MEDICAID QUALITY MEASURES FOR PERSONS WITH DISABILITIES

DATABASE RETRIEVABLE MEASURES FOR PERSONS WITH DISABILITIES

DELMARVA FOUNDATION
MARGARET MASTAL. PhD, RN
mastalm@dfmc.org
 MEDICAID QUALITY INDICATORS FOR INDIVIDUALS WITH DISABILITIES
NIDDR PROJECT: MEASURE ADVISORY PANEL (MAP)
Composite Table: Database Retrievable Quality Measures *
Access Measures: Member Demographics
No. Measure Working Definition Numerator Denominator Notes Source/Owner
1 Age Current HEDIS Enrollment by Product Line Most Current HEDIS ENP specifications. Beneficiaries Beneficiaries with NCQA
(ENP) measure. This measure reports the enrolled in disabilities are working age
total number of members enrolled stratified reporting entity (18 to 64 yrs) for all
by age and sex. product line measures

2 Gender Current HEDIS Enrollment by Product Line Most Current HEDIS ENP specifications. Beneficiaries See measure 1 NCQA
(ENP) measure. This measure reports the enrolled in
total number of members enrolled stratified reporting entity
by age and sex. product line
3 Race/Ethnic Current HEDIS Race/Ethnicity Diversity of Most current HEDIS RDM specifications. Beneficiaries NCQA
Origins Membership (RDM) measure. An enrolled in
unduplicated count of and percentage of reporting entity
members enrolled any time during the product line
measurement year by race and ethnicity.
4 Language Current HEDIS Language Diversity of Most current LDM specifications. Beneficiaries NCQA
Translation Membership (LDM) measure. enrolled in
reporting entity
product line
5 Type of Current HEDIS Enrollment by Product Line Most Current HEDIS ENP specifications. Beneficiaries Use HEDIS Enrollment by NCQA
Health (ENP) measure. This measure reports the enrolled in Product Line (EPN) measure.
Insurance: total number of members enrolled stratified reporting entity Dually eligible are reported
Dual by age and sex. Dually eligible members are product line separately in NCQA’s
Eligibility stratified. instructions – by eligibility
category (see category B).

Medicaid is reported as
member months because of
the instability of membership
in Medicaid programs. A
proxy for membership can be
calculated as “Member
years”. Member Months/12.

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 Access Measures: Member Demographics (cont’d)
No. Measure Working Definition Numerator Denominator Notes Source/Owner
6 Type of Living % of working age beneficiaries with # working age beneficiaries with disabilities in # working age  Need to define NIDRR MAP**
Arrangements disabilities who live in the different types of reporting year living in Institutions beneficiaries (18 to 64 “continuously”. Electronic
living structures: • -Long term (residing in a hospital, yrs) with disabilities, Suggest: with no Database
• Institutions nursing home, LTAC, etc. 6 continuously enrolled in discharges.
-Long term (residing in a hospital, months or longer) the reporting year, Administrative
nursing home, LTAC, etc. 6 -Short stay (residing in an LTAC or breaks would not
months or longer) nursing home less than 6 months constitute discharge
-Short stay (residing in an LTAC or  Need POS codes to
nursing home less than 6 months) # working age beneficiaries with disabilities in specify long-term
• Structured Community Residences reporting year living in structured community and short term
(residing in group/foster homes, residences; nursing homes.
assisted living, congregate living, • (residing in group/foster homes, assisted
homeless shelters) living, congregate living, homeless shelters)  Source of data at
plans is unknown.
• Independent Living (reside alone or Full development of
# working age beneficiaries with disabilities in the
with significant other/s in apt. or house. measure requires
reporting year living in independent situations
• (reside alone or with significant other/s in apt. input from plan staff
or house. – likely from data/IS,
Note: Specify carefully the types of possible quality, case
labels for the different categories of living management,
arrangements. enrollment, and/or
medical staff.
 Length of time in
setting/residence to
determine
categorization
needs to be
determined.
7 Migration % beneficiaries with disabilities whose # beneficiaries with disabilities in the reporting # working age Use same issues and NIDRR MAP
between types living arrangements changed from a year whose living arrangements changed from a beneficiaries with specifications as #6 Electronic
of living hospital or nursing home stay of longer hospital or nursing home stay of longer than 6 disabilities, continuously above Database
arrangements: than 6 months to either a structured living months to either a structured living arrangement enrolled in the reporting
De- arrangement or an independent living or an independent living arrangement. year,
institutionalized arrangement
8 Migration % beneficiaries whose living arrangements # beneficiaries whose living arrangements # working age Use same issues and NIDRR MAP
between types changed from structured living and changed from structured living and independent beneficiaries with specifications as #6 Electronic
of living independent living arrangements to a living arrangements to a hospital or nursing home disabilities, continuously above Database
arrangements: hospital or nursing home for longer than 6 for longer than 6 mos. enrolled in the reporting
Institutionalized mos. year,

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 Access Measures: Member Demographics (cont’d)
No. Measure Working Definition
9 Voluntary Termination % beneficiaries in the reporting year
who choose of their own volition to
terminate participating in the
program.
10 Involuntary % beneficiaries who terminate from
Terminations the program as a result of the
program’s decision or due to loss of
eligibility from change in
geographic location; death;
incarceration; income exceeds
eligibility standards.
11 Complaints and % beneficiaries in the reporting year
Grievances who filed written complaints or
grievances.
Note:States have different
definitions of and requirements for
handling complaints and/or
grievances.
Access Measures to Care Coordination: Staffing Patterns
12 Advanced Practice
Nurses (APNs) # of APNs directly providing care
coordination services per 1000
member months of enrollment
during the reporting year.
Numerator Denominator Notes Source/Owner
# beneficiaries in the reporting year # working age Need info on how this data is CMS – verify
who choose of their own volition to beneficiaries with stored received and maintained source
terminate participating in the program. disabilities, continuously at the various plans to finalize
enrolled in the reporting specifications.
year,
# beneficiaries who terminate from the # working age Need info on how this data is CMS – verify
program as a result of the program’s beneficiaries with stored received and maintained source
decision or due to loss of eligibility from disabilities, continuously at the various plans to finalize
change in geographic location; death; enrolled in the reporting specifications.
incarceration; income exceeds eligibility year,
standards.
# beneficiaries in the reporting year # working age Complaints and grievances are CMS – verify
who filed written complaints or beneficiaries with identified as any statement of source
grievances. disabilities, continuously dissatisfaction.
enrolled in the reporting
year, Need info on how this data is
stored received and maintained
at the various plans to finalize
specifications.
# of APNs, continuously employed for Per 1000 member Suggested definition of: NIDRR MAP
the full reporting year, directly providing months for beneficiaries employed for the measurement Electronic
care coordination services for with disabilities year with no more than one gap Database
beneficiaries with disabilities within the continuously enrolled in in employment of greater than
scope of APN practice as defined by the reporting year. 30 days.
state regulations and the organization’s Member months How would #APN’s be
job description. calculated as in HEDIS captured? Timekeeping
ENP measure. database/billing
database/assigned personnel to
a patient/ resource allocation
database – need plan input.
Need to clarify “directly
providing…”
Suggest changing measure to #
o f APNs /1000 member months
to attempt to standardize
performance across plans of
different sizes.
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 Access Measures to Care Coordination: Staffing Patterns
No. Measure Working Definition Numerator Denominator Notes Source/Owner
13 Registered Nurses # of RNs directly delivering care # RNs, continuously employed for the Per 1000 member Same definition for: employed NIDRR MAP
(RNs) coordination services per 1000 full reporting year, directly delivering months for beneficiaries as above. Electronic
member months of enrollment during care coordination services for with disabilities need plan input. Database
the reporting year. beneficiaries with disabilities within the continuously enrolled in
scope of licensed RN practice as the reporting year. Need to clarity “directly
defined by state regulations and the Member months providing…”
organizational job description. calculated as in HEDIS
ENP measure. Suggest changing measure to
# o f RNs /1000 member
months to attempt to
standardize performance
across plans of different sizes.
14 Social Workers # of LCSWs directly providing care # Social Workers, continuously Per 1000 member Same definition for: employed NIDRR MAP
(LCSWs) coordination services per 1000 employed for the full reporting year, months for beneficiaries as above. Electronic
member months of enrollment during directly providing care coordination with disabilities need plan input. Database
the reporting year. services for beneficiaries with continuously enrolled in
disabilities within the scope of licensed the reporting year. Need to clarity “directly
social worker practice as defined by Member months providing…”
state regulations and organizational job calculated as in HEDIS
descriptions. ENP measure. Suggest changing measure to #
o f LCSWs /1000 member
months to attempt to
standardize performance
across plans of different sizes.
15 Unlicensed Assistive # of Unlicensed Assistive Personnel # Unlicensed Assistive Personnel, as Per 1000 member List the specific types of NIDRR MAP
Personnel (UAPs) directly providing care defined by organizational job months for beneficiaries positions that organizations Electronic
(UAPs) coordination services per 1000 descriptions, continuously employed in with disabilities include as “unlicensed care Database
member months of enrollment during the reporting year, directly providing continuously enrolled in coordination staff,” excluding
the reporting year. care coordination services for the reporting year. personal care assistant
beneficiaries with disabilities. Member months personnel?
calculated as in HEDIS need plan input.
ENP measure.
Need to clarity “directly
providing…”
Suggest changing measure to #
o f LCSWs /1000 member
months to attempt to
standardize performance
across plans of different sizes.

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 Access Measures to Care Coordination: Timely Initiation of Admission Screens and ISPs
No. Measure Working Definition Numerator Denominator Notes Source/Owner
16 New Beneficiary % new beneficiaries with disabilities in # new beneficiaries with disabilities in the # working age Are there CPT codes NIDRR MAP
Assessment the reporting year receiving initial intake reporting year receiving initial intake assessment beneficiaries with to indicate initial Electronic
Screens within 30 assessment screens within 30 days of screens within 30 days of admission to the disabilities, continuously intake assessment Database
days of admission to the program. program. enrolled in the reporting screen ?
admission year, (99450, 99455, 99456).
Are these appropriate?
Need plan input.
Are there other methods
besides CPT coding to
capture data in plan
administrative systems?
Across plans, is there a
difference between
admission and
enrollment? If so, what
is most common use for
inclusion in specification
development?
17 New Beneficiary % new beneficiaries with disabilities in # new beneficiaries with disabilities in the # working age Same as above, but NIDRR MAP
Assessment the reporting year receiving initial intake reporting year receiving initial intake assessment beneficiaries with assessment within 60 Electronic
Screens within 60 assessment screens within 60 days of screens within 60 days of admission to the disabilities, continuously days of enrollment date Database
days of admission to the program. program. enrolled in the reporting
admission year,
18 Individual Service % new beneficiaries with disabilities in # new beneficiaries with disabilities in the # working age Where are ISP’s NIDRR MAP
Plans (ISPs) the reporting year with ISPs initiated reporting year with ISPs initiated within 30 days beneficiaries with documented? Electronic
initiated within 30 within 30 days of admission. of admission. disabilities, continuously Need plan input on how Database
days of enrolled in the reporting ISPs are documented
admission year, within administrative
systems. Are there
CPTs or other types of
data elements that
always and only indicate
ISP and date ISP
established?
Assessment within 30
days of enrollment date
19 Individual Service % new beneficiaries with disabilities in # new beneficiaries with disabilities in the # working age Same as above, but NIDRR MAP
Plans (ISPs) the reporting year with ISPs initiated reporting year with ISPs initiated within 60 days beneficiaries with assessment within 60 Electronic
initiated within 60 within 60 days of admission. of admission. disabilities, continuously days of enrollment date Database
days of enrolled in the reporting

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 admission year,

Access Measures: Utilization of Medical Benefits and Services

No. Measure Working Definition Numerator Denominator Notes Source
20 Beneficiaries % beneficiaries with disabilities, # beneficiaries with disabilities, continuously # working age Modify: HEDIS
with PCP continuously enrolled in the reporting enrolled in the reporting year, who had PCP members (18-64 years) Childhood/Adol Access
Encounters year, who had PCP encounters during the encounters during the reporting year. with disabilities, to PCP measure. Use
reporting year. continuously enrolled in denominator for this
the reporting year population instead of
HEDIS specs.
21 Beneficiaries % beneficiaries with disabilities, # beneficiaries with disabilities, continuously # working age Modify: HEDIS
with Medical continuously enrolled in the reporting enrolled in the reporting year, who had an office members (18-64 years) Childhood/Adol Access
Specialist year, who had an office visit with a visit with a medical specialist during the reporting with disabilities, to PCP measure. Use
Encounters medical specialist during the reporting year. continuously enrolled in denominator for this
year. the reporting year population instead of
HEDIS specs.

Team to develop list of

‘medical specialist’
physician specialty
codes from CMS
standardized list.
22 Beneficiaries % beneficiaries with disabilities, # beneficiaries with disabilities, continuously # working age Modify: HEDIS
with Surgical continuously enrolled in the reporting enrolled in the reporting year, who had an office members (18-64 years) Childhood/Adol Access
Specialty year, who had an office visit with a visit with a surgical specialist during the reporting with disabilities, to PCP measure. Use
Encounters surgical specialist during the reporting year. continuously enrolled in denominator for this
year. the reporting year population instead of
HEDIS specs.

Team to develop list of

‘surgical specialist’
physician specialty
codes from CMS
standardized list
23 Beneficiaries % beneficiaries with disabilities, # beneficiaries with disabilities, continuously # working age Modify HEDIS annual
with Dental continuously enrolled in the reporting enrolled in the reporting year, who had dental members (18-64 years) dental visit measure
Encounters year, who had dental encounters during encounters during the reporting year. with disabilities, specifications (Modify
the reporting year. continuously enrolled in age range)
the reporting year

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 Access Measures: Utilization of Medical Benefits and Services (cont’d)
No. Measure Working Definition Numerator Denominator Notes Source
24 Beneficiaries Current HEDIS IP Utilization General Most current HEDIS IPU specifications. Beneficiaries enrolled in Recommend HEDIS IP NCQA
with Hospital Acute Care (IPU) measure. This reporting entity product utilization General
Hospitalizations measure summarizes utilization of acute line Hospital/Acute Care
inpatient services in the following measure.
categories.
Total services Reports at /1000
Medicine member months
Surgery
Maternity
25 Beneficiaries Current HEDIS Ambulatory Care (AMB) Most current HEDIS AMB specifications. Beneficiaries enrolled in Recommend HEDIS NCQA
with ER measure. This measure summarizes reporting entity product Ambulatory Care
Encounters utilization of ambulatory services in the line measure use measure
following categories.
Outpatient visits Reports at /1000
Emergency department (ED) visits member months
Ambulatory surgery/procedures
performed in hospital, outpatient facilities
or freestanding surgical centers.
26 Access to During the reporting year, the average # beneficiaries with disabilities, continuously # working age Sum of count of days NIDRR MAP
Durable Medical time in days from the dates a first-time enrolled in the reporting year, who had request for members (18-64 years) between order and Electronic
Equipment request for wheelchairs were submitted wheelchair during the reporting year. with disabilities, receipt of each Database
(DME): until disabled beneficiaries received the continuously enrolled in wheelchair (electric or
Wheelchair wheelchair. the reporting year manual) divided by the
number wheelchair
orders. Does this
include time for
approval of payment
from Medicaid?

Data capture storage

and retrieval are
unknown. Need plan
input to finalize
indicator specs.

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 Access Measures: Utilization of Medical Benefits and Services (cont’d)
No. Measure Working Definition Numerator Denominator Notes Source
27 Access to During the reporting year, the average # beneficiaries with disabilities, continuously # working age Sum of count of days NIDRR MAP
Functional DME: time in days from the date wheelchair enrolled in the reporting year, who had request for members (18-64 years) between request for Electronic
Wheelchair repair requests were submitted for wheelchair repairs during the reporting year. with disabilities, repair of each Database
beneficiaries until the wheelchairs were continuously enrolled in wheelchair (electric or
repaired. the reporting year manual) and the
completion of repairs
divided by the number
wheelchair repair
requests.Same
comment as previous
measure

Data capture storage

and retrieval are
unknown. Need plan
input to finalize
indicator specs.
Effectiveness of Care Measures: Preventive Care

28 Colorectal Cancer HEDIS Technical Specifications HEDIS Technical Specifications # working age NCQA
Screening members (18-64 years) NQF***
with disabilities,
continuously enrolled in
the reporting year
29 Breast Cancer HEDIS Technical Specifications HEDIS Technical Specifications # working age NCQA
Screening members (18-64 years) NQF
with disabilities,
continuously enrolled in
the reporting year
30 Cervical Cancer HEDIS Technical Specifications HEDIS Technical Specifications # working age NCQA
Screening members (18-64 years) NQF
with disabilities,
continuously enrolled in
the reporting year
31 Chlamydia HEDIS Technical Specifications HEDIS Technical Specifications # working age NCQA
Screening: members (18-64 years) NQF
Women with disabilities,
continuously enrolled in

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 the reporting year

Effectiveness of Care Measures: Preventive Care (cont’d)

No. Measure Working Definition Numerator Denominator Notes Source
32 Flu Shots for HEDIS Technical Specifications HEDIS Technical Specifications # working age Survey measure NCQA
Adults Ages 50-64 members (18-64 years) should be included in NQF
with disabilities, CAHPS survey
continuously enrolled in administration.
the reporting year
Effectiveness of Care Measures: Management of Disabilities, Chronic Conditions and Secondary Complications
33 Diabetes Comprehensive Diabetes Care HEDIS Technical Specifications # working age NCQA
management –all indicators members (18-64 years) NQF
with disabilities,
continuously enrolled in
the reporting year
34 Asthma Use of appropriate medications for HEDIS Technical Specifications # working age NCQA
management people with asthma. members (18-64 years) NQF
with disabilities,
continuously enrolled in
the reporting year
35 Depression Antidepressant Medication management HEDIS Technical Specifications # working age NCQA
management members (18-64 years) NQF
with disabilities,
continuously enrolled in
the reporting year
36 Substance Abuse Identification of Alcohol and Other Drug HEDIS Technical Specifications # working age NCQA
Services members (18-64 years) NQF
with disabilities,
continuously enrolled in
the reporting year
37 Mental Illness Follow-up After Hospitalization for Mental HEDIS Technical Specifications # working age NCQA
management Illness members (18-64 years) NQF
FU after with disabilities
Hospitalization admitted to the hospital
for Mental Illness dx,
continuously enrolled in
the reporting year

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 Effectiveness of Care Measures: Management of Disabilities, Chronic Conditions and Secondary Complications (cont’d)
No. Measure Working Definition Numerator Denominator Notes Source
38 Mental Illness Readmission to hospital for Mental Illness Number of members that were readmitted to the # working age Not separate HEDIS (Measure #37)
Management: for members with disabilities hospital within 30 days of a hospitalization for members (18-64 years) Measure – Tech
Hospital -within 7 days mental illness. There are two calculations with disabilities specifications included
Readmission -within 30 days required. admitted to the hospital in previous HEDIS
-within 7 days for Mental Illness dx, measure. Identifying
-within 30 days continuously enrolled in readmissions is part of
the reporting year identifying the
denominator in #37.
39 Pressure Ulcer % beneficiaries in the reporting year with # members in the reporting year with a diagnosis # working age Pressure ulcer NIDRR MAP
Management a diagnosis of pressure ulcer listed as of pressure ulcer listed as one of the top 5 members (18-64 years) diagnosis: (ICD-9 Electronic
one of the top 5 diagnoses on hospital diagnoses on hospital discharge with disabilities, 707.0x) Database
discharge continuously enrolled in Discharges should be
the reporting year with identified as instructed
a hospital discharge in in most current version
the measurement year. of HEDIS.
40 Urinary Tract % beneficiaries in the reporting year with # members in the reporting year with a diagnosis # working age Urosepsis diagnosis: NIDRR MAP
Disorders a diagnosis of urosepsis listed as one of of urosepsis listed as one of the top 5 diagnoses members (18-64 years) (ICD-9 599.0) Electronic
Management the top 5 diagnoses on hospital discharge on hospital discharge with disabilities, Discharges should be Database
continuously enrolled in identified as instructed
the reporting year. in most current version
with a hospital of HEDIS.
discharge in the
measurement year.
41 Management of % beneficiaries in the reporting year with # members in the reporting year with a diagnosis # working age Bowel disorder NIDRR MAP
Bowel Disorders a diagnosis of bowel disorder listed as of bowel disorder listed as one of the top 5 members (18-64 years) diagnosis: (ICD-9 Electronic
one of the top 5 diagnoses on hospital diagnoses on hospital discharge with disabilities, 560,560.0 -560.3, Database
discharge continuously enrolled in 560.8, 560.81, 560.89,
the reporting year 564.8) )
with a hospital Discharges should be
discharge in the identified as instructed
measurement year. in most current version
of HEDIS.
42 Spasticity % beneficiaries receiving botox injections # members receiving botox injections and/or IV # working age Botox injections: (NDC: NIDRR MAP
Management and/or IV baclofen pump for spasticity baclofen pump for spasticity members (18-64 years) 00023-1145) Electronic
with disabilities, IV Baclofen pump Database
continuously enrolled in (ICD-9: 86.06 – 86.07,
the reporting year 3.90)
*Quality measures identified as important for disability care coordination organizations and are available for retrieval from electronic databases.
** Measurement Advisory Panel for the research project of the National Institute for Disability and Rehabilitation Research, U.S. Department of Education.
*** National Quality Forum, Voluntary Consensus Standards for Ambulatory Care: An Initial Physician Focused Performance Measure Set

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