Overview Top Package Entity

Dimensional Warehouse Model Data Model

---

Entity ACO - Care Coordination/ Patient Safety

Description

ACO Narrative Measure Specifications for the Care Coordination/Patient Safety Domain.

Attributes

ACO 10 Ambulatory Sensitive Conditions Admissions: Congestive Heart Failure

ACO 10-d Number Of Adults Assigned To ACO

ACO 10-n Number Of CHF Discharges

ACO 11-d Number Of ACO Primary Care Physicians

ACO 11-n Number Of ACO Primary Care Physicians Qualifying

ACO 11 Percent of Primary Care Physicians who Successfully Qualify for an EHR Program Incentive Payment

ACO 12-d Number Of Member Discharges

ACO 12 Medication Reconciliation: Reconciliation After Discharge from an Inpatient Facility

ACO 12-n Number Of Member Discharges With Medication Reconciliation

ACO 13-d Number Of Members Who Should Be Discussing Fall Risk

ACO 13-d Number Of Members Who Should Be Managing Fall Risk

ACO 13 Falls: Screening for Future Fall Risk

ACO 13-n Number Of Members Discussing Fall Risk

ACO 13-n Number Of Members Managing Fall Risk

ACO 8-d Number Of Discharges

ACO 8-n Number Of Readmissions Within 30 Days

ACO 8 Risk-Standardized, All Condition Readmission

ACO 9 Ambulatory Sensitive Conditions Admissions: Chronic Obstructive Pulmonary Disease or Asthma in Older Adults

ACO 9-d Number Of Older Adults Assigned To ACO

ACO 9-n Number Of COPD Or Asthma Discharges

Calendar Dk

Geographic Area Dk

Practitioner Dk

Provider Dk

Relationship

ACO - Care Coordination/ Patient Safety_Geographic Area Dimension_FK

ACO - Care Coordination/ Patient Safety_Provider Dimension_FK

ACO - Care Coordination/ Patient Safety_Practitioner Dimension_FK

ACO - Care Coordination/ Patient Safety_Calendar Dimension_FK

Primary Key

ACO - Care Coordination/ Patient Safety PK

Dependencies

NONE

Reverse Dependencies

Attribute Details

 ACO 10 Ambulatory Sensitive Conditions Admissions: Congestive Heart Failure

Description	ACO 10 (NQF #0277; AHRQ PQI #08): Ambulatory Sensitive Conditions Admissions: Congestive Heart Failure All discharges, age 18 years and older, with ICD-9-CM principal diagnosis code for CHF, per 1,000 ACO assigned beneficiaries. Formula: [(A/B) *1000] (see dependencies and their labels for measures used in the formula)
Data Type	Standards - Data Domains.ddm/Data Domains/Decimal Float [FLOAT(15)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

---

 ACO 10-d Number Of Adults Assigned To ACO

Description	Population of Medicare FFS beneficiaries assigned to an ACO aged 18 years and older.
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

---

 ACO 10-n Number Of CHF Discharges

Description	Risk adjusted discharges aged 18 years and older from an acute care hospital with a principal diagnosis of Congestive Heart Failure.
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

---

 ACO 11-d Number Of ACO Primary Care Physicians

Description	All primary care physicians (PCPs), identified by a primary care specialty code in one or more Medicare Part B claims, who are participating in an Accountable Care Organization (ACOs) under the Medicare Shared Savings Program. Physicians participating in an ACO are defined as those submitting one or more Medicare Part B claims with one or more of the ACO’s identified Tax Identification Numbers (TINs) included on the claim. Exception: For Federally Qualified Health Centers (FQHC) or Rural Health Clinics (RHC) participating in an Accountable Care Organization (ACO) under the Medicare Shared Savings Program, a primary care physician (PCP) is any physician included in an attestation by the FQHC or RHC as part of the process of joining the ACO program.
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

---

 ACO 11-n Number Of ACO Primary Care Physicians Qualifying

Description	Primary care physicians (PCPs) participating in an ACO and identified as included in the denominator for that ACO for this quality measure, who successfully qualify for either a Medicare or the Medicaid EHR Incentive Program incentive payment.
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

---

 ACO 11 Percent of Primary Care Physicians who Successfully Qualify for an EHR Program Incentive Payment

Description	ACO 11 (CMS): Percent of Primary Care Physicians who Successfully Qualify for an EHR Program Incentive Payment Percentage of Accountable Care Organization (ACO) primary care physicians (PCPs) who successfully qualify for either a Medicare or Medicaid Electronic Health Record (EHR) Incentive Program incentive payment. Formula: [(A/B) *100] (see dependencies and their labels for measures used in the formula)
Data Type	Standards - Data Domains.ddm/Data Domains/Percentage [FLOAT(2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

---

 ACO 12-d Number Of Member Discharges

Description	The number of discharges from January 1-December 1 of the measurement year for members 66 years of age and older.
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

---

 ACO 12 Medication Reconciliation: Reconciliation After Discharge from an Inpatient Facility

Description	The percentage of discharges from January 1-December 1 of the measurement year for members 66 years of age and older for whom medications were reconciled on or within 30 days of discharge. This definition is included with the permission of the National Committee for Quality Assurance (NCQA) and is an extract from the full measure definition published by NCQA. Refer to NCQA's HEDIS vol 2 measures for the complete measure definition. Formula: [(A/B) *100] (see dependencies and their labels for measures used in the formula)
Data Type	Standards - Data Domains.ddm/Data Domains/Percentage [FLOAT(2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

---

 ACO 12-n Number Of Member Discharges With Medication Reconciliation

Description	The number of discharges from January 1-December 1 of the measurement year for members 66 years of age and older for whom medications were reconciled on or within 30 days of discharge.
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

---

 ACO 13-d Number Of Members Who Should Be Discussing Fall Risk

Description	The number of Medicare members 75 years of age and older or 65-74 years of age with balance or walking problems or a fall in the past 12 months, who were seen by a practitioner in the past 12 months.
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

---

 ACO 13-d Number Of Members Who Should Be Managing Fall Risk

Description	The number of Medicare members 65 years of age and older who had a fall or had problems with balance or walking in the past 12 months, who were seen by a practitioner in the past 12 months.
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

---

 ACO 13 Falls: Screening for Future Fall Risk

Description	The two components of this measure assess different facets of fall risk management. - Discussing Fall Risk. The percentage of Medicare members 75 years of age and older or 65-74 years of age with balance or walking problems or a fall in the past 12 months, who were seen by a practitioner in the past 12 months and who discussed falls or problems with balance or walking with their current practitioner. - Managing Fall Risk. The percentage of Medicare members 65 years of age and older who had a fall or had problems with balance or walking in the past 12 months, who were seen by a practitioner in the past 12 months and who received fall risk intervention from their current practitioner. This definition is included with the permission of the National Committee for Quality Assurance (NCQA) and is an extract from the full measure definition published by NCQA. Refer to NCQA's HEDIS vol 2 measures for the complete measure definition. Formula: [((A/B) or (C/D)) *100] (see dependencies and their labels for measures used in the formula)
Data Type	Standards - Data Domains.ddm/Data Domains/Percentage [FLOAT(2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

---

 ACO 13-n Number Of Members Discussing Fall Risk

Description	The number of Medicare members 75 years of age and older or 65-74 years of age with balance or walking problems or a fall in the past 12 months, who were seen by a practitioner in the past 12 months and who discussed falls or problems with balance or walking with their current practitioner.
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

---

 ACO 13-n Number Of Members Managing Fall Risk

Description	The number of Medicare members 65 years of age and older who had a fall or had problems with balance or walking in the past 12 months, who were seen by a practitioner in the past 12 months and who received fall risk intervention from their current practitioner.
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

---

 ACO 8-d Number Of Discharges

Description	All hospitalizations not related to medical treatment of cancer, primary psychiatric disease, or rehabilitation care, fitting of prostheses, and adjustment devices for ACO assigned beneficiaries at non-Federal, short-stay acute-care or critical access hospitals, where the beneficiary was age 65 or older, was continuously enrolled in fee-for-service Medicare Part A for at least one month after discharge, was not discharged to another acute care hospital, was not discharged against medical advice, and was alive upon discharge and for 30 days post-discharge.
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

---

 ACO 8-n Number Of Readmissions Within 30 Days

Description	Risk-adjusted readmissions at a non-Federal, short-stay, acute-care or critical access hospital, within 30 days of discharge from the index admission included in the denominator, and excluding planned readmissions.
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

---

 ACO 8 Risk-Standardized, All Condition Readmission

Description	ACO 8 (CMS; adapted NQF #1789): Risk Standardized All Condition Readmission Risk-adjusted percentage of Accountable Care Organization (ACO) assigned beneficiaries who were hospitalized who were readmitted to a hospital within 30 days following discharge from the hospital for the index admission. Formula: [(A/B) *100] (see dependencies and their labels for measures used in the formula)
Data Type	Standards - Data Domains.ddm/Data Domains/Percentage [FLOAT(2)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

---

 ACO 9 Ambulatory Sensitive Conditions Admissions: Chronic Obstructive Pulmonary Disease or Asthma in Older Adults

Description	ACO 9 (NQF #0275; AHRQ PQI #05): Ambulatory Sensitive Conditions Admissions: Chronic Obstructive Pulmonary Disease or Asthma in Older Adults All discharges of age 40 years and older with ICD-9-CM principal diagnosis code for COPD or Asthma in adults ages 40 years and older, per 1,000 ACO assigned beneficiaries. Formula: [(A/B) *1000] (see dependencies and their labels for measures used in the formula)
Data Type	Standards - Data Domains.ddm/Data Domains/Decimal Float [FLOAT(15)]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

---

 ACO 9-d Number Of Older Adults Assigned To ACO

Description	Population of Medicare FFS beneficiaries assigned to an ACO aged 40 years and older.
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

---

 ACO 9-n Number Of COPD Or Asthma Discharges

Description	Risk adjusted discharges aged 40 years and older from an acute care hospital with a principal diagnosis of Chronic Obstructive Pulmonary Disease or Asthma.
Data Type	Standards - Data Domains.ddm/Data Domains/Count [INTEGER]
Is Part Of PrimaryKey	false
Is Required	false
Is Derived	false
Is Surrogate Key	false

---

 Calendar Dk

Description	A numeric surrogate key used to uniquely identify entities in the dimensional model.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key Large [LONG]
Is Part Of PrimaryKey	true
Is Required	true
Is Derived	false
Is Surrogate Key	false

---

 Geographic Area Dk

Description	A numeric surrogate key used to uniquely identify entities in the dimensional model.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key Large [LONG]
Is Part Of PrimaryKey	true
Is Required	true
Is Derived	false
Is Surrogate Key	false

---

 Practitioner Dk

Description	A numeric surrogate key used to uniquely identify entities in the dimensional model.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key Large [LONG]
Is Part Of PrimaryKey	true
Is Required	true
Is Derived	false
Is Surrogate Key	false

---

 Provider Dk

Description	A numeric surrogate key used to uniquely identify entities in the dimensional model.
Data Type	Standards - Data Domains.ddm/Data Domains/Surrogate Key Large [LONG]
Is Part Of PrimaryKey	true
Is Required	true
Is Derived	false
Is Surrogate Key	false

Relationship Details

 ACO - Care Coordination/ Patient Safety_Geographic Area Dimension_FK

Is Identifying Relationship	true
Child Table	ACO - Care Coordination/ Patient Safety
Child Multiplicity	ZERO_TO_MANY
Child Referential Integrity: On Delete	NONE
Child Referential Integrity: On Insert	NONE
Child Referential Integrity: On Update	NONE
Parent Table	Geographic Area Dimension
Parent Multiplicity	ONE
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

---

 ACO - Care Coordination/ Patient Safety_Provider Dimension_FK

Is Identifying Relationship	true
Child Table	ACO - Care Coordination/ Patient Safety
Child Multiplicity	ZERO_TO_MANY
Child Referential Integrity: On Delete	NONE
Child Referential Integrity: On Insert	NONE
Child Referential Integrity: On Update	NONE
Parent Table	Provider Dimension
Parent Multiplicity	ONE
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

---

 ACO - Care Coordination/ Patient Safety_Practitioner Dimension_FK

Is Identifying Relationship	true
Child Table	ACO - Care Coordination/ Patient Safety
Child Multiplicity	ZERO_TO_MANY
Child Referential Integrity: On Delete	NONE
Child Referential Integrity: On Insert	NONE
Child Referential Integrity: On Update	NONE
Parent Table	Practitioner Dimension
Parent Multiplicity	ONE
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

---

 ACO - Care Coordination/ Patient Safety_Calendar Dimension_FK

Is Identifying Relationship	true
Child Table	ACO - Care Coordination/ Patient Safety
Child Multiplicity	ZERO_TO_MANY
Child Referential Integrity: On Delete	NONE
Child Referential Integrity: On Insert	NONE
Child Referential Integrity: On Update	NONE
Parent Table	Calendar Dimension
Parent Multiplicity	ONE
Parent Referential Integrity: On Delete	NONE
Parent Referential Integrity: On Insert	NONE
Parent Referential Integrity: On Update	NONE

Primary Key Details

 ACO - Care Coordination/ Patient Safety PK

Key Attribute	Calendar Dk
Key Attribute	Geographic Area Dk
Key Attribute	Provider Dk
Key Attribute	Practitioner Dk

---

Overview Top Package Entity

Dimensional Warehouse Model Data Model