Stroke Education

Last updated: July 12, 2017

CMS Measure ID: CMS107v4
Version: 4
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 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: The Joint Commission
Domain: Person and Caregiver-Centered Experience Outcomes
Short Name: Stroke8
Next Version: Stroke Education
Previous Version: Stroke Education
Measure Score: Proportion
Improvement Notation:

Improvement noted as an increase in rate.

Guidance:

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.

Specifications

Release Notes

Header

  • Copyright updated.
  • eMeasure version number incremented.
  • Removed reference to observation patients from guidance header field, since value set does not include observation encounters.

Logic

  • Added timing relationship for each indivdual 'AND' statement in the Numerator logic to clarify the applicability of the timing relationship.
  • Corrected 'Communication: From Patient to Provider' datatype to 'Communication: From Provider to Patient' in Numerator criterion representing patient refusal of written materials.
  • Introduced function 'satisfies all' to specify that qualifying events must meet all conditions from a set of conditions or 'satisfies any' to specify that qualifying events must meet at least one condition from a set of conditions to streamline expression logic.
  • Introduced occurrencing on variables to enforce that the same instance of a clinical event is used throughout the measure when the logic within the variable does not limit the event to a single instance, e.g., FIRST or MOST RECENT.
  • Introduced the 'Intersection of' operator to specify the selection of the data sets common to all individual statements underneath the 'Intersection of'.
  • Introduced variables $EncounterInpatientNonElective and $InterventionComfortMeasures to allow re-use of logical expressions and reduce redundancy/complexity.
  • Removed occurrencing and added timing constraint to 'Encounter, Performed: Emergency Department Visit' when this QDM element is used on the right-hand side of a temporal operation, to enforce a constraint that wasn't necessarily achieved through occurrencing alone.
  • Replaced 'Patient Characteristic Birthdate' with 'Age at' operator.
  • Replaced 'ORs' with 'Union of' operator to provide a mechanism for specifying that qualifying event(s) must be a member of at least one of the data elements being unioned (if appropriate for measure intent).
  • Replaced timing relationship 'during' with 'starts during' where both a start datetime and an end datetime associated with a particular QDM element are not critical to fulfill the measure intent.
  • Replaced timing relationship 'ends before start of' with 'ends before or concurrent with start of' in logic criteria relating 'Encounter, Performed: Emergency Department Visit' and $EncounterInpatient, allowing for the Emergency Department Visit discharge to occur in the same minute as the inpatient admission.
  • The top level logical operator for the Numerator Exclusions, Denominator Exclusions, Denominator Exceptions, and Measure Population Exclusions defaults to 'OR'.

Value Sets

No changes

External Resources