Specifications Manual for Joint Commission National Quality Measures (v2018B1)

Release Notes:
Measure Information Form
Version 2018B1


Measure Information Form

Measure Set: Advanced Certification Heart Failure (ACHF)

Set Measure ID: ACHF-06

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

Description: Patients who receive a re-evaluation for symptoms worsening and treatment compliance by a program team member within 72 hours after inpatient discharge.

Rationale: Today, hospitals and providers in the United States are challenged to provide high-quality, cost-effective healthcare. Preventing readmissions to the hospital is one opportunity to control costs and deliver quality care. According to Hospital Compare (2010), the national 30-day readmission rate for heart failure is 24.7%. Jha and colleagues (2009) have concluded that data collection for discharge planning and instruction measures has not reduced unnecessary readmissions. Alternative interventions are needed to meet heart failure treatment goals post-discharge. Ongoing evaluation of patient symptoms and their functional consequences may help prevent hospital readmissions

The Joint Commission's 2017 Disease-Specific Care Advanced Certification Heart Failure standards require that care, treatment, and services are provided in a planned and timely manner. Compliance with this standard is demonstrated through a re-evaluation of the patient by a program team member within 72 hours after inpatient discharge. The re-evaluation may be conducted via phone call, home visit, or scheduled office appointment.

Type Of Measure: Process

Improvement Noted As: Increase in the rate

Numerator Statement: Patients who have a documented re-evaluation conducted via phone call or home visit within 72 hours after discharge.
Included Populations: Not applicable

Excluded Populations: None

Data Elements:

Denominator Statement: All heart failure patients discharged from a hospital inpatient setting to home or home care AND patients leaving against medical advice (AMA).
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
  • Patients who left against medical advice (AMA)

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

Data Elements:

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. Aggregate rate generated from count data reported as a proportion

Selected References:
  1. Hoyt RE, Bowling LS. Reducing Readmissions for Congestive Heart Failure. Am Fam Physician 2001;63(8):1593-1598.
  2. Jha AK, Orav EJ, Epstein AM. Public Reporting of Discharge Planning and Rate of Readmissions. N Eng J Med 2009; 361(27):2637-2645.
  3. 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.

Measure Algorithm:

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