NJ DSRIP Planning Protocol Addendum 3 - DY7 and DY8 Stage 3 Population Focused Improvement Measures Catalogue
*Definitions and Acronyms are located at the end of this document.
Universal Code / Measure Name / DSRIP # / NQF# / Measure Steward / NJ Data Source / Reporting Entity/ Setting of Care / Reporting Period / P4P or P4R
11 / Follow-up After Hospitalization for Mental Illness – 7 days post discharge / 41 / 0576 / NCQA / MMIS / Multi-setting / Annual; April / P4P
12 / Engagement of alcohol and other drug treatment / 38 / 0004 / NCQA / MMIS / Multi-setting / Annual; April / P4P
16 / Controlling High Blood Pressure / 31 / 0018 / NCQA / Chart/
EHR / Outpatient / Annual; April / P4P
18 / Ischemic Vascular Disease (IVD): Complete Lipid Profile and LDL-C Control <100mg/dL / 55 / 0075
(based on) / NCQA / Chart/
EHR / Outpatient / Annual; April / P4R
19 / Preventive Care & Screening: Tobacco Use: Screening & Cessation Intervention / 76 / 0028 / AMA-PCPI / Chart/
EHR / Outpatient / Annual; April / P4R
21 / CD4 T-Cell Count / 20 / Not Found / HRSA / MMIS / Multi-Setting / Annual; April / P4R
25 / Chlamydia Screening in Women / 28 / 0033 / NCQA / MMIS / Multi-Setting / Annual; April / P4R
26 / Child Immunization Status / 25 / 0038
(based on) / NCQA / MMIS / Multi-Setting / Annual; April / P4R
27 / Well-Child Visits in First 15 Months of Life / 88 / 1392
(based on) / NCQA / MMIS / Outpatient / Annual; April / P4P
30 / Hospital Acquired Potentially Preventable Venous Thromboembolism / 47 / Not Found / Joint Commission / Chart/
EHR / Hospital/
Inpatient / Annual; April / P4R
32 / Diabetes Short-Term Complications Admission Rate / 36 / 0272
(based on) / AHRQ / MMIS / Hospital/
Inpatient / Annual; April / P4P
33 / Ambulatory Care – Emergency Department Visits / 8 / Not Found / NCQA / MMIS / Hospital/
Emergency Department / Annual; April / P4P
40 / Cesarean Rate for Nulliparous Singleton Visits / 23 / 0471 / Joint Commission / Chart/
EHR / Hospital/
Inpatient / Annual; April / P4R
42 / 30-Day All-Cause Readmission Following Heart Failure (HF) Hospitalization / 3 / 0330
(based on) / CMS / MMIS / Hospital/
Inpatient / Annual; April / P4P
Definition Key:
Department–Refers to the New Jersey Department of Health
DSRIP Network– Refers to the DSRIP hospital’s outpatient (non-ED, non-inpatient) reporting entities. This may include the hospital-based clinic (as identified through hospital billing practices) a community-based reporting partner, or a combination of the two.
Hospital – Refers to the participating DSRIP hospital
Inpatient – Refers to the setting where care is received as a result of an admission order to a hospital.
OutpatientCare– Refers to outpatient, (non-ED, non-inpatient) ambulatory care. This may include physical health or behavioral health care.
Acronym Key:
AHRQ – Agency for Healthcare Research and Quality
AMA- PCPI – American Medical Association – Physician Consortium for Performance Improvement
CDC – Centers for Disease Control and Prevention
CMS – Centers for Medicare & Medicaid Services
EHR – Electronic Health Record
HRSA – Health Resources and Services Administration
MMIS – Medicaid Management Information System
NCQA – National Committee for Quality Assurance
June 2018, Version 2.0Page 1 of 2