Action Network Measurement Plan Detail
All Members of the Action Network – Outcome Measures
1) Percent 30-Day All-Cause Readmissions - Percent of discharges with readmission for any cause within 30 days
Numerator Denominator Calculation Measurement How to
Numerator Definition: The number of acute care discharges in the measurement month resulting in a readmission for any cause within 30 days of the index discharge date.
Numerator Exclusions:

*Planned/Elective
Admissions
Denominator Definition: The number of index acute care discharges from the hospital the measurement month
Denominator Exclusions:


Patients less than 18 years of age
Patients who died prior to discharge

Patients who were transferred to another hospital

Labor & Delivery
Patients
(numerator / denominator) x
100; as percent
Period
Monthly
Write a report to run no sooner than 31 days after the end of the measurement month.
This report will:
1a. Pull all the discharges in the measurement month
1b: Remove exclusions (transfers to other acute care, deceased before discharge, Labor and Delivery, < 18)
The number of discharges after you remove the exclusions is your denominator (or “index discharges”)
2a. Through the unique medical record identifier, identify those (index) discharges that resulted in readmissions within 30 days of the discharge
2b. Remove exclusions (planned readmissions like chemotherapy, radiation, rehab, planned surgery)
The number of (index) discharges that resulted in
readmissions within 30 days will be your numerator
*Comments – Some ADT systems capture planned admissions using an elective code. If that is the case in your organization exclude elective admissions. If your ADT system does not capture planned admissions using an elective code then you can exclude these cases using the attached list of ICD-9 codes or by excluding OSHPD – Admission Type 1 Scheduled (arranged with the hospital at least 24 hrs prior to admission).
2) Percent 90-Day All-Cause Readmissions - Percent of discharges with readmission for any cause within 90 days
Numerator
Numerator Definition: The number of acute care
Denominator
Denominator Definition: The number of index acute care
Calculation Measurement
Period
(numerator / denominator) x
Monthly
How to
Write a report to run no sooner than 121 days after
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Action Network Measurement Plan Detail
2) Percent 90-Day All-Cause Readmissions - Percent of discharges with readmission for any cause within 90 days
Numerator Denominator Calculation Measurement
Period
How to discharges in the measurement month resulting in a readmission for any cause within 90 days of the index discharge date.
Numerator Exclusions:

*Planned/Elective
Admissions discharges from the hospital the measurement month
Denominator Exclusions:
 Patients less than 18
100; as percent the end of the measurement month.
This report will:
1a. Pull all the discharges in the measurement month years of age

Patients who died prior to discharge

Patients who were transferred to another hospital

Labor & Delivery
Patients
1b: Remove exclusions (transfers to other acute care, deceased before discharge, Labor and Delivery, < 18)
The number of discharges after you remove the exclusions is your denominator (or “index discharges”)
2a. Through the unique medical record identifier, identify those (index) discharges that resulted in readmissions within 90 days of the discharge
2b. Remove exclusions (planned readmissions like chemotherapy, radiation, rehab, planned surgery)
The number of (index) discharges that resulted in readmissions within 90 days will be your numerator
*Comments – Some ADT systems capture planned admissions using an elective code. If that is the case in your organization exclude elective admissions. If your ADT system does not capture planned admissions using an elective code then you can exclude these cases using the attached list of ICD-9 codes or by excluding OSHPD – Admission Type 1 Scheduled (arranged with the hospital at least 24 hrs prior to admission).
3) 30 Day Readmissions Count Hospital-overall - Number of readmissions (numerator for 30-day all cause readmissions measure) for hospital
Numerator
Numerator Definition: The number of acute care discharges in the measurement month resulting in a readmission for any cause
NA
Denominator Calculation Measurement
Period
Numerator only as a count
Monthly
How to
Use your numerator from measure 1.
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Action Network Measurement Plan Detail
3) 30 Day Readmissions Count Hospital-overall - Number of readmissions (numerator for 30-day all cause readmissions measure) for hospital
Numerator Denominator Calculation Measurement
Period
How to within 30 days of the index discharge date.
Numerator Exclusions:

*Planned/Elective
Admissions
*Comments – Some ADT systems capture planned admissions using an elective code. If that is the case in your organization exclude elective admissions. If your ADT system does not capture planned admissions using an elective code then you can exclude these cases using the attached list of ICD-9 codes or by excluding OSHPD – Admission Type 1 Scheduled (arranged with the hospital at least 24 hrs prior to admission).
4) 90 Day Readmissions Count Hospital-overall - Number of readmissions (numerator for 90-day all cause readmissions measure) for hospital
Numerator Denominator Calculation Measurement
Period
How to
Numerator Definition: The number of acute care discharges in the measurement month resulting in a readmission for any cause within 90 days of the index
NA Numerator only as a count
Monthly Use your numerator from measure 1. discharge date.
Numerator Exclusions:
 *Planned/Elective
Admissions
*Comments – Some ADT systems capture planned admissions using an elective code. If that is the case in your organization exclude elective admissions. If your ADT system does not capture planned admissions using an elective code then you can exclude these cases using the attached list of ICD-9 codes or by excluding OSHPD – Admission Type 1 Scheduled (arranged with the hospital at least 24 hrs prior to admission).
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Action Network Measurement Plan Detail
5) HCAHPS Question #19 -
Did hospital staff talk with you about whether you would have the help you needed when you left the hospital?
Numerator Denominator Calculation Measurement
Period
How to
Numerator Definition:
Number patients surveyed in the quarter who answered,
“yes”
Denominator Definition:
Number patients surveyed in the quarter who responded to the question
(numerator / denominator) x
100; as percent
Quarterly Report the data provided by your survey vendor. Input your numerator and denominator quarterly.
6) HCAHPS Question #20 - Did you get information in writing about what symptoms or health problems to look out for after you left the hospital?
Numerator Denominator Calculation Measurement
Period
How to
Numerator Definition:
Number patients surveyed in the quarter who answered,
“yes”
Denominator Definition:
Number patients surveyed in the quarter who responded to the question
(numerator / denominator) x
100; as percent
Quarterly Report the data provided by your survey vendor. Input your numerator and denominator quarterly.
7) Underdevelopment will replace #5 &6 once reported by CHART
Care Transitions - CHART HCAHPS+6 Continuity/Transition to Home questions
Numerator Denominator Calculation Measurement Period How to
*Comments – This measure is underdevelopment. Once completed, data will be obtained from CHART and uploaded for each member of the Action Network.
It is expected that this measure will be available in six months. In the mean time facilities should review their HCAHPS results, particularly questions 19 & 20.
“Did hospital staff talk with you about whether you would have the help you needed when you left the hospital?” (Q19)
“Did you get information in writing about what symptoms or health problems to look out for after you left the hospital?” (Q20)
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Action Network Measurement Plan Detail
Optional Outcome Measures
1) Percent 30-Day All-Cause Readmissions Selected Patient Population - Percent of discharges from the selected patient population with readmission for any cause within 30 days (e.g. HF, COPD, etc.)
Numerator Denominator Calculation Measurement
Period
How to
Numerator Definition: The number of acute care discharges in the
Denominator Definition: The number of index acute care discharges from the hospital
(numerator / denominator) x
100; as percent
Monthly Write a report to run no sooner than 31 days after the end of the measurement month.
This report will: measurement month from the selected patient population resulting in a readmission for the measurement month from the selected patient population
1a. Pull all the discharges in the measurement month from the selected patient population any cause within 30 days of the index discharge date.
Numerator Exclusions:

*Planned/Elective
Admissions
Denominator Exclusions:

Patients less than 18 years of age

Patients who died prior to discharge

Patients who were transferred to another hospital
 Labor & Delivery
1b: Remove exclusions (transfers to other acute care, deceased before discharge, Labor and Delivery, < 18)
The number of discharges after you remove the exclusions is your denominator (or “index discharges”)
2a. Through the unique medical record identifier, identify those (index) discharges that resulted in readmissions within 30 days of the discharge
2b. Remove exclusions (planned readmissions like chemotherapy, radiation, rehab, planned surgery)
Patients The number of (index) discharges that resulted in
readmissions within 30 days will be your numerator
*Comments – Some ADT systems capture planned admissions using an elective code. If that is the case in your organization exclude elective admissions. If your ADT system does not capture planned admissions using an elective code then you can exclude these cases using the attached list of ICD-9 codes.
2) Percent 90-Day All-Cause Readmissions Selected Patient Population - Percent of discharges from the selected
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Action Network Measurement Plan Detail patient population with readmission for any cause within 30 days (e.g. HF, COPD, etc.)
Numerator Denominator Calculation Measurement
Period
How to
Numerator Definition: The number of acute care discharges in the measurement month from the
Denominator Definition: The number of index acute care discharges from the hospital the measurement month
(numerator / denominator) x
100; as percent
Monthly Write a report to run no sooner than 121 days after the end of the measurement month.
This report will: selected patient population resulting in a readmission for any cause within 90 days of the index discharge date.
Numerator Exclusions:

*Planned/Elective
Admissions from the selected patient population
Denominator Exclusions:

Patients less than 18 years of age

Patients who died prior to discharge
 Patients who were
1a. Pull all the discharges in the measurement month from the selected patient population
1b: Remove exclusions (transfers to other acute care, deceased before discharge, Labor and Delivery, < 18)
The number of discharges after you remove the exclusions is your denominator (or “index discharges”)
2a. Through the unique medical record identifier, identify those (index) discharges that resulted in readmissions within 30 days of the discharge transferred to another hospital

Labor & Delivery
Patients
2b. Remove exclusions (planned readmissions like chemotherapy, radiation, rehab, planned surgery)
The number of (index) discharges that resulted in
readmissions within 30 days will be your numerator
*Comments – Some ADT systems capture planned admissions using an elective code. If that is the case in your organization exclude elective admissions. If your ADT system does not capture planned admissions using an elective code then you can exclude these cases using the attached list of ICD-9 codes.
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