Stroke Education

Last updated: September 15, 2017

CMS Measure ID: CMS107v5
Version: 5
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 than 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
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.

Addendum Notes: Value Set content updated, Jan 2017 and Sept 2017

Specifications

Release Notes

Header

  • Updated Copyright.

    Measure Section: Copyright

    Source of Change: Annual Update

  • Incremented eMeasure Version number.

    Measure Section: eMeasure Version number

    Source of Change: Measure Lead

  • Removed unit of measurement language from Guidance. HQMF now has a header field, 'measure item count', where the unit of measurement can be identified in a computable fashion.

    Measure Section: Guidance

    Source of Change: Measure Lead

  • Updated initial population header to harmonize across all stroke measures.

    Measure Section: Initial Population

    Source of Change: Measure Lead

Logic

  • Introduced the operator 'Intersection of' to condense logic and reduce complexity.

    Measure Section: Initial Population

    Source of Change: Measure Lead

  • Replaced 'Diagnosis, Active: XXX (ordinality: Principal)' datatype with 'Encounter, Performed: XXX (principal diagnosis: XXX)' datatype to conform with QDM 4.2 changes and provide more accurate logic.

    Measure Section: Initial Population

    Source of Change: QDM Standards

  • Added new attribute 'principal diagnosis' to 'Encounter, performed' datatype to conform to QDM 4.2 changes and provide more accurate logic. Removed QDM data element Attribute: 'Ordinality: Principal' using 'Principal SNOMEDCT Value Set (2.16.840.1.113883.3.1.7.1.14.)’ to conform to QDM 4.2. changes and provide more accurate logic.

    Measure Section: QDM Data Elements

    Source of Change: QDM Standards

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 Instructions for Follow Up After Discharge (2.16.840.1.113883.3.117.1.7.1.378): Added 1 SNOMEDCT code (183616001) and deleted 1 SNOMEDCT code (61342007).

    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): Added 3 SNOMEDCT codes (230701008, 307363008, 426107000) and deleted 5 SNOMEDCT codes (233964008, 288723005, 300920004, 64586002, 71444005). Deleted 18 ICD10CM codes.

    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): Added 1 ICD10CM code (I60.2) and deleted 3 ICD10CM codes (I60.20, I60.21, I60.22).

    Measure Section: QDM Data Elements

    Source of Change: ICD-10 Addendum

  • Value set Ischemic Stroke (2.16.840.1.113883.3.117.1.7.1.247): Added 18 ICD10CM codes.

    Measure Section: QDM Data Elements

    Source of Change: ICD-10 Addendum

  • 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: 4Q 2017 Addendum

  • 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: 4Q 2017 Addendum

  • 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: 4Q 2017 Addendum

External Resources