","RHP",2,"094092602.1.5","1.3.1 "]
["RHP 2_094092602.1.7","RHP",2,"094092602.1.7","1.10.2"]
["RHP 2_094092602.1.8","RHP",2,"094092602.1.8","1.4.1 "]
["RHP 2_094092602.1.9","RHP",2,"094092602.1.9","1.5.3 "]
["RHP 2_094092602.2.1","RHP",2,"094092602.2.1","2.1.1 "]
["RHP 2_094092602.2.10","RHP",2,"094092602.2.10","2.10.1"]
["RHP 2_094092602.2.11","RHP",2,"094092602.2.11","2.11.1"]
["RHP 2_094092602.2.12","RHP",2,"094092602.2.12","2.12.2"]
["RHP 2_094092602.2.2","RHP",2,"094092602.2.2","2.8.8 "]
["RHP 2_094092602.2.3","RHP",2,"094092602.2.3","2.9.1 "]
["RHP 2_094092602.2.4","RHP",2,"094092602.2.4","2.12.1"]
["RHP 2_094092602.2.5","RHP",2,"094092602.2.5","2.12.1"]
["RHP 2_094092602.2.6","RHP",2,"094092602.2.6","2.12.2"]
["RHP 2_094092602.2.7","RHP",2,"094092602.2.7","2.12.2"]
["RHP 2_094092602.2.8","RHP",2,"094092602.2.8","2.5.1 "]
["RHP 2_094092602.2.9","RHP",2,"094092602.2.9","2.6.1 "]
["RHP 2_094148602.2.1","RHP",2,"094148602.2.1","2.2.2 "]
["RHP 2_094148602.2.2","RHP",2,"094148602.2.2","2.9.1 "]
["RHP 2_096166602.1.1","RHP",2,"096166602.1.1","1.9.2"]
["RHP 2_096166602.1.3","RHP",2,"096166602.1.3","1.12.2"]
["RHP 2_096166602.1.5, updated to 096166602.2.12","RHP",2,"096166602.1.5, updated to 096166602.2.12"," 2.14.1"]
["RHP 2_096166602.1.6","RHP",2,"096166602.1.6","1.13.1"]
["RHP 2_096166602.1.7","RHP",2,"096166602.1.7","1.12.2"]
["RHP 2_096166602.2.1","RHP",2,"096166602.2.1","2.15.1"]
["RHP 2_096166602.2.10","RHP",2,"096166602.2.10","2.13.1"]
["RHP 2_096166602.2.11","RHP",2,"096166602.2.11","2.13.1"]
["RHP 2_096166602.2.2","RHP",2,"096166602.2.2","2.13.1"]
["RHP 2_096166602.2.3","RHP",2,"096166602.2.3","2.13.1"]
["RHP 2_096166602.2.6","RHP",2,"096166602.2.6","2.13.1"]
["RHP 2_096166602.2.7","RHP",2,"096166602.2.7","2.18.1"]
["RHP 2_096166602.2.8","RHP",2,"096166602.2.8","2.13.1"]
["RHP 2_096166602.2.9","RHP",2,"096166602.2.9","2.6.1"]
[{"$f":"CONCATENATE(B131,\" \",C131,\"_\",D131)","v":"RHP 2_109372601.1.1"},"RHP",2,"109372601.1.1","1.9.2 "]
["RHP 2_109372601.1.2","RHP",2,"109372601.1.2","1.11.2"]
["RHP 2_109372601.1.3","RHP",2,"109372601.1.3","1.2.1 "]
["RHP 2_109372601.2.1","RHP",2,"109372601.2.1","2.12.2"]
["RHP 2_109372601.2.2","RHP",2,"109372601.2.2","2.15.1"]
["RHP 2_109372601.2.3","RHP",2,"109372601.2.3","2.8.1 "]
["RHP 2_112671602.1.1","RHP",2,"112671602.1.1","1.1.2 "]
["RHP 2_112671602.2.1","RHP",2,"112671602.2.1","2.2.2 "]
["RHP 2_094092602.1.11","RHP",2,"094092602.1.11","1.1.2 "]
["RHP 2_094092602.1.12","RHP",2,"094092602.1.12","1.1.2"]
["RHP 2_094092602.1.13","RHP",2,"094092602.1.13","1.1.2 "]
["RHP 2_094092602.2.13","RHP",2,"094092602.2.13","2.9.1 "]
["RHP 2_131030203.1.1","RHP",2,"131030203.1.1","1.1.1 "]
["RHP 2_131030203.1.2","RHP",2,"131030203.1.2","1.1.2 "]
["RHP 2_131030203.1.3","RHP",2,"131030203.1.3","1.3.1 "]
["RHP 2_131030203.1.4","RHP",2,"131030203.1.4","1.9.2"]
["RHP 2_131030203.2.1","RHP",2,"131030203.2.1","2.6.2 "]
["RHP 2_131030203.2.2","RHP",2,"131030203.2.2","2.4.1 "]
["RHP 2_135222109.1.1","RHP",2,"135222109.1.1","1.13.1"]
["RHP 2_135222109.1.2","RHP",2,"135222109.1.2","1.12.2"]
["RHP 2_135222109.1.3","RHP",2,"135222109.1.3","1.13.1"]
["RHP 2_135222109.1.4","RHP",2,"135222109.1.4","1.11.2"]
["RHP 2_135222109.1.5","RHP",2,"135222109.1.5","1.13.1"]
["RHP 2_135222109.2.1","RHP",2,"135222109.2.1","2.15.1"]
["RHP 2_135222109.2.2","RHP",2,"135222109.2.2","2.13.1"]
["RHP 2_136367307.1.1","RHP",2,"136367307.1.1","1.12.2"]
["RHP 2_136367307.1.2","RHP",2,"136367307.1.2","1.7.1 "]
["RHP 2_136367307.2.1","RHP",2,"136367307.2.1","2.18.1"]
["RHP 2_136367307.2.4","RHP",2,"136367307.2.4","2.15.1"]
["RHP 2_136367307.2.5","RHP",2,"136367307.2.5","2.13.1"]
["RHP 2_136381405.1.1","RHP",2,"136381405.1.1","1.1.2 "]
["RHP 2_136381405.2.1","RHP",2,"136381405.2.1","2.4.1 "]
["RHP 2_138296208.1.1","RHP",2,"138296208.1.1","1.1.1 "]
["RHP 2_138296208.2.1","RHP",2,"138296208.2.1","2.2.2 "]
["RHP 2_261955689.1.1","RHP",2,"261955689.1.1","1.1.2 "]
["RHP 2_284333601.1.1","RHP",2,"284333601.1.1","1.1.2 "]
["RHP 3_020817501.1.1","RHP",3,"020817501.1.1","1.1.2 "]
["RHP 3_020817501.1.2","RHP",3,"020817501.1.2","1.7.1 "]
["RHP 3_020834001.1.1","RHP",3,"020834001.1.1","1.1.1 "]
["RHP 3_020834001.1.2","RHP",3,"020834001.1.2","1.6.2 "]
["RHP 3_020834001.1.3","RHP",3,"020834001.1.3","1.12.2"]
["RHP 3_020834001.1.4","RHP",3,"020834001.1.4","1.1.2 "]
["RHP 3_020834001.2.1","RHP",3,"020834001.2.1","2.2.5 "]
["RHP 3_081522701.1.1","RHP",3,"081522701.1.1","1.12.2"]
["RHP 3_081522701.1.2","RHP",3,"081522701.1.2","1.13.1"]
["RHP 3_081522701.1.3","RHP",3,"081522701.1.3","1.9.2 "]
["RHP 3_081522701.2.1","RHP",3,"081522701.2.1","2.13.1"]
["RHP 3_082006001.1.1","RHP",3,"082006001.1.1","1.1.1 "]
["RHP 3_093774008.1.1","RHP",3,"093774008.1.1","1.8.9 "]
["RHP 3_093774008.1.2","RHP",3,"093774008.1.2","1.7.3"]
["RHP 3_093774008.1.3","RHP",3,"093774008.1.3","1.8.11"]
["RHP 3_093774008.2.1","RHP",3,"093774008.2.1","2.6.3 "]
["RHP 3_093774008.2.10","RHP",3,"093774008.2.10","2.12.2"]
["RHP 3_093774008.2.2","RHP",3,"093774008.2.2","2.9.1 "]
["RHP 3_093774008.2.3","RHP",3,"093774008.2.3","2.9.1 "]
["RHP 3_093774008.2.4","RHP",3,"093774008.2.4","2.7.1"]
["RHP 3_093774008.2.5","RHP",3,"093774008.2.5","2.6.2"]
["RHP 3_093774008.2.6 updated to 093774008.1.4","RHP",3,"093774008.2.6 updated to 093774008.1.4","1.13.1"]
["RHP 3_093774008.2.7","RHP",3,"093774008.2.7","2.7.4"]
["RHP 3_093774008.2.8","RHP",3,"093774008.2.8","2.13.1"]
["RHP 3_093774008.2.9","RHP",3,"093774008.2.9","2.7.1"]
["RHP 3_094187402.2.1","RHP",3,"094187402.2.1","2.9.1 "]
["RHP 3_096166602.1.1 updated to 096166602.2.2","RHP",3,"096166602.1.1 updated to 096166602.2.2","2.14.1"]
["RHP 3_096166602.2.1","RHP",3,"096166602.2.1","2.15.1"]
[{"$f":"CONCATENATE(B195,\" \",C195,\"_\",D195)","v":"RHP 3_111810101.1.1"},"RHP",3,"111810101.1.1","1.1.2 "]
["RHP 3_111810101.1.10","RHP",3,"111810101.1.10","1.9.2 "]
["RHP 3_111810101.1.2","RHP",3,"111810101.1.2","1.2.1 "]
["RHP 3_111810101.1.3","RHP",3,"111810101.1.3","1.2.2 "]
["RHP 3_111810101.1.4","RHP",3,"111810101.1.4","1.3.1 "]
["RHP 3_111810101.1.5","RHP",3,"111810101.1.5","1.6.2 "]
["RHP 3_111810101.1.6","RHP",3,"111810101.1.6","1.1.1"]
["RHP 3_111810101.1.7","RHP",3,"111810101.1.7","1.9.2 "]
["RHP 3_111810101.1.8","RHP",3,"111810101.1.8","1.10.2"]
["RHP 3_111810101.1.9","RHP",3,"111810101.1.9","1.1.1 "]
["RHP 3_111810101.2.1","RHP",3,"111810101.2.1","2.1.3 "]
["RHP 3_111810101.2.2","RHP",3,"111810101.2.2","2.2.1 "]
["RHP 3_111810101.2.3","RHP",3,"111810101.2.3","2.9.1 "]
["RHP 3_111810101.2.4","RHP",3,"111810101.2.4","2.10.1"]
["RHP 3_111810101.2.5","RHP",3,"111810101.2.5","2.11.1"]
["RHP 3_111810101.2.6","RHP",3,"111810101.2.6","2.12.2"]
["RHP 3_111810101.2.7","RHP",3,"111810101.2.7","2.15.1"]
["RHP 3_111810101.2.8","RHP",3,"111810101.2.8","2.15.1"]
["RHP 3_112672402.2.1","RHP",3,"112672402.2.1","2.7.1 "]
["RHP 3_112672402.2.2","RHP",3,"112672402.2.2","2.7.2 "]
["RHP 3_112672402.2.3","RHP",3,"112672402.2.3","2.7.2 "]
["RHP 3_112672402.2.4","RHP",3,"112672402.2.4","2.7.1 "]
["RHP 3_112672402.2.5","RHP",3,"112672402.2.5","2.7.2 "]
["RHP 3_113180703.1.1","RHP",3,"113180703.1.1","1.12.2"]
["RHP 3_113180703.1.10","RHP",3,"113180703.1.10","1.9.2 "]
["RHP 3_113180703.1.11","RHP",3,"113180703.1.11","1.13.1"]
["RHP 3_113180703.1.12","RHP",3,"113180703.1.12","1.12.2"]
["RHP 3_113180703.1.3","RHP",3,"113180703.1.3","1.9.2 "]
["RHP 3_113180703.1.4","RHP",3,"113180703.1.4","1.12.2"]
["RHP 3_113180703.1.5","RHP",3,"113180703.1.5","1.12.2"]
["RHP 3_113180703.1.6","RHP",3,"113180703.1.6","1.12.2"]
["RHP 3_113180703.1.7","RHP",3,"113180703.1.7","1.12.2"]
["RHP 3_113180703.1.8","RHP",3,"113180703.1.8","1.13.1"]
["RHP 3_113180703.1.9","RHP",3,"113180703.1.9","1.12.2"]
["RHP 3_113180703.2.1","RHP",3,"113180703.2.1","2.15.1"]
["RHP 3_113180703.2.2","RHP",3,"113180703.2.2","2.13.1"]
["RHP 3_113180703.2.3","RHP",3,"113180703.2.3","2.17.1"]
["RHP 3_113180703.2.4","RHP",3,"113180703.2.4","2.13.1"]
["RHP 3_113180703.2.5","RHP",3,"113180703.2.5","2.13.1"]
["RHP 3_113180703.2.7","RHP",3,"113180703.2.7","2.13.1"]
["RHP 3_113180703.2.8","RHP",3,"113180703.2.8","2.13.1"]
["RHP 3_113180703.2.9","RHP",3,"113180703.2.9","2.17.1"]
["RHP 3_127300503.2.1","RHP",3,"127300503.2.1","2.12.1"]
["RHP 3_127300503.2.2","RHP",3,"127300503.2.2","2.2.2 "]
["RHP 3_127303903.1.1","RHP",3,"127303903.1.1","1.3.1 "]
["RHP 3_127303903.1.2","RHP",3,"127303903.1.2","1.2.2 "]
["RHP 3_127303903.1.3","RHP",3,"127303903.1.3","1.9.1 "]
["RHP 3_127303903.2.1","RHP",3,"127303903.2.1","2.4.1 "]
["RHP 3_127303903.2.2","RHP",3,"127303903.2.2","2.9.1 "]
["RHP 3_127303903.2.3","RHP",3,"127303903.2.3","2.6.1 "]
["RHP 3_127303903.2.4","RHP",3,"127303903.2.4","2.6.2"]
["RHP 3_130959304.1.1","RHP",3,"130959304.1.1","1.9.2 "]
["RHP 3_130959304.1.3","RHP",3,"130959304.1.3","1.1.2"]
["RHP 3_130959304.2.1","RHP",3,"130959304.2.1","2.9.1 "]
["RHP 3_131044305.1.1\n(288523801.1.1)\n","RHP",3,"131044305.1.1\n(288523801.1.1)\n","1.1.2 "]
["RHP 3_131045004.2.1","RHP",3,"131045004.2.1","2.4.1 "]
["RHP 3_133355104.1.1","RHP",3,"133355104.1.1","1.1.1 "]
["RHP 3_133355104.1.10","RHP",3,"133355104.1.10","1.12.2"]
["RHP 3_133355104.1.11","RHP",3,"133355104.1.11","1.3.1 "]
["RHP 3_133355104.1.12","RHP",3,"133355104.1.12","1.10.2"]
["RHP 3_133355104.1.13","RHP",3,"133355104.1.13","1.9.2 "]
["RHP 3_133355104.1.14","RHP",3,"133355104.1.14","1.1.1 "]
["RHP 3_133355104.1.15","RHP",3,"133355104.1.15","1.8.6 "]
["RHP 3_133355104.1.16 updated to 133355104.2.8","RHP",3,"133355104.1.16 updated to 133355104.2.8","2.2.1"]
[{"$f":"CONCATENATE(B259,\" \",C259,\"_\",D259)","v":"RHP 3_133355104.1.17"},"RHP",3,"133355104.1.17","1.8.6 "]
["RHP 3_133355104.1.2","RHP",3,"133355104.1.2","1.1.1 "]
["RHP 3_133355104.1.3","RHP",3,"133355104.1.3","1.1.2 "]
["RHP 3_133355104.1.4","RHP",3,"133355104.1.4","1.1.1 "]
["RHP 3_133355104.1.5","RHP",3,"133355104.1.5","1.1.1 "]
["RHP 3_133355104.1.6","RHP",3,"133355104.1.6","1.1.1 "]
["RHP 3_133355104.1.7 updated to 133355104.2.9","RHP",3,"133355104.1.7 updated to 133355104.2.9","2.8.8"]
["RHP 3_133355104.1.8","RHP",3,"133355104.1.8","1.1.2 "]
["RHP 3_133355104.1.9","RHP",3,"133355104.1.9","1.12.2"]
["RHP 3_133355104.2.1","RHP",3,"133355104.2.1","2.5.3"]
["RHP 3_133355104.2.2","RHP",3,"133355104.2.2","2.9.1 "]
["RHP 3_133355104.2.3","RHP",3,"133355104.2.3","2.8.6 "]
["RHP 3_133355104.2.4","RHP",3,"133355104.2.4","2.9.1 "]
["RHP 3_133355104.2.5","RHP",3,"133355104.2.5","2.2.1 "]
["RHP 3_133355104.2.7","RHP",3,"133355104.2.7","2.10.1"]
["RHP 3_135033204.1.1","RHP",3,"135033204.1.1","1.7.1 "]
["RHP 3_135254407.2.1","RHP",3,"135254407.2.1","2.15.1"]
["RHP 3_137805107.1.1","RHP",3,"137805107.1.1","1.1.1 "]
["RHP 3_137805107.1.2","RHP",3,"137805107.1.2","1.13.1"]
["RHP 3_137805107.2.1","RHP",3,"137805107.2.1","2.9.1"]
["RHP 3_137805107.2.2","RHP",3,"137805107.2.2","2.10.1"]
["RHP 3_137909111.1.1","RHP",3,"137909111.1.1","1.1.2"]
["RHP 3_137909111.2.1","RHP",3,"137909111.2.1","2.5.3"]
["RHP 3_137909111.2.2","RHP",3,"137909111.2.2","2.4.1 "]
["RHP 3_137909111.2.3","RHP",3,"137909111.2.3","2.4.3"]
["RHP 3_137949705.2.1","RHP",3,"137949705.2.1","2.17.1"]
["RHP 3_139135109.1.1","RHP",3,"139135109.1.1","1.9.2 "]
["RHP 3_139135109.1.10","RHP",3,"139135109.1.10","1.9.2 "]
["RHP 3_139135109.1.11","RHP",3,"139135109.1.11","1.9.2 "]
["RHP 3_139135109.1.12","RHP",3,"139135109.1.12","1.9.2 "]
["RHP 3_139135109.1.13","RHP",3,"139135109.1.13","1.9.2 "]
["RHP 3_139135109.1.14","RHP",3,"139135109.1.14","1.9.2 "]
["RHP 3_139135109.1.15","RHP",3,"139135109.1.15","1.9.2 "]
["RHP 3_139135109.1.16","RHP",3,"139135109.1.16","1.9.2 "]
["RHP 3_139135109.1.2","RHP",3,"139135109.1.2","1.9.2 "]
["RHP 3_139135109.1.3","RHP",3,"139135109.1.3","1.9.2 "]
["RHP 3_139135109.1.4","RHP",3,"139135109.1.4","1.9.2 "]
["RHP 3_139135109.1.5","RHP",3,"139135109.1.5","1.9.2 "]
["RHP 3_139135109.1.6","RHP",3,"139135109.1.6","1.9.2 "]
["RHP 3_139135109.1.7","RHP",3,"139135109.1.7","1.9.2 "]
["RHP 3_139135109.1.8","RHP",3,"139135109.1.8","1.9.2 "]
["RHP 3_139135109.1.9","RHP",3,"139135109.1.9","1.9.2 "]
["RHP 3_139135109.2.1","RHP",3,"139135109.2.1","2.2.6"]
["RHP 3_140713201.2.1","RHP",3,"140713201.2.1","2.17.1"]
["RHP 3_181706601.2.1","RHP",3,"181706601.2.1","2.17.1"]
["RHP 3_181706601.2.2","RHP",3,"181706601.2.2","2.15.1"]
["RHP 3_212060201.1.1","RHP",3,"212060201.1.1","1.1.2 "]
["RHP 3_212060201.1.2","RHP",3,"212060201.1.2","1.7.1 "]
["RHP 3_212060201.1.3","RHP",3,"212060201.1.3","1.1.1 "]
["RHP 3_212060201.1.4","RHP",3,"212060201.1.4","1.6.1 "]
["RHP 3_212060201.1.5","RHP",3,"212060201.1.5","1.9.2 "]
["RHP 3_212060201.1.6","RHP",3,"212060201.1.6","1.1.2 "]
["RHP 3_212060201.2.1","RHP",3,"212060201.2.1","2.7.1 "]
["RHP 3_212060201.2.2","RHP",3,"212060201.2.2","2.2.2 "]
["RHP 3_212060201.2.3","RHP",3,"212060201.2.3","2.6.2 "]
["RHP 3_296760601.1.1","RHP",3,"296760601.1.1","1.13.1"]
["RHP 3_296760601.1.2","RHP",3,"296760601.1.2","1.1.2 "]
["RHP 3_296760601.2.1","RHP",3,"296760601.2.1","2.9.1 "]
["RHP 3_296760601.2.2","RHP",3,"296760601.2.2","2.13.1"]
["RHP 3_296760601.2.3","RHP",3,"296760601.2.3","2.3.2"]
["RHP 3_296760601.2.4","RHP",3,"296760601.2.4","2.7.1 "]
["RHP 4_020811801.1.1","RHP",4,"020811801.1.1","1.3.1"]
["RHP 4_020811801.1.2","RHP",4,"020811801.1.2","1.7.6"]
["RHP 4_020811801.1.3","RHP",4,"020811801.1.3","1.1.1"]
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["RHP 4_020811801.2.2","RHP",4,"020811801.2.2","2.11.1"]
["RHP 4_020811801.2.3","RHP",4,"020811801.2.3","2.11.2"]
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["RHP 4_020973601.1.1","RHP",4,"020973601.1.1","1.1.2 "]
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["RHP 4_020973601.1.3","RHP",4,"020973601.1.3","1.9.1"]
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["RHP 4_020973601.2.2","RHP",4,"020973601.2.2","2.8.11"]
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["RHP 4_080368601.2.1","RHP",4,"080368601.2.1","2.15.1"]
["RHP 4_094118902.1.1","RHP",4,"094118902.1.1","1.12.2"]
["RHP 4_094118902.1.3","RHP",4,"094118902.1.3","1.2.3"]
["RHP 4_094118902.2.1","RHP",4,"094118902.2.1","2.2.1"]
["RHP 4_094118902.2.2","RHP",4,"094118902.2.2","2.7.4"]
["RHP 4_094222902.1.1","RHP",4,"094222902.1.1","1.1.2"]
["RHP 4_094222902.1.2","RHP",4,"094222902.1.2","1.3.1"]
["RHP 4_094222902.1.3","RHP",4,"094222902.1.3","1.7.6"]
["RHP 4_094222902.2.1","RHP",4,"094222902.2.1","2.11.1"]
["RHP 4_094222902.2.2","RHP",4,"094222902.2.2","2.11.2"]
["RHP 4_094222902.2.3","RHP",4,"094222902.2.3","2.8.11"]
["RHP 4_094222902.2.4","RHP",4,"094222902.2.4","2.19.1"]
["RHP 4_094222902.2.5","RHP",4,"094222902.2.5","2.12.2"]
["RHP 4_094222902.2.6","RHP",4,"094222902.2.6","2.15.1"]
["RHP 4_112673204.1.1","RHP",4,"112673204.1.1","1.1.1"]
["RHP 4_112673204.1.2","RHP",4,"112673204.1.2","1.9.2"]
["RHP 4_121775403.1.1","RHP",4,"121775403.1.1","1.1.2"]
["RHP 4_121775403.1.2","RHP",4,"121775403.1.2","1.3.1"]
["RHP 4_121775403.1.3","RHP",4,"121775403.1.3","1.7.6"]
["RHP 4_121775403.1.4","RHP",4,"121775403.1.4","1.9.1"]
["RHP 4_121775403.1.5","RHP",4,"121775403.1.5","1.13.1"]
["RHP 4_121775403.1.6","RHP",4,"121775403.1.6","1.9.1"]
["RHP 4_121775403.2.1","RHP",4,"121775403.2.1","2.6.1"]
["RHP 4_121775403.2.10","RHP",4,"121775403.2.10","2.12.2"]
["RHP 4_121775403.2.11","RHP",4,"121775403.2.11","2.8.1"]
["RHP 4_121775403.2.2","RHP",4,"121775403.2.2","2.12.1"]
["RHP 4_121775403.2.3 updated to 121775403.1.7","RHP",4,"121775403.2.3 updated to 121775403.1.7","1.2.1"]
["RHP 4_121775403.2.4","RHP",4,"121775403.2.4","2.15.1"]
["RHP 4_121775403.2.5","RHP",4,"121775403.2.5","2.19.1"]
["RHP 4_121775403.2.6","RHP",4,"121775403.2.6","2.1.1"]
["RHP 4_121775403.2.7","RHP",4,"121775403.2.7","2.11.1"]
["RHP 4_121775403.2.8","RHP",4,"121775403.2.8","2.11.2"]
["RHP 4_121775403.2.9","RHP",4,"121775403.2.9","2.8.11"]
["RHP 4_121785303.1.1","RHP",4,"121785303.1.1","1.1.2"]
["RHP 4_121785303.1.3","RHP",4,"121785303.1.3","1.7.2"]
["RHP 4_121808305.1.1","RHP",4,"121808305.1.1","1.9.2"]
["RHP 4_121990904.1.1","RHP",4,"121990904.1.1","1.12.3"]
["RHP 4_121990904.2.1","RHP",4,"121990904.2.1","2.15.1"]
["RHP 4_126844305.2.1","RHP",4,"126844305.2.1","2.9.1"]
["RHP 4_130958505.1.2","RHP",4,"130958505.1.2","1.3.1"]
["RHP 4_130958505.2.1","RHP",4,"130958505.2.1","2.6.3"]
["RHP 4_130958505.2.2","RHP",4,"130958505.2.2","2.7.5"]
["RHP 4_130958505.2.3","RHP",4,"130958505.2.3","2.9.1"]
["RHP 4_132812205.1.1","RHP",4,"132812205.1.1","1.1.2"]
["RHP 4_132812205.1.2","RHP",4,"132812205.1.2","1.8.9"]
["RHP 4_132812205.1.3","RHP",4,"132812205.1.3","1.9.2"]
["RHP 4_132812205.1.4","RHP",4,"132812205.1.4","1.7.1"]
["RHP 4_132812205.1.5","RHP",4,"132812205.1.5","1.9.2"]
["RHP 4_132812205.2.2","RHP",4,"132812205.2.2","2.6.2"]
["RHP 4_132812205.2.3","RHP",4,"132812205.2.3","2.12.2"]
["RHP 4_135233809.1.1","RHP",4,"135233809.1.1","1.1.2"]
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["RHP 4_135254407.1.2","RHP",4,"135254407.1.2","1.7.3"]
["RHP 4_135254407.2.1","RHP",4,"135254407.2.1","2.15.1"]
["RHP 4_136412710.1.1","RHP",4,"136412710.1.1","1.7.1"]
["RHP 4_136436606.1.1","RHP",4,"136436606.1.1","1.3.1"]
["RHP 4_136436606.1.2","RHP",4,"136436606.1.2","1.7.6"]
["RHP 4_136436606.2.1","RHP",4,"136436606.2.1","2.11.1"]
["RHP 4_136436606.2.2","RHP",4,"136436606.2.2","2.11.2"]
["RHP 4_136436606.2.3","RHP",4,"136436606.2.3","2.8.11"]
["RHP 4_136436606.2.4","RHP",4,"136436606.2.4","2.12.2"]
["RHP 4_136436606.2.5","RHP",4,"136436606.2.5","2.19.1"]
["RHP 4_137907508.1.1","RHP",4,"137907508.1.1","1.1.2"]
["RHP 4_137907508.2.1","RHP",4,"137907508.2.1","2.8.1"]
["RHP 4_138305109.2.1","RHP",4,"138305109.2.1","2.15.1"]
["RHP 4_138305109.2.2","RHP",4,"138305109.2.2","2.18.1"]
["RHP 4_138305109.2.3","RHP",4,"138305109.2.3","2.6.1"]
["RHP 4_138305109.2.4","RHP",4,"138305109.2.4","2.13.1"]
["RHP 5_085144601.1.1","RHP",5,"085144601.1.1","1.2.4"]
["RHP 5_085144601.1.2","RHP",5,"085144601.1.2","1.9.1"]
["RHP 5_085144601.1.3","RHP",5,"085144601.1.3","1.2.3"]
["RHP 5_085144601.2.1","RHP",5,"085144601.2.1","2.1.3"]
["RHP 5_085144601.2.2","RHP",5,"085144601.2.2","2.2.1"]
["RHP 5_085144601.2.3","RHP",5,"085144601.2.3","2.9.1"]
["RHP 5_085144601.2.4","RHP",5,"085144601.2.4","2.6.1"]
["RHP 5_121989102.1.1","RHP",5,"121989102.1.1","1.11.2"]
["RHP 5_121989102.1.2","RHP",5,"121989102.1.2","1.14.1"]
["RHP 5_121989102.1.3","RHP",5,"121989102.1.3","1.13.1"]
["RHP 5_121989102.2.1","RHP",5,"121989102.2.1","2.15.1"]
["RHP 5_121989102.2.2","RHP",5,"121989102.2.2","2.13.1"]
["RHP 5_132812205.1.1","RHP",5,"132812205.1.1","1.8.12"]
["RHP 5_132812205.1.2","RHP",5,"132812205.1.2","1.9.2"]
["RHP 5_132812205.2.1","RHP",5,"132812205.2.1","2.6.2"]
["RHP 5_136332705.1.1","RHP",5,"136332705.1.1","1.1.2"]
["RHP 5_136332705.1.2","RHP",5,"136332705.1.2","1.9.2"]
["RHP 5_136332705.2.1","RHP",5,"136332705.2.1","2.8.1"]
["RHP 5_138708601.1.1","RHP",5,"138708601.1.1","1.12.1"]
["RHP 5_138708601.1.2","RHP",5,"138708601.1.2","1.12.1"]
["RHP 5_138708601.1.3 updated to 138708601.2.9","RHP",5,"138708601.1.3 updated to 138708601.2.9","2.13.1"]
["RHP 5_138708601.1.4","RHP",5,"138708601.1.4","1.7.1"]
["RHP 5_138708601.2.1","RHP",5,"138708601.2.1","2.15.1"]
["RHP 5_138708601.2.2","RHP",5,"138708601.2.2","2.13.1"]
["RHP 5_138708601.2.3","RHP",5,"138708601.2.3","2.15.1"]
["RHP 5_138708601.2.4","RHP",5,"138708601.2.4","2.2.5"]
["RHP 5_138708601.2.5","RHP",5,"138708601.2.5","2.18.1"]
["RHP 5_138708601.2.6","RHP",5,"138708601.2.6","2.18.1"]
["RHP 5_138708601.2.7","RHP",5,"138708601.2.7","2.9.1"]
["RHP 5_138708601.2.8","RHP",5,"138708601.2.8","2.9.1"]
["RHP 5_160709501.1.1","RHP",5,"160709501.1.1","1.2.4"]
["RHP 5_160709501.1.2","RHP",5,"160709501.1.2","1.2.4"]
["RHP 5_160709501.1.3","RHP",5,"160709501.1.3","1.2.4"]
["RHP 5_160709501.1.4","RHP",5,"160709501.1.4","1.9.1"]
["RHP 6_020844901.1.1","RHP",6,"020844901.1.1","1.1.2"]
["RHP 6_020844901.2.1","RHP",6,"020844901.2.1","2.1.2"]
["RHP 6_020844901.2.2","RHP",6,"020844901.2.2","2.12.1"]
["RHP 6_020844903.1.1","RHP",6,"020844903.1.1","1.9.2"]
["RHP 6_020844903.1.2","RHP",6,"020844903.1.2","1.1.1"]
["RHP 6_085144601.1.1","RHP",6,"085144601.1.1","1.10.1"]
["RHP 6_085144601.1.11","RHP",6,"085144601.1.11","1.1.1"]
["RHP 6_085144601.1.12","RHP",6,"085144601.1.12","1.8.6"]
["RHP 6_085144601.1.13","RHP",6,"085144601.1.13","1.10.2"]
["RHP 6_085144601.1.15","RHP",6,"085144601.1.15","1.7.1"]
["RHP 6_085144601.1.16","RHP",6,"085144601.1.16","1.7.2"]
["RHP 6_085144601.1.2","RHP",6,"085144601.1.2","1.3.1"]
["RHP 6_085144601.1.20","RHP",6,"085144601.1.20","1.10.1"]
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["RHP 6_085144601.1.3","RHP",6,"085144601.1.3","1.2.3"]
["RHP 6_085144601.1.5","RHP",6,"085144601.1.5","1.3.1"]
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["RHP 6_085144601.1.7","RHP",6,"085144601.1.7","1.9.2"]
["RHP 6_085144601.1.8","RHP",6,"085144601.1.8","1.9.2"]
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["RHP 6_085144601.2.3","RHP",6,"085144601.2.3","2.13.1"]
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["RHP 6_091308902.1.1","RHP",6,"091308902.1.1","1.8.9"]
["RHP 6_091308902.2.1","RHP",6,"091308902.2.1","2.6.1"]
["RHP 6_091308902.2.2","RHP",6,"091308902.2.2","2.7.5"]
["RHP 6_091308902.2.3","RHP",6,"091308902.2.3","2.6.2"]
["RHP 6_091308902.2.4","RHP",6,"091308902.2.4","2.7.1"]
["RHP 6_091308902.2.5","RHP",6,"091308902.2.5","2.7.5"]
["RHP 6_092414401.1.1","RHP",6,"092414401.1.1","1.2.2"]
["RHP 6_092414401.2.1","RHP",6,"092414401.2.1","2.2.2"]
["RHP 6_092414401.2.2","RHP",6,"092414401.2.2","2.1.1"]
["RHP 6_094154402.1.1","RHP",6,"094154402.1.1","1.7.1"]
["RHP 6_094154402.1.2","RHP",6,"094154402.1.2","1.1.1"]
["RHP 6_094154402.2.1","RHP",6,"094154402.2.1","2.4.2"]
["RHP 6_094154402.2.2","RHP",6,"094154402.2.2","2.8.11"]
["RHP 6_112676501.2.1","RHP",6,"112676501.2.1","2.1.1"]
["RHP 6_112676501.2.2","RHP",6,"112676501.2.2","2.8.1"]
["RHP 6_112676501.2.3","RHP",6,"112676501.2.3","2.9.1"]
["RHP 6_112688002.1.1","RHP",6,"112688002.1.1","1.1.2"]
["RHP 6_112688002.1.2","RHP",6,"112688002.1.2","1.7.1"]
["RHP 6_112690603.1.1","RHP",6,"112690603.1.1","1.9.1"]
["RHP 6_112690603.1.2","RHP",6,"112690603.1.2","1.6.2"]
["RHP 6_112742503.1.1","RHP",6,"112742503.1.1","1.9.2"]
["RHP 6_119877204.1.1","RHP",6,"119877204.1.1","1.1.1"]
["RHP 6_119877204.1.2","RHP",6,"119877204.1.2","1.9.2"]
["RHP 6_119877204.1.3","RHP",6,"119877204.1.3","1.7.1"]
["RHP 6_121782003.1.1","RHP",6,"121782003.1.1","1.2.2"]
["RHP 6_121782003.2.1","RHP",6,"121782003.2.1","2.10.1"]
["RHP 6_121990904.1.1","RHP",6,"121990904.1.1","1.13.1"]
["RHP 6_121990904.1.2","RHP",6,"121990904.1.2","1.12.3"]
["RHP 6_126844305.1.1","RHP",6,"126844305.1.1","1.13.1"]
["RHP 6_126844305.1.2","RHP",6,"126844305.1.2","1.12.2"]
["RHP 6_126844305.2.1","RHP",6,"126844305.2.1","2.9.1"]
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["RHP 12_127373205.1.1","RHP",12,"127373205.1.1","1.12.2"]
["RHP 12_127373205.1.2","RHP",12,"127373205.1.2","1.9.2"]
["RHP 12_127374005.1.1","RHP",12,"127374005.1.1","1.11.2"]
["RHP 12_127374005.2.1","RHP",12,"127374005.2.1","2.15.1"]
["RHP 12_127374005.2.2","RHP",12,"127374005.2.2","2.18.1"]
["RHP 12_127378105.1.1","RHP",12,"127378105.1.1","1.13.1"]
["RHP 12_127378105.2.1","RHP",12,"127378105.2.1","2.13.1"]
["RHP 12_127378105.2.2","RHP",12,"127378105.2.2","2.15.1"]
["RHP 12_127378105.2.3","RHP",12,"127378105.2.3","2.18.1"]
["RHP 12_130618504.1.1","RHP",12,"130618504.1.1","1.1.2"]
["RHP 12_130618504.2.2","RHP",12,"130618504.2.2","2.9.1"]
["RHP 12_130725806.1.1","RHP",12,"130725806.1.1","1.7.1"]
["RHP 12_130725806.1.2","RHP",12,"130725806.1.2","1.13.1"]
["RHP 12_130725806.2.1","RHP",12,"130725806.2.1","2.15.1"]
["RHP 12_130826407.1.1","RHP",12,"130826407.1.1","1.1.2"]
["RHP 12_130826407.1.3","RHP",12,"130826407.1.3","1.8.6"]
["RHP 12_130877708.1.1","RHP",12,"130877708.1.1","1.1.1"]
["RHP 12_130877708.2.1","RHP",12,"130877708.2.1","2.6.2"]
["RHP 12_133250406.1.1","RHP",12,"133250406.1.1","1.6.2"]
["RHP 12_133250406.2.1","RHP",12,"133250406.2.1","2.1.3"]
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["RHP 12_133544006.1.2","RHP",12,"133544006.1.2","1.12.2"]
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["RHP 12_137999206.2.2 updated to 137999206.1.4","RHP",12,"137999206.2.2 updated to 137999206.1.4","1.1.1"]
["RHP 12_137999206.2.3","RHP",12,"137999206.2.3","2.11.2"]
["RHP 12_137999206.2.4","RHP",12,"137999206.2.4","2.10.1"]
["RHP 12_139461107.2.1","RHP",12,"139461107.2.1","2.8.11"]
["RHP 12_139461107.2.2","RHP",12,"139461107.2.2","2.9.1"]
["RHP 12_139461107.2.3","RHP",12,"139461107.2.3","2.17.1"]
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["RHP 12_178848102.1.1","RHP",12,"178848102.1.1","1.1.2"]
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["RHP 12_189947801.1.2","RHP",12,"189947801.1.2","1.7.2"]
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["RHP 12_197063401.1.1","RHP",12,"197063401.1.1","1.3.1"]
["RHP 12_197063401.1.2","RHP",12,"197063401.1.2","1.1.2"]
["RHP 12_197063401.1.3","RHP",12,"197063401.1.3","1.1.2"]
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["RHP 13_020989201.1.1","RHP",13,"020989201.1.1","1.1.2 "]
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["RHP 13_121806703.1.2","RHP",13,"121806703.1.2","1.1.1 "]
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["RHP 13_130616905.2.3","RHP",13,"130616905.2.3","2.2.1 "]
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["RHP 13_133339505.1.1","RHP",13,"133339505.1.1","1.11.1"]
["RHP 13_133340307.2.1","RHP",13,"133340307.2.1","2.13.1"]
["RHP 13_133340307.2.2","RHP",13,"133340307.2.2","2.13.1"]
["RHP 13_133340307.2.3","RHP",13,"133340307.2.3","2.13.1"]
["RHP 13_133340307.2.4","RHP",13,"133340307.2.4","2.18.1"]
["RHP 13_136144610.1.2","RHP",13,"136144610.1.2","1.1.2 "]
["RHP 13_136144610.2.2","RHP",13,"136144610.2.2","2.1.3 "]
["RHP 13_137226005.1.1","RHP",13,"137226005.1.1","1.1.1 "]
["RHP 13_137226005.1.4","RHP",13,"137226005.1.4","1.3.1 "]
["RHP 13_137226005.1.5","RHP",13,"137226005.1.5","1.1.1"]
["RHP 13_137226005.2.1","RHP",13,"137226005.2.1","2.4.1"]
["RHP 13_137226005.2.2","RHP",13,"137226005.2.2","2.8.1 "]
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["RHP 14_112711003.1.5","RHP",14,"112711003.1.5","1.9.2 "]
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["RHP 14_136145310.2.1","RHP",14,"136145310.2.1","2.2.1 "]
["RHP 14_138364812.1.1","RHP",14,"138364812.1.1","1.9.2 "]
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["RHP 14_176354201.2.1","RHP",14,"176354201.2.1","2.1.3"]
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["RHP 15_065086301.1.2","RHP",15,"065086301.1.2","1.5.3 "]
["RHP 15_065086301.1.3","RHP",15,"065086301.1.3","1.8.7 "]
["RHP 15_065086301.1.5","RHP",15,"065086301.1.5","1.5.2 "]
["RHP 15_065086301.2.1","RHP",15,"065086301.2.1","2.7.1"]
["RHP 15_084597603.1.1","RHP",15,"084597603.1.1","1.9.3 "]
["RHP 15_084597603.1.2","RHP",15,"084597603.1.2","1.3.1 "]
["RHP 15_084597603.1.3","RHP",15,"084597603.1.3","1.9.1"]
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["RHP 15_084597603.1.5","RHP",15,"084597603.1.5","1.9.2 "]
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["RHP 15_094109802.1.3","RHP",15,"094109802.1.3","1.3.1 "]
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["RHP 15_094109802.2.3","RHP",15,"094109802.2.3","2.8.1"]
["RHP 15_094109802.2.4","RHP",15,"094109802.2.4","2.2.2 "]
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["RHP 15_127376505.1.3","RHP",15,"127376505.1.3","1.13.1"]
["RHP 15_127376505.2.1","RHP",15,"127376505.2.1","2.13.1"]
["RHP 15_127376505.2.2","RHP",15,"127376505.2.2","2.13.1"]
["RHP 15_130601104.1.1","RHP",15,"130601104.1.1","1.1.2 "]
["RHP 15_130601104.1.2","RHP",15,"130601104.1.2","1.4.4 "]
["RHP 15_130601104.1.3","RHP",15,"130601104.1.3","1.9.1 "]
["RHP 15_130601104.2.1","RHP",15,"130601104.2.1","2.12.2"]
["RHP 15_138951211.1.1","RHP",15,"138951211.1.1","1.9.1 "]
["RHP 15_138951211.1.2","RHP",15,"138951211.1.2","1.10.2"]
["RHP 15_138951211.1.3","RHP",15,"138951211.1.3","1.1.1 "]
["RHP 15_138951211.1.4","RHP",15,"138951211.1.4","1.1.2 "]
["RHP 15_138951211.1.5","RHP",15,"138951211.1.5","1.1.2 "]
["RHP 15_138951211.1.6","RHP",15,"138951211.1.6","1.2.3"]
["RHP 15_138951211.1.8","RHP",15,"138951211.1.8","1.9.3 "]
["RHP 15_138951211.1.9","RHP",15,"138951211.1.9","1.4.1"]
["RHP 15_138951211.2.1","RHP",15,"138951211.2.1","2.6.2"]
["RHP 15_138951211.2.2","RHP",15,"138951211.2.2","2.7.6 "]
["RHP 15_138951211.2.3","RHP",15,"138951211.2.3","2.9.1 "]
["RHP 15_138951211.2.4","RHP",15,"138951211.2.4","2.1.1 "]
["RHP 15_138951211.2.5","RHP",15,"138951211.2.5","2.2.1 "]
["RHP 15_138951211.2.6","RHP",15,"138951211.2.6","2.11.2"]
["RHP 15_138951211.2.7","RHP",15,"138951211.2.7","2.10.1"]
["RHP 15_138951211.2.8","RHP",15,"138951211.2.8","2.12.2"]
["RHP 15_138951211.2.9","RHP",15,"138951211.2.9","2.8.1 "]
["RHP 15_196829901.1.1","RHP",15,"196829901.1.1","1.1.2 "]
["RHP 15_196829901.1.2","RHP",15,"196829901.1.2","1.4.4 "]
["RHP 15_196829901.1.3","RHP",15,"196829901.1.3","1.9.1 "]
["RHP 15_196829901.2.1","RHP",15,"196829901.2.1","2.12.2"]
["RHP 15_291854201.2.1","RHP",15,"291854201.2.1","2.8.1"]
["RHP 16_081771001.1.1","RHP",16,"081771001.1.1","1.11.2"]
["RHP 16_081771001.1.2","RHP",16,"081771001.1.2","1.13.1"]
["RHP 16_081771001.1.3","RHP",16,"081771001.1.3","1.10.2"]
["RHP 16_084859002.1.1","RHP",16,"084859002.1.1","1.12.2"]
["RHP 16_084859002.2.1","RHP",16,"084859002.2.1","2.15.1"]
["RHP 16_084859002.2.2","RHP",16,"084859002.2.2","2.13.1"]
["RHP 16_084859002.2.3","RHP",16,"084859002.2.3","2.18.1"]
["RHP 16_084859002.2.4","RHP",16,"084859002.2.4","2.13.1"]
["RHP 16_084859002.2.5","RHP",16,"084859002.2.5","2.2.5"]
["RHP 16_084859002.2.6","RHP",16,"084859002.2.6","2.13.1"]
["RHP 16_084859002.2.7","RHP",16,"084859002.2.7","2.13.1"]
["RHP 16_111829102.1.1","RHP",16,"111829102.1.1","1.7.1"]
["RHP 16_121792903.1.3","RHP",16,"121792903.1.3","1.1.2"]
["RHP 16_121792903.1.4","RHP",16,"121792903.1.4","1.7.1"]
["RHP 16_121792903.2.10","RHP",16,"121792903.2.10","2.2.2"]
["RHP 16_121792903.2.6","RHP",16,"121792903.2.6","2.2.2"]
["RHP 16_121792903.2.7","RHP",16,"121792903.2.7","2.2.1"]
["RHP 16_121792903.2.8","RHP",16,"121792903.2.8","2.12.1"]
["RHP 16_121792903.2.9","RHP",16,"121792903.2.9","2.10.1"]
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["RHP 16_134772611.1.4","RHP",16,"134772611.1.4","1.1.2"]
["RHP 16_134772611.1.5","RHP",16,"134772611.1.5","1.9.2"]
["RHP 16_134772611.2.4","RHP",16,"134772611.2.4","2.10.1"]
["RHP 16_134772611.2.5","RHP",16,"134772611.2.5","2.1.3"]
["RHP 16_134772611.2.6","RHP",16,"134772611.2.6","2.6.3"]
["RHP 16_134772611.2.7","RHP",16,"134772611.2.7","2.7.5"]
["RHP 16_137075109.1.4","RHP",16,"137075109.1.4","1.1.2"]
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["RHP 16_137075109.2.1","RHP",16,"137075109.2.1","2.11.1"]
["RHP 16_138962907.1.1","RHP",16,"138962907.1.1","1.9.2"]
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