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Stroke Education

CMS Measure ID
CMS107v6
Version
6
NQF Number
None
Measure Description

Ischemic or hemorrhagic stroke patients or their caregivers who were given educational materials during the hospital stay addressing all of the following: activation of emergency medical system, need for follow-up after discharge, medications prescribed at discharge, risk factors for stroke, and warning signs and symptoms of stroke

Initial Population

Patients age 18 and older discharged from inpatient care (non-elective admissions) with a principal diagnosis of ischemic or hemorrhagic stroke and a length of stay less than or equal to 120 days that ends during the measurement period

Denominator Statement

Ischemic stroke or hemorrhagic stroke patients discharged to home, home care, or court/law enforcement

Denominator Exclusions

Patients with comfort measures documented

Numerator Statement

Ischemic or hemorrhagic stroke patients with written documentation that they or their caregivers were given educational material addressing all of the following:

1. Activation of emergency medical system

2. Follow-up after discharge

3. Medications prescribed at discharge

4. Risk factors for stroke

5. Warning signs and symptoms of stroke

Numerator Exclusions

Not Applicable

Denominator Exceptions

None

Measure Steward
Short Name
Stroke8
Next Version
Measure Scoring
Measure Type
Improvement Notation

Improvement noted as an increase in rate

Guidance

Written information given to the patient is required to address each and every one of the educational components. These components are modeled in the population criteria and data criteria as communication from provider to patient :activation of emergency medical system, follow-up after discharge, medications prescribed at discharge, risk factors and signs and symptoms, and are intended to be specific to stroke.

The "Non-elective admissions" value set intends to capture all non-scheduled hospitalizations. This value set is a subset of the "Inpatient encounter" value set, excluding concepts that specifically refer to elective hospital admissions. Non-elective admissions include emergency, urgent and unplanned admissions.

Specifications

Release Notes

Header

  • Incremented eMeasure Version number.

    Measure Section: eMeasure Version number

    Source of Change: Measure Lead

  • Updated Copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Added 'ends during the measurement period' to the Initial Population narrative statement to better align with measure logic.

    Measure Section: Initial Population

    Source of Change: JIRA (CQM-2520)

Value Set

The VSAC is the source of truth for the value set content, please visit the VSAC for downloads of current value sets.

  • Value set Patient Refusal (2.16.840.1.113883.3.117.1.7.1.93): Added 3 SNOMEDCT codes (183946001, 183956002, 609589008).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Hemorrhagic Stroke (2.16.840.1.113883.3.117.1.7.1.212): Deleted 2 ICD9CM codes (430, 431).

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

  • Value set Ischemic Stroke (2.16.840.1.113883.3.117.1.7.1.247): Deleted 12 ICD9CM codes.

    Measure Section: QDM Data Elements

    Source of Change: Annual Update

Last Updated: Aug 19, 2019