This measure evaluates follow up treatment for selected chronic conditions.

The numerator is the sum of acute exacerbations for which follow-up care was received within the time-frame recommended by clinical practice guidelines, as detailed below: Hypertension: Follow up within 14 days of the date of discharge for high-acuity patients or within 30 days for medium-acuity patients Asthma: Follow up within 14 days of the date of discharge Heart Failure: Follow up within 14 days of the date of discharge Coronary Artery Disease: Follow up within 7 days of the date of discharge for high-acuity patients or within 6 weeks for low-acuity patients Chronic Obstructive Pulmonary Disease: Follow up within 30 days of the date of discharge Diabetes: Follow up within 14 days of the date of discharge for high-acuity patients Numerator events (timely follow up) are identified by matching claims (at the patient level) that indicate an acute exacerbation (ED visit, observation stay, inpatient admission) for the conditions listed above, to the follow up visit. To qualify as a numerator event, the follow-up visit must occur within the condition-specific time-frame noted above. Follow up visits are identified in claims as non-emergency outpatient visits after the discharge date of the initial exacerbation, using CPT or HCPCS code indicating appropriate follow up as defined by clinical guidelines and clinical coding experts. The follow-up visit may be a general office visit or telehealth visit and can also take place in certain chronic care or transitional care management settings. For a list of individual codes for timely follow-up, please refer to the 'Final Condition Codes' tab in the Value Set (i.e. Data Dictionary) and their rules as described in the denominator details section of this document. For two conditions, CAD and hypertension, the cohort is subdivided based on the acuity of the exacerbation; and the code set for each portion of the cohort has its own follow-up window. The follow-up visit time-frames are based on the most recent, evidence-based clinical guidelines.

The sum of all acute exacerbation events for six clinical conditions attributed to an ACO among the target population during the performance period. If a patient has multiple qualifying acute exacerbation events during the performance period, these would all be included in the measure outcome calculation. Exacerbations are defined as an acute-care visit (i.e., ED visit, observation stay, or inpatient hospitalisation) for any of the six conditions of interest (with eight category cohorts): coronary artery disease (CAD) [high or low acuity], hypertension [high or medium acuity], heart failure (HF), diabetes, asthma, and chronic obstructive pulmonary disease (COPD). The cohorts for hypertension, CAD, and diabetes were divided based on acuity of condition because clinical guidelines reflected heterogeneity in follow-up timeline recommendations for exacerbations of different acuities; therefore, because CAD and HTN were subdivided into high and lower acuity categories, the measure structure reflects eight condition cohorts for the six conditions of interest.

Subsequent acute events that occur two days after the prior discharge, but still during the follow-up interval of the prior event for the same reason. To prevent double counting, only the first acute event will be included in the denominator. Acute events after which the patient does not have continuous enrolment for two months for all the condition groups, except the low-acuity CAD group, which requires continuous enrolment of three months. Acute events where the discharge status of the last claim is not "to community" (e.g., "left against medical advice" is not a discharge to community). For a list of the appropriate codes, please refer to the "Discharge to Community" codes on the 'Inpat, Obs, ED, Discharge' tab in the Value Set. Acute events for which the calendar year ends before the follow-up window ends (e.g., Acute asthma events occurring fewer than 14 days before December 31 will not be included.). Acute events where the patient enters a skilled nursing facility (SNF), non-acute care, or hospice care within the follow-up interval. For a list of the appropriate codes to identify non-acute care, please refer to the "Non-Acute" tab in the Value Set.

Social risk factors: dual eligibility (DE), low socioeconomic status (SES) defined by the Area Deprivation Index (ADI), race/ethnicity other than white.

By social risk factors: (1) dual eligibility (DE); (2) low socioeconomic status (SES) as defined by the Area Deprivation Index (ADI); and (3) race/ethnicity other than white (i.e., non-white). As of the 2022 model performance year (Calendar Year 2022), CMS provides the stratified results to ACOs quarterly, in Quarterly Quality Reports (QQRs), and annually, in Annual Quality Reports (AQRs). The stratified results are provided to ACOs confidentially.

Claims data, 2019 Area deprivation index. CMS uses final-action claims for Medicare FFS Part A and B, administrative (enrolment data) from the Medicare Beneficiary Summary File. Measure scores are calculated for REACH ACOs and their aligned beneficiaries, as well as non-REACH ACO provider groups (TINs and CCNs that bill Medicare FFS Parts A and B) and beneficiaries aligned using the same ACO REACH Model alignment criteria. Non-REACH ACO provider groups must have at least 1000 aligned and eligible beneficiaries to be included in the benchmarking population. This is a claims-based measure, and the measure score is calculated automatically from 100% final-action claims; claims data are routinely generated during the delivery of care. We did not encounter any difficulties with respect to data feasibility, reliability, or validity. The 2019 Area Deprivation Index data and the RTIRACECD variable from the Integrated Data Repository is also used for race/ethnicity stratification.

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p4qm.org/measures/3455 p4qm.org/sites/default/files/2024-05/Attachment%20BTables%20and%20FiguresTimely%20Follow-Up%20Measure%20CBE%20%233455Update%2005012024final.pdf