Measure Information Form

Measure Set: Advanced Certification Heart Failure (ACHF)

Set Measure ID: ACHF-02

Performance Measure Name: Post-Discharge Appointment for Heart Failure Patients

Description: Patients for whom a follow-up appointment for an office or home health visit for management of heart failure was scheduled within 7 days post-discharge and documented including location, date, and time.

Rationale: Care coordination is important for all patients, but especially for vulnerable populations, such as patients with heart failure and other chronic diseases. Today, the average Medicare patient sees two primary care and five specialists per year (NQF, 2010). For patients with multiple chronic conditions, the number of healthcare providers involved in the care of the patient is even higher.

The exchange of information from one healthcare provider to another should smooth the transition of care from the inpatient to outpatient setting. According to Bell and colleagues (2008), the separation of hospital and ambulatory care may result in significant care discontinuities after discharge. Therefore, it is paramount that discussions between providers summarize the patient's history and communicate the plan for follow-up care after discharge in order to be effective. When done well, this exchange of information can avoid conflicting plans of care; overuse, underuse, and misuse of medications, tests and therapies; reduce costs and potentially adverse events.

The Joint Commission's 2017 Disease-Specific Care Advanced Certification Heart Failure standards require: “The program [to provide] care coordination services across inpatient and outpatient settings.” Scheduling of the initial follow-up appointment with the primary care provider is a first-step to ensuring continuity of care. In addition, standards require that care, treatment, and services are provided in a planned and timely manner, which includes the arrangement of a follow-up appointment with a health care provider to occur within seven days after discharge.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Patients for whom a follow-up appointment for an office or home health visit for management of heart failure was scheduled within 7 days post-discharge and documented including location, date, and time.

Included Populations: Not applicable
Excluded Populations: None
Data Elements:

Post-Discharge Appointment Scheduled Within 7 Days

Denominator Statement: All heart failure patients discharged from a hospital inpatient setting to home or home care.

Included Populations:

Discharges with ICD-10-CM Principal Diagnosis Code for HF as defined in Appendix A, Table 2.1, and

A discharge to home, home care, or court/law enforcement

Excluded Populations:

Patients who had a left ventricular assistive device (LVAD) or heart transplant procedure during hospital stay (ICD-10-PCS procedure code for LVAD and heart transplant as defined in Appendix A, Table 2.2)

Patients less than 18 years of age

Patient who have a Length of Stay greater than 120 days

Patients with Comfort Measures Only documented

Patients enrolled in a Clinical Trial

Patients discharged to locations other than home, home care, or law enforcement

Patients with a documented Reason for No Post-Discharge Appointment Within 7 Days

Patients who left against medical advice (AMA)

Data Elements:

Admission Date

Birthdate

Clinical Trial

Comfort Measures Only

Discharge Date

Discharge Disposition

ICD-10-CM Principal Diagnosis Code

ICD-10-PCS Other Procedure Codes

ICD-10-PCS Principal Procedure Code

ICD-10-PCS Principal Procedure Date

Reason for No Post-Discharge Appointment Within 7 Days

Risk Adjustment: No.

Data Collection Approach: Retrospective data sources for required data elements include administrative data and medical records.

Data Accuracy: Variation may exist in the assignment of ICD-10 codes; therefore, coding practices may require evaluation to ensure consistency.

Measure Analysis Suggestions: None

Sampling: Yes. Please refer to the measure set specific sampling requirements and for additional information see the Population and Sampling Specifications section.

Data Reported As: Aggregate rate generated from count data reported as a proportion.

Selected References:

American College of Cardiology Foundation, American Heart Association, Physician Consortium for Performance Improvement® (PCPI). Heart Failure Performance Measurement Set. Jan. 2011; 47-56.
American Heart Association. Get With The Guidelines® Outpatient Fact Sheet. 2010.
Hunt SA, Abraham WT, Chin MH, Felman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW. 2009 Focused update incorporated Into the ACC/AHA 2005 guidelines for the diagnosis and management of heart failure in adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. Circulation. 2009;119(14):e391-e479.
Lindenfeld J, Albert NM, Boehmer JP, Collins SP, Ezekowitz JA, Givertz MM, Klapholz M, MoserDK, Rogers JG, Starling RC, Stevenson WG, Tang WHW, Teerlink JR, Walsh MN. Executive Summary: HFSA 2010 Comphrensive Heart Failure Practice Guideline. J Card Fail 2010;16:475-539.
The Joint Commission. The Joint Commission's 2017 Comprehensive Certification Manual for Disease-Specific Care: Advanced Certification in Heart Failure Addendum. Oakbrook Terrace, IL: Author. 2017.
Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE Jr, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJV, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WHW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA guideline for the management of heart failure: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. Circulation. 2013;128:e240–e327.

Measure Algorithm:

Measure Information Form ACHF-02

Specifications Manual for Joint Commission National Quality Measures (v2018B1)
Discharges 01-01-19 (1Q19) through 06-30-19 (2Q19)