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Deaconess Care Integration: Quality Performance Results

Measure number Performance measure 2012 Performance Summary Statistics
ACO performance rate Mean performance rate for all ACOs
ACO #1 Getting Timely Care, Appointments, and Information 88.16 81.69
ACO #2 How Well Your Doctors Communicate 93.89 92.84
ACO #3 Patients' Rating of Doctor 92.49 91.86
ACO #4 Access to Specialists 84.27 85.11
ACO #5 Health Promotion and Education 53.28 56.61
ACO #6 Shared Decision Making 71.68 73.99
ACO #7 Health Status/Functional Status 68.41 70.35
ACO #8 Risk Standardized, All Condition Readmissions 15.59 15.42
ACO #9 ASC Admissions: COPD or Asthma in Older Adults 1.32 1.13
ACO #10 ASC Admission: Heart Failure 1.4 1.09
ACO #11 Percent of Primary Care Providers who Qualified for EHR Incentive Payment 0 25.7
ACO #12 Medication Reconciliation 95.91 72.37
ACO #13 Falls: Screening for Fall Risk 36.28 28.27
ACO #14 Influenza Immunization 69.16 50.58
ACO #15 Pneumococcal Vaccination 80.18 48.62
ACO #16 Adult Weight Screening and Follow-up 65.47 53.91
ACO #17 Tobacco Use Assessment and Cessation Intervention 92.09 80.12
ACO #18 Depression Screening 2.75 22.48
ACO #19 Colorectal Cancer Screening 48.8 50.21
ACO #20 Mammography Screening 70.8 62.23
ACO #21 Proportion of Adults who had blood pressure screened in past 2 years 87.7 71.56
ACO #23- 26 Beneficiaries with diabetes who met of all the following criteria: Hemoglobin A1c Control (HbA1c) (<8 percent), Low Density Lipoprotein (LDL) (< 100 mg/dL), Blood Pressure (BP) < 140/90, Tobacco Non-Use, Aspirin Use 26.7 22.78
ACO #27 Percent of beneficiaries with diabetes whose HbA1c in poor control (>9 percent) 11.65 25.94
ACO #28 Percent of beneficiaries with hypertension whose BP < 140/90 64.25 63.22
ACO #29 Percent of beneficiaries with IVD with complete lipid profile and LDL control < 100mg/dl 54.26 52.02
ACO #30 Percent of beneficiaries who use Aspirin or other antithrombotic 87.83 72.6
ACO #31 Beta-Blocker Therapy for LVSD 88.46 79.6
ACO #32- 33 Percent of beneficiaries with CAD who met all of the following criteria: Drug Therapy for Lowering LDL-Cholesterol, (ACE) Inhibitor or (ARB) Therapy for Patients with CAD and Diabetes and/or (LVSD) 60.44 61.69
 
Measure number Performance measure 2013 Performance Summary Statistics
ACO performance rate Mean performance rate for all ACOs
ACO #1 Getting Timely Care, Appointments, and Information (ACO-1) 86.97 81.48
ACO #2 How Well Your Doctors Communicate (ACO-2) 93.59 92.96
ACO #3 Patients' Rating of Doctor (ACO-3) 92.46 92.06
ACO #4 Access to Specialists (ACO-4) 84.67 85.12
ACO #5 Health Promotion and Education (ACO-5) 56.61 58.38
ACO #6 Shared Decision Making (ACO-6) 71.54 74.53
ACO #7 Health Status/Functional Status (ACO-7) 69.89 71.12
ACO #8 Risk Standardized, All Condition Readmissions (ACO-8) 14.33 14.9
ACO #9 ASC Admissions: COPD or Asthma in Older Adults (ACO-9) 1.3 1.17
ACO #10 ASC Admission: Heart Failure (ACO-10) 1.37 1.2
ACO #11 Percent of Primary Care Providers who Qualified for EHR Incentive Payment (ACO-11) 90.41 66.21
ACO #12 Medication Reconciliation (ACO-12) 95.38 73.56
ACO #13 Falls: Screening for Fall Risk (ACO-13) 59.95 39.57
ACO #14 Influenza Immunization (ACO-14) 74.33 56.93
ACO #15 Pneumococcal Vaccination (ACO-15) 81.1 54.76
ACO #16 Adult Weight Screening and Follow-up (ACO-16) 63.92 61.61
ACO #17 Tobacco Use Assessment and Cessation Intervention (ACO-17) 92 84.01
ACO #18 Depression Screening (ACO-18) 48.39 31.19
ACO #19 Colorectal Cancer Screening (ACO-19) 52.17 59.3
ACO #20 Mammography Screening (ACO-20) 64.56 62.05
ACO #21 Proportion of Adults who had blood pressure screened in past 2 years (ACO-21) 59.15 74.25
ACO #23- 26 Beneficiaries with diabetes who met of all the following criteria: Hemoglobin A1c Control (HbA1c) (<8 percent), Low Density Lipoprotein (LDL) (< 100 mg/dL), Blood Pressure (BP) < 140/90, Tobacco Non-Use, Aspirin Use 34.14 22.21
ACO #27 Percent of beneficiaries with diabetes whose HbA1c in poor control (>9 percent) (ACO-27) 10.65 22.11
ACO #28 Percent of beneficiaries with hypertension whose BP < 140/90 (ACO-28) 64.48 67.79
ACO #29 Percent of beneficiaries with IVD with complete lipid profile and LDL control < 100mg/dl (ACO-29) 60.39 55.44
ACO #30 Percent of beneficiaries who use Aspirin or other antithrombotic (ACO-30) 80.43 76.35
ACO #31 Beta-Blocker Therapy for LVSD (ACO-31) 87.21 79.82
ACO #32- 33 Percent of beneficiaries with CAD who met all of the following criteria: Drug Therapy for Lowering LDL-Cholesterol, (ACE) Inhibitor or (ARB) Therapy for Patients with CAD and Diabetes and/or (LVSD) 65.45 62.78
 
 
 
Measure number Performance measure 2014 Performance Summary Statistics
ACO performance rate Mean performance rate for all ACOs
ACO #1 Getting Timely Care, Appointments, and Information (ACO-1) 83.16 80.13
ACO #2 How Well Your Doctors Communicate (ACO-2) 91.3 92.39
ACO #3 Patients' Rating of Doctor (ACO-3) 91.4 91.58
ACO #4 Access to Specialists (ACO-4) 85.97 83.97
ACO #5 Health Promotion and Education (ACO-5) 58.68 58.29
ACO #6 Shared Decision Making (ACO-6) 72.36 74.6
ACO #7 Health Status/Functional Status (ACO-7) 69.52 71.1
ACO #8 Risk Standardized, All Condition Readmissions (ACO-8) 15.44 15.15
ACO #9 ASC Admissions: COPD or Asthma in Older Adults (ACO-9) 1.38 1.08
ACO #10 ASC Admission: Heart Failure (ACO-10) 1.47 1.19
ACO #11 Percent of Primary Care Providers who Qualified for EHR Incentive Payment (ACO-11) 98.61 76.71
ACO #12 Medication Reconciliation (ACO-12) 76.66 82.61
ACO #13 Falls: Screening for Fall Risk (ACO-13) 81.27 45.6
ACO #14 Influenza Immunization (ACO-14) 74.15 57.51
ACO #15 Pneumococcal Vaccination (ACO-15) 83.41 55.03
ACO #16 Adult Weight Screening and Follow-up (ACO-16) 47.45 66.75
ACO #17 Tobacco Use Assessment and Cessation Intervention (ACO-17) 86.41 86.79
ACO #18 Depression Screening (ACO-18) 61.2 39.27
ACO #19 Colorectal Cancer Screening (ACO-19) 59.37 56.14
ACO #20 Mammography Screening (ACO-20) 71.05 61.41
ACO #21 Proportion of Adults who had blood pressure screened in past 2 years (ACO-21) 37.83 60.24
ACO #23- 26 Beneficiaries with diabetes who met of all the following criteria: Hemoglobin A1c Control (HbA1c) (<8 percent), Low Density Lipoprotein (LDL) (< 100mg/dL), Blood Pressure (BP) < 140/90, Tobacco Non-Use, Aspirin Use 32.12 25.41
ACO #27 Percent of beneficiaries with diabetes whose HbA1c in poor control (>9 percent) (ACO-27) 11.92 20.35
ACO #28 Percent of beneficiaries with hypertension whose BP < 140/90 (ACO-28) 69.6 68.02
ACO #29 Percent of beneficiaries with IVD with complete lipid profile and LDL control < 100mg/dl (ACO-29) 61.63 57.29
ACO #30 Percent of beneficiaries who use Aspirin or other antithrombotic (ACO-30) 91.13 80.79
ACO #31 Beta-Blocker Therapy for LVSD (ACO-31) 92.81 82.71
ACO #32- 33 Percent of beneficiaries with CAD who met all of the following criteria: Drug Therapy for Lowering LDL-Cholesterol, ACE Inhibitor or ARB Therapy for Patients with CAD and Diabetes and/or LVSD) 75.6 66.9
 
Measure number Measure Name 2015 reporting period  
ACO Mean performance rate (SSP- ACOs)  
performance rate  
ACO-1 CAHPS: Getting Timley Care, Appointments, and Information 86.64 80.61   
ACO-2 CAHPS: How Well Your Providers Communicate 92.81  92.65  
ACO-3 CAHPS: Patients' Rating of Provider 91.9  91.94  
ACO-4 CAHPS: Access to Specialists 82.89  83.61  
ACO-5 CAHPS: Health Promotion and Education 53.16  59.06  
ACO-6 CAHPS: Shared Decision Making 72.1  75.17  
ACO-7 CAHPS: Health Status/Functional Status 71.88  72.30  
ACO-34 CAHPS: Stewardship of Patient Resources* 26.04  26.87  
ACO-8 Risk Standardized, All Condition Readmission 15.18 14.86  
ACO-35 Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM)* Readmission 17.05 18.07   
ACO-36 All-Cause Unplanned Admissions for Patients with Diabetes* 71.72 54.60   
ACO-37 All-Cause Unplanned Admissions for Patients with Heart Failure* 104.26 76.96   
ACO-38 All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions 82.68 62.92   
ACO-9 Ambulatory Sensitive Condition Admissions: Chronic Obstructive Pulmonary Disease or Asthma in Older Adults (AHRQ Prevention Quality Indicator (PQI) #5 1.42 1.11   
ACO-10 Ambulatory Sensitive Conditions Admission: Heart Failure (AHRQ Prevention Quality Indicator (PQI) #8 1.38 1.04   
ACO-11 Percent of Primary Care Physicians who Successfully Meet Meaningful Use Requirements 100% 76.22%   
ACO-39 Documentation of Current Medications in the Medical Record* 22.81% 84.07%   
ACO-13 Falls: Screening for Future Fall Risk 78.31% 56.46%   
ACO-14 Preventive Care and Screening: Influenza Immunization 73.29% 62.03%   
ACO-15 Pneumonia Vaccination Status for Older Adults 82.49% 63.73%   
ACO-16 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up Plan 78.00%  71.15%  
ACO-17 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 91.16% 90.16%   
ACO-18 Preventive Care and Screening: Screening for Clinical Depression and Follow-up 67.05% 45.25%   
ACO-19 Colorectal Cancer Screening 58.06% 60.06%   
ACO-20 Breast Cancer Screening 78.80% 65.67%   
ACO-21 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 36.40% 70.04%   
ACO-40 Depression Remission at Tweleve Months* N/A N/A  
ACO-27 Diabetes Mellitus: Hemoglobin A1c Poor Control 10.89% 20.38%   
ACO-41 Diabetes: Eye Exam* 40.86% 41.05%   
ACO-28 Hypertension: Controlling High Blood Pressure 68.13% 69.62%   
ACO-30 Ischemic Vascular Disease: Use of Aspirin or Another Antithrombotic 75.81% 83.82%   
ACO-31 Heart Failure: Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) 85.79% 87.22%   
ACO-33 Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy = for patients with CAD and Diabetes or Left Ventricular Systolic Dysfunction (LVEF<40%) 75.00% 77.73%   
CAHPS= Consumer Assessment of Healthcare Providers and Systems, PQI= Prevention Quality Indicator, LVSD= left ventricular systolic dysfunction, ACE= angiotensin-converting enzyme, ARB= angiotensin receptor blocker, CAD= coronary artery disease
*= Measure required beginning Reporting Year 2015.
N/A= Reporting on the depression remission measure is not required for 2015, as indicated by N/A
 
 
 
 
 
 
Measure number Performance measure 2016 Performance Summary Statistics
ACO performance rate Mean Performance Rate (Next Generation Model ACOs)
ACO-1 CAHPS: Getting Timley Care, Appointments, and Information 84.81 81.91
ACO-2 CAHPS: How Well Your Providers Communicate 93.79 93.15
ACO-3 CAHPS: Patients' Rating of Provider 93.72 92.56
ACO-4 CAHPS: Access to Specialists 82.29 83.33
ACO-5 CAHPS: Health Promotion and Education 57.29 61.09
ACO-6 CAHPS: Shared Decision Making 77.54 76.41
ACO-7 CAHPS: Health Status/Functional Status 72.37 73.78
ACO-34 CAHPS: Stewardship of Patient Resources* 33.27 26.14
ACO-8 Risk Standardized, All Condition Readmissions 15.17 14.75
ACO-35 Skilled Nursing Facility 30-Day All-Cause Readmission Measure (SNFRM)* Readmission 18.15 18.56
ACO-36 All-Cause Unplanned Admissions for Patients with Diabetes* 67.43 53.05
ACO-37 All-Cause Unplanned Admissions for Patients with Heart Failure* 89.04 75.78
ACO-38 All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions 71.17 60.74
ACO-9 Ambulatory Sensitive Condition Admissions: Chronic Obstructive Pulmonary Disease or Asthma in Older Adults (AHRQ Prevention Quality Indicator (PQI) #5 11.41 8.79
ACO-10 Ambulatory Sensitive Conditions Admission: Heart Failure (AHRQ Prevention Quality Indicator (PQI) #8 20.28 14.79
ACO-39 Documentation of Current Medications in the Medical Record* 32.96% 77.74%
ACO-13 Falls: Screening for Future Fall Risk 81.34% 67.45%
ACO-14 Preventive Care and Screening: Influenza Immunization 75.21% 72.70%
ACO-15 Pneumonia Vaccination Status for Older Adults 67.70% 75.18%
ACO-16 Preventive Care and Screening: Body Mass Index (BMI) Screening and Follow-up Plan 69.96% 70.21%
ACO-17 Preventive Care and Screening: Tobacco Use: Screening and Cessation Intervention 80.76% 92.96%
ACO-18 Preventive Care and Screening: Screening for Clinical Depression and Follow-up 63.46% 56.92%
ACO-19 Colorectal Cancer Screening 58.59% 65.75%
ACO-20 Breast Cancer Screening 71.09% 72.92%
ACO-21 Preventive Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 72.55% 70.22%
ACO-42 Statin therapy for the Prevention and Treatment of Cardiovascular Disease 73.91% 81.31%
ACO-40 Depression Remission at Twelve Months 10.71% 5.99%
ACO-27 Diabetes Mellitus: Hemoglobin A1c Poor Control 14.19% 19.49%
ACO-41 Diabetes: Eye Exam 39.79% 49.58%
ACO-28 Hypertension (HTN): Controlling High Blood Pressure 67.63% 73.95%
ACO-30 Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 84.19% 86.42%
ACO-31 Heart Failure (HF): Beta-Blocker Therapy for Left Ventricular Systolic Dysfunction (LVSD) 83.52% 88.24%
ACO-33 Angiotensin-Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy- for patients with CAD and Diabetes or Left Ventricular Systolic Dysfunction (LVEF<40%) 79.1% 79.71%
CAHPS= Consumer Assessment of Healthcare Providers and Systems, PQI= Prevention Quality Indicator, LVSD= left ventricular systolic dysfunction, ACE= angiotensin-converting enzyme, ARB= angiotensin receptor blocker, CAD= coronary artery disease  
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