Stroke Education

Last updated: May 3, 2018

CMS Measure ID: CMS107v3
Version: 3
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 Patient 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 or equal to 120 days.

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 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:


Measure Steward: The Joint Commission
Domain: Person and Caregiver-Centered Experience Outcomes
Short Name: Stroke8
Next Version:
Measure Score: Proportion
Score Type: Process
Improvement Notation:

An increase in rate


The unit of measurement for this measure is an inpatient episode of care. Each distinct hospitalization should be reported, regardless of whether the same patient is admitted for inpatient care more than once during the measurement period. In addition, the eMeasure logic intends to represent events within or surrounding a single occurrence of an inpatient hospitalization.

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, including patients admitted for observation.


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