Table public_hospital_redesign_and_incentives_in_medi_cal_pri_b389fb68

Table: public_hospital_redesign_and_incentives_in_medi_cal_pri_b389fb68

year dph_dmph hospital number metric numerator numerator_annotation_code denominator denominator_annotation_code achievement_value achievement_rate achievement_rate_annotation_code baseline_rate baseline_rate_annotation_code target_rate allocation

DY12 DPH Alameda Health System 1.1.1.a Alcohol and Drug Misuse (SBIRT) 318 0 20342 0 1 0.0156 0 0 0 0 1044098.98

DY12 DPH Alameda Health System 1.1.2 Care Coordinator Assignment 83 0 911 0 1 0.0911 0 0 0 0 1044098.98

DY12 DPH Alameda Health System 1.1.3.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 1431 0 4775 0 1 0.2997 0 0.3497 0 0.3444 1044098.99

DY12 DPH Alameda Health System 1.1.4 Depression Remission at 12 Months (CMS159v4) 0 0 None 4 0 None 4 None 1 0 $-

DY12 DPH Alameda Health System 1.1.5.f Screening for Clinical Depression and follow-up 2685 0 17761 0 1 0.1512 0 0.0077 0 0 1044098.99

DY12 DPH Alameda Health System 1.1.6.t Tobacco Assessment and Counseling 14984 0 15822 0 1 0.947 0 0.8911 0 0.8978 1044098.99

DY12 DPH Alameda Health System 1.2.1.a Alcohol and Drug Misuse (SBIRT) 318 0 20342 0 1 0.0156 0 0 0 0 1044098.98

DY12 DPH Alameda Health System 1.2.11 REAL data completeness 26150 0 26151 0 1 1 0 0.9998 0 NA 1044098.99

DY12 DPH Alameda Health System 1.2.12.f Screening for Clinical Depression and follow-up 2685 0 17761 0 1 0.1512 0 0.0077 0 0 1044098.99

DY12 DPH Alameda Health System 1.2.13 SO/GI data completeness 23 0 18748 0 1 0.0012 0 0 0 0 1044098.99

DY12 DPH Alameda Health System 1.2.14.t Tobacco Assessment and Counseling 14984 0 15822 0 1 0.947 0 0.8911 0 0.8978 1044098.99

DY12 DPH Alameda Health System 1.2.2 CG-CAHPS: Provider Rating 724 0 1000 0 1 0.724 0 0.6621 0 0.6662 1044098.98

DY12 DPH Alameda Health System 1.2.3.c Colorectal Cancer Screening 5911 0 9495 0 1 0.6225 0 0.5554 0 0.5656 1044098.98

DY12 DPH Alameda Health System 1.2.4.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 1431 0 4775 0 1 0.2997 0 0.3497 0 0.3444 1044098.98

DY12 DPH Alameda Health System 1.2.5.b Controlling Blood Pressure 4209 0 5949 0 1 0.7075 0 0.7146 0 0.7032 1044098.98

DY12 DPH Alameda Health System 1.2.6 Documented REAL and/or SO/GI disparity reduction plan: Documented disparity reduction plan? Yes Yes 0 Plan ? 0 1 0 0 NA 0 NA 1044098.98

DY12 DPH Alameda Health System 1.2.7.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 532 0 591 0 1 0.9002 0 0.3676 0 0.6808 1044098.98

DY12 DPH Alameda Health System 1.2.8 Prevention Quality Overall Composite #90 237 0 40175 0 1 0.0059 0 0.0064 0 0 1044098.98

DY12 DPH Alameda Health System 1.2.9 Primary Care Redesign metrics stratified by REAL categories and SO/GI: Primary care redesign metrics stratified? Yes Yes 0 Stratified ? 0 1 0 0 NA 0 NA 1044098.99

DY12 DPH Alameda Health System 1.3.1 Closing the referral loop: receipt of specialist report (CMS50v3) 8337 0 11088 0 1 0.7519 0 0.2828 0 0 1044098.98

DY12 DPH Alameda Health System 1.3.2 DHCS All-Cause Readmissions 113 0 1057 0 1 0.1069 0 0.1156 0 0.1318 1044098.98

DY12 DPH Alameda Health System 1.3.3 Influenza Immunization 4119 0 7230 0 1 0.5697 0 0.6489 0 0 1044098.99

DY12 DPH Alameda Health System 1.3.4 Post Procedure ED Visits 153 0 9264 0 1 0.0165 0 0.022 0 0 1044098.99

DY12 DPH Alameda Health System 1.3.5 Request for Specialty Care Expertise Turnaround Time 30468 0 34999 0 1 0.8705 0 0.1037 0 0 1044098.99

DY12 DPH Alameda Health System 1.3.6 Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters 474 0 34999 0 1 0.0135 0 0.013 0 0 1044098.99

DY12 DPH Alameda Health System 1.3.7 Tobacco Assessment and Counseling 9735 0 10337 0 1 0.9418 0 0.8528 0 0.8633 1044098.99

DY12 DPH Alameda Health System 1.4.1 Abnormal Results Follow-Up: Abnormal INR Follow-up 0 0 0 0 0 0 0 0.337 0 NA $-

DY12 DPH Alameda Health System 1.4.1 Abnormal Results Follow-Up: Abnormal BIRADS Follow-up 0 0 0 0 0 0 0 0.4758 0 NA $-

DY12 DPH Alameda Health System 1.4.1 Abnormal Results Follow-Up: Abnormal Potassium Follow-up 0 0 0 0 0 0 0 0.4832 0 NA $-

DY12 DPH Alameda Health System 1.4.2 Annual Monitoring for Patients on Persistent Medications 0 0 0 0 0 0 0 0.7532 0 0.8446 $-

DY12 DPH Alameda Health System 1.4.3 INR Monitoring for Individuals on Warfarin 0 0 0 0 0 0 0 0.1261 0 0 473107.35

DY12 DPH Alameda Health System 1.5.1.b Controlling Blood Pressure 4209 0 5949 0 1 0.7075 0 0 0 0 1044098.99

DY12 DPH Alameda Health System 1.5.2.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 532 0 591 0 1 0.9002 0 0 0 0 1044098.99

DY12 DPH Alameda Health System 1.5.3 PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 8572 0 10250 0 1 0.8363 0 0 0 0 1044098.99

DY12 DPH Alameda Health System 1.5.4.t Tobacco Assessment and Counseling 14984 0 15822 0 1 0.947 0 0 0 0 1044098.99

DY12 DPH Alameda Health System 1.6.1 BIRADS to Biopsy 0 0 0 0 0 0 0 0.1932 0 0 473107.36

DY12 DPH Alameda Health System 1.6.2 Breast Cancer Screening 0 0 0 0 0 0 0 0.571 0 0.5853 $-

DY12 DPH Alameda Health System 1.6.3 Cervical Cancer Screening 0 0 0 0 0 0 0 0.2555 0 0.5433 $-

DY12 DPH Alameda Health System 1.6.4.c Colorectal Cancer Screening 0 0 0 0 0 0 0 0.5554 0 0.5656 473107.35

DY12 DPH Alameda Health System 1.6.5 Receipt of appropriate follow-up for abnormal CRC screening 0 0 0 0 0 0 0 0.5263 0 0 473107.35

DY12 DPH Alameda Health System 2.1.1 Baby Friendly Hospital designation: BFUSA Designation Yes Yes 0 BFUSA Cert? 0 1 0 0 NA 0 NA 1119001.74

DY12 DPH Alameda Health System 2.1.2 Exclusive Breast Milk Feeding (PC-05) 265 0 365 0 0 0.726 0 0.8571 0 0.798 1119001.74

DY12 DPH Alameda Health System 2.1.3 OB Hemorrhage: Massive Transfusion None 1 1401 0 1 None 1 None 1 0 1119001.74

DY12 DPH Alameda Health System 2.1.4 OB Hemorrhage: Total Products Transfused 124 0 1401 0 1 0.0885 0 0.0641 0 0 1119001.74

DY12 DPH Alameda Health System 2.1.5 PC-02 Cesarean Section 71 0 494 0 1 0.1437 0 0.1586 0 0.185 1119001.74

DY12 DPH Alameda Health System 2.1.6 Prenatal and Postpartum Care: Prenatal Care 728 0 905 0 1 0.80441989 0 0.7456 0 0.7744 559500.87

DY12 DPH Alameda Health System 2.1.6 Prenatal and Postpartum Care: Postpartum Care 541 0 905 0 1 0.597790055 0 0.5061 0 0.5547 559500.87

DY12 DPH Alameda Health System 2.1.7 Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage 40 0 133 0 1 0.3008 0 0.1981 0 0 1119001.74

DY12 DPH Alameda Health System 2.1.8 Unexpected Newborn Complications (UNC) 99 0 1064 0 1 0.093 0 0.0997 0 0 1119001.74

DY12 DPH Alameda Health System 2.1.9 OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed)
[Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) 8 0 16 0 1 0 0 NA 0 NA 1119001.73

DY12 DPH Alameda Health System 2.2.1 DHCS All-Cause Readmissions 130 0 1526 0 1 0.0852 0 0.0969 0 0.1318 1119001.74

DY12 DPH Alameda Health System 2.2.2 H-CAHPS: Care Transition Metrics (3) 4647 0 10000 0 0 0.4647 0 0.409 0 0.48 1119001.74

DY12 DPH Alameda Health System 2.2.3 Medication Reconciliation 30 days 787 0 938 0 1 0.839 0 0 0 0 1119001.74

DY12 DPH Alameda Health System 2.2.4 Reconciled Medication List Received by Discharged Patients 875 0 2979 0 1 0.2937 0 0 0 0 1119001.74

DY12 DPH Alameda Health System 2.2.5 Timely Transmission of Transition Record 63 0 2422 0 1 0.026 0 0 0 0 1119001.74

DY12 DPH Alameda Health System 2.3.1 Care Coordinator Assignment 140 0 2206 0 1 0.0635 0 0.1203 0 0 1119001.74

DY12 DPH Alameda Health System 2.3.2 Medication Reconciliation 30 days 740 0 866 0 1 0.8545 0 0 0 0 1119001.74

DY12 DPH Alameda Health System 2.3.3 Prevention Quality Overall Composite #90 231 0 2205 0 1 0.1048 0 0.0834 0 0 1119001.74

DY12 DPH Alameda Health System 2.3.4 Timely Transmission of Transition Record 48 0 1848 0 1 0.026 0 0 0 0 1119001.73

DY12 DPH Alameda Health System 2.6.1 Alcohol and Drug Misuse (SBIRT) 170 0 1357 0 1 0.1253 0 0 0 0 1119001.74

DY12 DPH Alameda Health System 2.6.2 Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen 44 0 183 0 1 0.2404 0 0 0 0 1119001.74

DY12 DPH Alameda Health System 2.6.3 Patients with chronic pain on long term opioid therapy checked in PDMPs 46 0 183 0 1 0.2514 0 0 0 0 1119001.74

DY12 DPH Alameda Health System 2.6.4 Screening for Clinical Depression and follow-up 181 0 1205 0 1 0.1502 0 0 0 0 1119001.74

DY12 DPH Alameda Health System 2.6.5 Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy 1172 0 1296 0 1 0.9043 0 0 0 0 1119001.74

DY12 DPH Alameda Health System 3.1.1 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis 88 0 129 0 1 0.6822 0 0.6014 0 0.4038 1447708.5

DY12 DPH Alameda Health System 3.1.2 Avoidance of Antibiotic Treatment with Low Colony Urinary Cultures 0 0 0 0 0 0 0 0.1507 0 NA 643426

DY12 DPH Alameda Health System 3.1.3 National Healthcare Safety Network (NHSN) Antimicrobial Use Measure 23447 0 168989 0 1 0.1387 0 0.0334 0 0 1447708.5

DY12 DPH Alameda Health System 3.1.4 Peri-operative Prophylactic Antibiotics Administered after Surgical Closure 151 0 265 0 1 0.5698 0 0.4746 0 0 1447708.5

DY12 DPH Alameda Health System 3.1.5 Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR No 9670 0 10000 0 1 0.967 0 0 0 0 1447708.5

DY12 DMPH Antelope Valley Hospital, Lancaster 2.1.1 Baby Friendly Hospital designation: BFUSA Designation Yes Yes 0 BFUSA Cert? 0 1 0 0 NA 0 NA 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 2.1.2 Exclusive Breast Milk Feeding (PC-05) 287 0 502 0 1 0.5717 0 0 0 0 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 2.1.3 OB Hemorrhage: Massive Transfusion None 1 860 0 1 None 1 0 0 0 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 2.1.4 OB Hemorrhage: Total Products Transfused 44 0 860 0 1 0.0512 0 0 0 0 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 2.1.5 PC-02 Cesarean Section 60 0 224 0 1 0.2679 0 0 0 0 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 2.1.6 Prenatal and Postpartum Care: Prenatal Care 21 0 215 0 1 0.097674419 0 0 0 0.7744 193459.46

DY12 DMPH Antelope Valley Hospital, Lancaster 2.1.6 Prenatal and Postpartum Care: Postpartum Care 80 0 215 0 1 0.372093023 0 0 0 0.5547 193459.46

DY12 DMPH Antelope Valley Hospital, Lancaster 2.1.7 Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage 13 0 42 0 1 0.3095 0 0 0 0 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 2.1.8 Unexpected Newborn Complications (UNC) None 1 672 0 1 None 1 0 0 0 386918.91

DY12 DMPH Antelope Valley Hospital, Lancaster 2.1.9 OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed)
[Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) 9 0 16 0 1 0 0 NA 0 NA 386918.91

DY12 DMPH Antelope Valley Hospital, Lancaster 2.2.1 DHCS All-Cause Readmissions 539 0 6175 0 1 0.0873 0 0 0 0 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 2.2.2 H-CAHPS: Care Transition Metrics (3) 1739 0 4005 0 1 0.4342 0 0 0 0 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 2.2.3 Medication Reconciliation 30 days 0 0 0 0 1 0 0 0 0 0 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 2.2.4 Reconciled Medication List Received by Discharged Patients 635 0 708 0 1 0.8969 0 0 0 0 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 2.2.5 Timely Transmission of Transition Record 0 0 9576 0 1 0 0 0 0 0 386918.91

DY12 DMPH Antelope Valley Hospital, Lancaster 2.3.1 Care Coordinator Assignment 4697 0 6781 0 1 0.6927 0 0 0 0 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 2.3.2 Medication Reconciliation 30 days 0 0 0 0 1 0 0 0 0 0 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 2.3.3 Prevention Quality Overall Composite #90 1039 0 6783 0 1 0.1532 0 0 0 0 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 2.3.4 Timely Transmission of Transition Record 0 0 9576 0 1 0 0 0 0 0 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 2.7.1 Advance Care Plan 506 0 1020 0 1 0.4961 0 0 0 0 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 2.7.2 Ambulatory Palliative Care Team Established: Ambulatory Palliative Care Team Established? No Yes 0 Team Established? 0 1 0 0 NA 0 NA 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 2.7.3 MWM #8: Treatment Preferences (documentation) Inpatient 34 0 96 0 1 0.3542 0 0 0 0 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 2.7.4 MWM #8: Treatment Preferences (documentation) Outpatient 0 0 0 0 1 0 0 0 0 0 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 2.7.5 Palliative Care Service Offered at Time of Diagnosis of Advanced Illness 0 0 0 0 1 0 0 0 0 0 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 2.7.6 Proportion Admitted to Hospice for Less Than 3 Days None 1 44 0 1 None 1 0 0 0 386918.91

DY12 DMPH Antelope Valley Hospital, Lancaster 3.1.1 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis 193 0 386 0 1 0.5 0 0 0 0 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 3.1.3 National Healthcare Safety Network (NHSN) Antimicrobial Use Measure 26703 0 69535 0 1 0.384 0 0 0 0 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 3.1.4 Peri-operative Prophylactic Antibiotics Administered after Surgical Closure 183 0 377 0 1 0.4854 0 0 0 0 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 3.1.5 Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR No 9350 0 10000 0 1 0.935 0 0 0 0 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 3.2.1 Imaging for Routine Headaches (Choosing Wisely) 88 0 502 0 1 0.1753 0 0 0 0 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 3.2.2 Appropriate Emergency Department Utilization of CT for Pulmonary Embolism 101 0 377 0 1 0.2679 0 0 0 0 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 3.2.3 Use of Imaging Studies for Low Back Pain 1403 0 1963 0 1 0.7147 0 0 0 0 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 3.2.4 Use of Imaging Studies for Low Back Pain (anytime) Variation of HEDIS Use of Imaging Studies for Low Back Pain measures: Appropriate Score 106 0 177 0 1 0.598870056 0 0 0 NA 193459.46

DY12 DMPH Antelope Valley Hospital, Lancaster 3.2.4 Use of Imaging Studies for Low Back Pain (anytime) Variation of HEDIS Use of Imaging Studies for Low Back Pain measures: Inappropriate Score 40 0 177 0 1 0.225988701 0 0 0 NA 193459.46

DY12 DMPH Antelope Valley Hospital, Lancaster 3.4.1 ePBM-01 Pre-op Anemia Screening, Selected Elective Surgical Patients 114 0 289 0 1 0.3945 0 0 0 0 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 3.4.2 ePBM-02 Pre-op Hemoglobin Level, Selected Elective Surgical Patients 28 0 30 0 1 0.9333 0 0 0 0 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 3.4.3 ePBM-03 Pre-op Type and Crossmatch, Type and Screen, Selected elective Surgical Patients 236 0 298 0 1 0.7919 0 0 0 0 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 3.4.4 ePBM-04 Initial Transfusion Threshold 379 0 379 0 1 1 0 0 0 0 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster 3.4.5 ePBM-05 Outcome of Patient Blood Management, Selected Elective Surgical Patients None 1 114 0 1 None 1 0 0 0 386918.92

DY12 DMPH Antelope Valley Hospital, Lancaster None Assign or hire a palliative care nurse to oversee improvements and PRIME None None None None 1 None None None None None 424387.35

DY12 DMPH Antelope Valley Hospital, Lancaster None Conduct at least two trainings on updated protocols. None None None None 1 None None None None None 424387.35

DY12 DMPH Antelope Valley Hospital, Lancaster None Conduct literature review of best practices in care for complex populations. None None None None 1 None None None None None 424387.36

DY12 DMPH Antelope Valley Hospital, Lancaster None Conduct training on new policies and procedures document. None None None None 1 None None None None None 424387.35

DY12 DMPH Antelope Valley Hospital, Lancaster None Conduct training with antibiotic stewardship staff on updated protocols. None None None None 1 None None None None None 424387.35

DY12 DMPH Antelope Valley Hospital, Lancaster None Conduct training with blood product management staff on updated protocols. None None None None 1 None None None None None 424387.35

DY12 DMPH Antelope Valley Hospital, Lancaster None Conduct training with care management staff on updated protocols. None None None None 1 None None None None None 424387.35

DY12 DMPH Antelope Valley Hospital, Lancaster None Conduct training with palliative care staff on updated protocols. None None None None 1 None None None None None 424387.35

DY12 DMPH Antelope Valley Hospital, Lancaster None Create a workflow map for palliative care discussion within 3 days of ICU admission. None None None None 1 None None None None None 424387.35

DY12 DMPH Antelope Valley Hospital, Lancaster None Create or update a policies and procedures document for improvement in one metric. None None None None 1 None None None None None 424387.36

DY12 DMPH Antelope Valley Hospital, Lancaster None Create policy for PRIME reporting process for high-cost imaging metrics None None None None 1 None None None None None 424387.35

DY12 DMPH Antelope Valley Hospital, Lancaster None Create relationships with post-acute care partners. Strengthen discharge referrals and improve strategies to reduce readmissions via post-acute care None None None None 1 None None None None None 424387.36

DY12 DMPH Antelope Valley Hospital, Lancaster None Develop a community outreach plan for prenatal and postpartum care. None None None None 1 None None None None None 424387.35

DY12 DMPH Antelope Valley Hospital, Lancaster None Develop hospital-wide dashboard for sharing progress in antibiotic stewardship. None None None None 1 None None None None None 424387.35

DY12 DMPH Antelope Valley Hospital, Lancaster None Develop hospital-wide dashboard for sharing progress in blood product utilization. None None None None 1 None None None None None 424387.35

DY12 DMPH Antelope Valley Hospital, Lancaster None Identify data collection workflow and gaps for each high-cost imaging metric. None None None None 1 None None None None None 424387.35

DY12 DMPH Antelope Valley Hospital, Lancaster None Identify group of four stakeholders including and distribute best practices. None None None None 1 None None None None None 207478.27

DY12 DMPH Antelope Valley Hospital, Lancaster None Perform one PDSA cycle on exclusive breast feeding. None None None None 1 None None None None None 424387.35

DY12 DMPH Antelope Valley Hospital, Lancaster None Revise and update patient discharge protocols. None None None None 1 None None None None None 424387.35

DY12 DMPH Antelope Valley Hospital, Lancaster None Update existing protocols for antibiotic stewardship based on findings in literature review. None None None None 1 None None None None None 424387.35

DY12 DMPH Antelope Valley Hospital, Lancaster None Update existing protocols for blood product management based on findings in literature review. None None None None 1 None None None None None 424387.35

DY12 DMPH Antelope Valley Hospital, Lancaster None Update existing protocols for clinical care management based on findings in literature review. None None None None 1 None None None None None 424387.35

DY12 DMPH Antelope Valley Hospital, Lancaster None Update existing protocols for palliative care based on findings in literature review. None None None None 1 None None None None None 424387.35

DY12 DPH Arrowhead Regional Medical Center 1.1.1.a Alcohol and Drug Misuse (SBIRT) None 1 377 0 1 None 1 0 0 0 1484965.52

DY12 DPH Arrowhead Regional Medical Center 1.1.2 Care Coordinator Assignment 191 0 1567 0 1 0.1219 0 0.6633 0 0 1484965.52

DY12 DPH Arrowhead Regional Medical Center 1.1.3.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 1512 0 4720 0 1 0.3203 0 0.3481 0 0.343 1484965.52

DY12 DPH Arrowhead Regional Medical Center 1.1.4 Depression Remission at 12 Months (CMS159v4) 72 0 1089 0 1 0.0661 0 0 0 0 1484965.52

DY12 DPH Arrowhead Regional Medical Center 1.1.5.f Screening for Clinical Depression and follow-up 238 0 377 0 1 0.6313 0 0 0 0 1484965.51

DY12 DPH Arrowhead Regional Medical Center 1.1.6.t Tobacco Assessment and Counseling 338 0 377 0 1 0.8966 0 0.7215 0 0.7451 1484965.51

DY12 DPH Arrowhead Regional Medical Center 1.2.1.a Alcohol and Drug Misuse (SBIRT) None 1 377 0 1 None 1 0 0 0 1484965.52

DY12 DPH Arrowhead Regional Medical Center 1.2.11 REAL data completeness 3821 0 22049 0 0 0.1733 0 0.1561 0 NA 1484965.51

DY12 DPH Arrowhead Regional Medical Center 1.2.12.f Screening for Clinical Depression and follow-up 9954 0 12819 0 1 0.7765 0 0 0 0 1484965.51

DY12 DPH Arrowhead Regional Medical Center 1.2.13 SO/GI data completeness 14621 0 16543 0 1 0.8838 0 0 0 0 1484965.51

DY12 DPH Arrowhead Regional Medical Center 1.2.14.t Tobacco Assessment and Counseling 338 0 377 0 1 0.8966 0 0.7215 0 0.7451 1484965.51

DY12 DPH Arrowhead Regional Medical Center 1.2.2 CG-CAHPS: Provider Rating 992 0 1195 0 1 0.8301 0 0.7043 0 0.7029 1484965.52

DY12 DPH Arrowhead Regional Medical Center 1.2.3.c Colorectal Cancer Screening 3797 0 7349 0 1 0.5167 0 0.4082 0 0.4331 1484965.52

DY12 DPH Arrowhead Regional Medical Center 1.2.4.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 1674 0 5097 0 1 0.3284 0 0.3481 0 0.343 1484965.52

DY12 DPH Arrowhead Regional Medical Center 1.2.5.b Controlling Blood Pressure 4491 0 6696 0 1 0.6707 0 0.6058 0 0.6155 1484965.52

DY12 DPH Arrowhead Regional Medical Center 1.2.6 Documented REAL and/or SO/GI disparity reduction plan: Documented disparity reduction plan? Yes Yes 0 Plan ? 0 1 0 0 NA 0 NA 1484965.52

DY12 DPH Arrowhead Regional Medical Center 1.2.7.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 258 0 330 0 1 0.7818 0 0.7647 0 0.7811 1484965.52

DY12 DPH Arrowhead Regional Medical Center 1.2.8 Prevention Quality Overall Composite #90 458 0 28677 0 1 0.016 0 0.0204 0 0 1484965.52

DY12 DPH Arrowhead Regional Medical Center 1.2.9 Primary Care Redesign metrics stratified by REAL categories and SO/GI: Primary care redesign metrics stratified? Yes Yes 0 Stratified ? 0 1 0 0 NA 0 NA 1484965.52

DY12 DPH Arrowhead Regional Medical Center 1.3.1 Closing the referral loop: receipt of specialist report (CMS50v3) 3623 0 25678 0 1 0.1411 0 0 0 0 1484965.52

DY12 DPH Arrowhead Regional Medical Center 1.3.2 DHCS All-Cause Readmissions 287 0 2016 0 1 0.1424 0 0.1469 0 0.1454 1484965.52

DY12 DPH Arrowhead Regional Medical Center 1.3.3 Influenza Immunization 174 0 357 0 1 0.4874 0 0 0 0 1484965.52

DY12 DPH Arrowhead Regional Medical Center 1.3.4 Post Procedure ED Visits 1367 0 16816 0 1 0.0813 0 0 0 0 1484965.52

DY12 DPH Arrowhead Regional Medical Center 1.3.5 Request for Specialty Care Expertise Turnaround Time 31788 0 53251 0 1 0.5969 0 0 0 0 1484965.52

DY12 DPH Arrowhead Regional Medical Center 1.3.6 Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters None 1 53251 0 1 None 1 0 0 0 1484965.51

DY12 DPH Arrowhead Regional Medical Center 1.3.7 Tobacco Assessment and Counseling 4630 0 6392 0 1 0.7243 0 0 0 0.7237 1484965.51

DY12 DPH Arrowhead Regional Medical Center 1.7.1 BMI Screening and Follow-up 254 0 377 0 1 0.6737 0 0.3024 0 0.4009 1484965.52

DY12 DPH Arrowhead Regional Medical Center 1.7.2 Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Numerator - Criteria Met (If your system has more than one hospital, please enter the sum of all criteria met)
Denominator - Required Criteria (If your system has more than one hospital, multiply the number of hospitals by 2) 2 0 8 0 1 0 0 NA 0 NA 1484965.52

DY12 DPH Arrowhead Regional Medical Center 1.7.3 Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI 2446 0 2472 0 1 0 0 0.6393 0 0.661 494988.51

DY12 DPH Arrowhead Regional Medical Center 1.7.3 Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition 333 0 341 0 1 0 0 0.4428 0 0.5198 494988.51

DY12 DPH Arrowhead Regional Medical Center 1.7.3 Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity 322 0 341 0 1 0 0 0.3167 0 0.4416 494988.51

DY12 DPH Arrowhead Regional Medical Center 2.1.1 Baby Friendly Hospital designation: BFUSA Designation Yes Yes 0 BFUSA Cert? 0 1 0 0 NA 0 NA 1437963.14

DY12 DPH Arrowhead Regional Medical Center 2.1.2 Exclusive Breast Milk Feeding (PC-05) 83 0 177 0 0 0.4689 0 0.5 0 0.5298 1437963.13

DY12 DPH Arrowhead Regional Medical Center 2.1.3 OB Hemorrhage: Massive Transfusion None 1 704 0 1 None 1 None 1 0 1437963.13

DY12 DPH Arrowhead Regional Medical Center 2.1.4 OB Hemorrhage: Total Products Transfused 72 0 704 0 1 0.1023 0 0.0521 0 0 1437963.13

DY12 DPH Arrowhead Regional Medical Center 2.1.5 PC-02 Cesarean Section 45 0 218 0 0 0.2064 0 0.2066 0 0.2044 1437963.13

DY12 DPH Arrowhead Regional Medical Center 2.1.6 Prenatal and Postpartum Care: Prenatal Care 75 0 570 0 1 0.131578947 0 0.434 0 0.7744 718981.57

DY12 DPH Arrowhead Regional Medical Center 2.1.6 Prenatal and Postpartum Care: Postpartum Care 271 0 570 0 1 0.475438596 0 0.5021 0 0.5547 718981.57

DY12 DPH Arrowhead Regional Medical Center 2.1.7 Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage 21 0 42 0 1 0.5 0 0.4324 0 0 1437963.13

DY12 DPH Arrowhead Regional Medical Center 2.1.8 Unexpected Newborn Complications (UNC) 17 0 318 0 1 0.0535 0 0.0274 0 0 1437963.13

DY12 DPH Arrowhead Regional Medical Center 2.1.9 OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed)
[Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) 12 0 16 0 1 0 0 NA 0 NA 1437963.13

DY12 DPH Arrowhead Regional Medical Center 2.2.1 DHCS All-Cause Readmissions 336 0 2563 0 1 0.1311 0 0.151 0 0.1491 1437963.13

DY12 DPH Arrowhead Regional Medical Center 2.2.2 H-CAHPS: Care Transition Metrics (3) 778 0 1547 0 1 0.5029 0 0.49 0 0.502 1437963.13

DY12 DPH Arrowhead Regional Medical Center 2.2.3 Medication Reconciliation 30 days 334 0 358 0 1 0.933 0 0.2493 0 0 1437963.13

DY12 DPH Arrowhead Regional Medical Center 2.2.4 Reconciled Medication List Received by Discharged Patients 32 0 482 0 1 0.0664 0 0 0 0 1437963.13

DY12 DPH Arrowhead Regional Medical Center 2.2.5 Timely Transmission of Transition Record 2717 0 2956 0 1 0.9191 0 0 0 0 1437963.13

DY12 DPH Arrowhead Regional Medical Center 2.3.1 Care Coordinator Assignment 77 0 467 0 1 0.1649 0 None 1 0 1437963.13

DY12 DPH Arrowhead Regional Medical Center 2.3.2 Medication Reconciliation 30 days 272 0 282 0 1 0.9645 0 0.2941 0 0 1437963.13

DY12 DPH Arrowhead Regional Medical Center 2.3.3 Prevention Quality Overall Composite #90 124 0 467 0 1 0.2655 0 0.0541 0 0 1437963.13

DY12 DPH Arrowhead Regional Medical Center 2.3.4 Timely Transmission of Transition Record 671 0 753 0 1 0.8911 0 0 0 0 1437963.13

DY12 DPH Arrowhead Regional Medical Center 2.4.1 Adolescent Well-Care Visit 0 0 0 0 0 0 0 None 1 0.5166 $-

DY12 DPH Arrowhead Regional Medical Center 2.4.2 Developmental Screening in the First Three Years of Life 0 0 0 0 0 0 0 0 0 0 689024

DY12 DPH Arrowhead Regional Medical Center 2.4.3 Documentation of Current Medications in the Medical Record (0-18 yo) 0 0 0 0 0 0 0 0 0 0 689024

DY12 DPH Arrowhead Regional Medical Center 2.4.4 Screening for Clinical Depression and follow-up 0 0 0 0 0 0 0 None 1 0 $-

DY12 DPH Arrowhead Regional Medical Center 2.4.5 Tobacco Assessment and Counseling (13 yo and older) 0 0 0 0 0 0 0 None 1 0 $-

DY12 DPH Arrowhead Regional Medical Center 2.4.6 Well Child Visits - First 15 months of life 0 0 0 0 0 0 0 None 1 0.0096 $-

DY12 DPH Arrowhead Regional Medical Center 2.4.7 Well Child Visits - Third, Fourth, Fifth, and Sixth Years of life 0 0 0 0 0 0 0 None 1 0.8375 $-

DY12 DPH Arrowhead Regional Medical Center 2.6.1 Alcohol and Drug Misuse (SBIRT) 18 0 1460 0 1 0.0123 0 0 0 0 1437963.13

DY12 DPH Arrowhead Regional Medical Center 2.6.2 Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen 12 0 249 0 1 0.0482 0 0 0 0 1437963.13

DY12 DPH Arrowhead Regional Medical Center 2.6.3 Patients with chronic pain on long term opioid therapy checked in PDMPs 31 0 249 0 1 0.1245 0 0 0 0 1437963.13

DY12 DPH Arrowhead Regional Medical Center 2.6.4 Screening for Clinical Depression and follow-up 1174 0 1443 0 1 0.8136 0 0 0 0 1437963.13

DY12 DPH Arrowhead Regional Medical Center 2.6.5 Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy 386 0 436 0 1 0.8853 0 0 0 0 1437963.13

DY12 DPH Arrowhead Regional Medical Center 3.1.1 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis 81 0 192 0 1 0.4219 0 0 0 0.22 1937880

DY12 DPH Arrowhead Regional Medical Center 3.1.2 Avoidance of Antibiotic Treatment with Low Colony Urinary Cultures 0 0 0 0 0 0 0 0.4094 0 NA 861280

DY12 DPH Arrowhead Regional Medical Center 3.1.3 National Healthcare Safety Network (NHSN) Antimicrobial Use Measure 24542 0 156600 0 1 0.1567 0 0 0 0 1937880

DY12 DPH Arrowhead Regional Medical Center 3.1.4 Peri-operative Prophylactic Antibiotics Administered after Surgical Closure 2410 0 3590 0 1 0.6713 0 0 0 0 1937880

DY12 DPH Arrowhead Regional Medical Center 3.1.5 Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR No 5200 0 10000 0 1 0.52 0 0 0 0 1937880

DY12 DMPH Bear Valley Community Hospital, Big Bear Lake 2.6.1 Alcohol and Drug Misuse (SBIRT) None 1 1378 0 1 None 1 0 0 0 180000

DY12 DMPH Bear Valley Community Hospital, Big Bear Lake 2.6.2 Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen 108 0 134 0 1 0.806 0 0 0 0 180000

DY12 DMPH Bear Valley Community Hospital, Big Bear Lake 2.6.3 Patients with chronic pain on long term opioid therapy checked in PDMPs 117 0 134 0 1 0.8731 0 0 0 0 180000

DY12 DMPH Bear Valley Community Hospital, Big Bear Lake 2.6.4 Screening for Clinical Depression and follow-up 586 0 1132 0 1 0.5177 0 0 0 0 180000

DY12 DMPH Bear Valley Community Hospital, Big Bear Lake 2.6.5 Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy 118 0 134 0 1 0.8806 0 0 0 0 180000

DY12 DMPH Bear Valley Community Hospital, Big Bear Lake None Develop and pilot protocol for annual depression, alcohol and drug misuse screening. None None None None 1 None None None None None 50000

DY12 DMPH Bear Valley Community Hospital, Big Bear Lake None Develop and pilot protocol for follow up with social worker for patients with positive screening. None None None None 1 None None None None None 50000

DY12 DMPH Bear Valley Community Hospital, Big Bear Lake None Develop a customized Pain Management document in Clinic EHR documentation software to promote continuity of care. None None None None 1 None None None None None 50000

DY12 DMPH Bear Valley Community Hospital, Big Bear Lake None Train staff and providers in psychosocial and cultural mindfulness and how it relates to chronic pain. None None None None 1 None None None None None 50000

DY12 DMPH Bear Valley Community Hospital, Big Bear Lake None Identify and assess existing alternative pain management therapies within the District None None None None 1 None None None None None 50000

DY12 DMPH Bear Valley Community Hospital, Big Bear Lake None Identify multi-modal pain management resources available to patient population in community None None None None 1 None None None None None 50000

DY12 DMPH Bear Valley Community Hospital, Big Bear Lake None Implementation of opioid safe prescribing guidelines in the Emergency Department None None None None 1 None None None None None 50000

DY12 DMPH Bear Valley Community Hospital, Big Bear Lake None Develop mechanism to identify patients in the pain management program to ensure continuity of care and minimize overutilization of opioids. None None None None 1 None None None None None 50000

DY12 DMPH Bear Valley Community Hospital, Big Bear Lake None Standardize pain management protocols and prescribing guidelines. None None None None 1 None None None None None 50000

DY12 DMPH Bear Valley Community Hospital, Big Bear Lake None Develop a process for scheduling pain focused follow up visits to ensure patients receive refills in a timely, appropriate manner. None None None None 1 None None None None None 50000

DY12 DMPH Bear Valley Community Hospital, Big Bear Lake None Develop and implement protocols for prescribing naloxone to patients receiving opioids for chronic pain. None None None None 1 None None None None None 50000

DY12 DMPH Bear Valley Community Hospital, Big Bear Lake None Train providers to identify signs of prescription opioid use disorders and provide treatment options. None None None None 1 None None None None None 50000

DY12 DMPH Coalinga Regional Medical Center, Coalinga 1.5.1.b Controlling Blood Pressure 15 0 None 4 0 None 4 0.5161 0 0.5348 $-

DY12 DMPH Coalinga Regional Medical Center, Coalinga 1.5.2.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic None 1 None 1 0 None 1 None 1 0.7679 $-

DY12 DMPH Coalinga Regional Medical Center, Coalinga 1.5.3 PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 143 0 143 0 1 1 0 0.9929 0 0 300000

DY12 DMPH Coalinga Regional Medical Center, Coalinga 1.5.4.t Tobacco Assessment and Counseling 13 0 143 0 0 0.0909 0 0.0851 0 0.7237 300000

DY12 DMPH Coalinga Regional Medical Center, Coalinga 1.7.1 BMI Screening and Follow-up 54 0 143 0 1 0.3776 0 0 0 0.4009 300000

DY12 DMPH Coalinga Regional Medical Center, Coalinga 1.7.2 Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Numerator - Criteria Met (If your system has more than one hospital, please enter the sum of all criteria met)
Denominator - Required Criteria (If your system has more than one hospital, multiply the number of hospitals by 2) 2 0 8 0 1 0 0 NA 0 NA 300000

DY12 DMPH Coalinga Regional Medical Center, Coalinga 1.7.3 Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI 88 0 88 0 1 1 0 0 0 0.5127 100000

DY12 DMPH Coalinga Regional Medical Center, Coalinga 1.7.3 Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition 30 0 88 0 1 0 0 0 0 0.5198 100000

DY12 DMPH Coalinga Regional Medical Center, Coalinga 1.7.3 Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity 21 0 88 0 1 0 0 0 0 0.4416 100000

DY12 DPH Contra Costa Regional Medical Center 1.1.1.a Alcohol and Drug Misuse (SBIRT) 4835 0 47362 0 1 0.1021 0 0.1205 0 0 1213958.07

DY12 DPH Contra Costa Regional Medical Center 1.1.2 Care Coordinator Assignment 2020 0 2377 0 1 0.8498 0 0.989 0 0 1213958.07

DY12 DPH Contra Costa Regional Medical Center 1.1.3.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 2373 0 7934 0 1 0.2991 0 0.3133 0 0.3117 1213958.07

DY12 DPH Contra Costa Regional Medical Center 1.1.4 Depression Remission at 12 Months (CMS159v4) None 1 910 0 1 None 1 None 1 0 1213958.06

DY12 DPH Contra Costa Regional Medical Center 1.1.5.f Screening for Clinical Depression and follow-up 12672 0 32505 0 1 0.3898 0 0.3677 0 0 1213958.06

DY12 DPH Contra Costa Regional Medical Center 1.1.6.t Tobacco Assessment and Counseling 33089 0 37437 0 1 0.8839 0 0.8212 0 0.8349 1213958.06

DY12 DPH Contra Costa Regional Medical Center 1.2.1.a Alcohol and Drug Misuse (SBIRT) 4835 0 47362 0 1 0.1021 0 0.1205 0 0 1213958.07

DY12 DPH Contra Costa Regional Medical Center 1.2.11 REAL data completeness 28267 0 55170 0 1 0.5124 0 0.2279 0 NA 1213958.06

DY12 DPH Contra Costa Regional Medical Center 1.2.12.f Screening for Clinical Depression and follow-up 12672 0 32505 0 1 0.3898 0 0.3677 0 0 1213958.06

DY12 DPH Contra Costa Regional Medical Center 1.2.13 SO/GI data completeness 16552 0 39707 0 1 0.4169 0 0 0 0 1213958.06

DY12 DPH Contra Costa Regional Medical Center 1.2.14.t Tobacco Assessment and Counseling 33089 0 37437 0 1 0.8839 0 0.8212 0 0.8349 1213958.06

DY12 DPH Contra Costa Regional Medical Center 1.2.2 CG-CAHPS: Provider Rating 732 0 1013 0 1 0.7226 0 0.6103 0 0.6196 1213958.07

DY12 DPH Contra Costa Regional Medical Center 1.2.3.c Colorectal Cancer Screening 11700 0 18012 0 1 0.6496 0 0.5684 0 0.5773 1213958.07

DY12 DPH Contra Costa Regional Medical Center 1.2.4.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 2373 0 7934 0 1 0.2991 0 0.3133 0 0.3117 1213958.07

DY12 DPH Contra Costa Regional Medical Center 1.2.5.b Controlling Blood Pressure 7338 0 10366 0 1 0.7079 0 0.614 0 0.6229 1213958.07

DY12 DPH Contra Costa Regional Medical Center 1.2.6 Documented REAL and/or SO/GI disparity reduction plan: Documented disparity reduction plan? Yes Yes 0 Plan ? 0 1 0 0 NA 0 NA 1213958.07

DY12 DPH Contra Costa Regional Medical Center 1.2.7.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 1558 0 1796 0 1 0.8675 0 0.8349 0 0.8443 1213958.06

DY12 DPH Contra Costa Regional Medical Center 1.2.8 Prevention Quality Overall Composite #90 455 0 63378 0 1 0.0072 0 0.0095 0 0 1213958.06

DY12 DPH Contra Costa Regional Medical Center 1.2.9 Primary Care Redesign metrics stratified by REAL categories and SO/GI: Primary care redesign metrics stratified? Yes Yes 0 Stratified ? 0 1 0 0 NA 0 NA 1213958.06

DY12 DPH Contra Costa Regional Medical Center 1.3.1 Closing the referral loop: receipt of specialist report (CMS50v3) 21134 0 21134 0 1 1 0 1 0 0 1213958.07

DY12 DPH Contra Costa Regional Medical Center 1.3.2 DHCS All-Cause Readmissions 124 0 1955 0 1 0.0634 0 0.0922 0 0.1318 1213958.07

DY12 DPH Contra Costa Regional Medical Center 1.3.3 Influenza Immunization 16946 0 26751 0 1 0.6335 0 0.6096 0 0 1213958.07

DY12 DPH Contra Costa Regional Medical Center 1.3.4 Post Procedure ED Visits 219 0 15572 0 1 0.0141 0 0.0143 0 0 1213958.06

DY12 DPH Contra Costa Regional Medical Center 1.3.5 Request for Specialty Care Expertise Turnaround Time 35772 0 51755 0 1 0.6912 0 0.6012 0 0 1213958.06

DY12 DPH Contra Costa Regional Medical Center 1.3.6 Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters 130 0 53375 0 1 0.0024 0 0.0006 0 0 1213958.06

DY12 DPH Contra Costa Regional Medical Center 1.3.7 Tobacco Assessment and Counseling 13471 0 14972 0 1 0.8997 0 0.8342 0 0.8466 1213958.06

DY12 DPH Contra Costa Regional Medical Center 1.6.1 BIRADS to Biopsy 57 0 66 0 1 0.8636 0 0.6098 0 0 1213958.07

DY12 DPH Contra Costa Regional Medical Center 1.6.2 Breast Cancer Screening 8720 0 12449 0 1 0.7005 0 0.6825 0 0.6857 1213958.07

DY12 DPH Contra Costa Regional Medical Center 1.6.3 Cervical Cancer Screening 15447 0 26037 0 1 0.5933 0 0.515 0 0.5433 1213958.06

DY12 DPH Contra Costa Regional Medical Center 1.6.4.c Colorectal Cancer Screening 11700 0 18012 0 1 0.6496 0 0.5684 0 0.5773 1213958.06

DY12 DPH Contra Costa Regional Medical Center 1.6.5 Receipt of appropriate follow-up for abnormal CRC screening 160 0 325 0 1 0.4923 0 0.4859 0 0 1213958.06

DY12 DPH Contra Costa Regional Medical Center 2.1.1 Baby Friendly Hospital designation: Discovery Phase Complete Yes Yes 0 Discovery Phase? 0 1 0 0 NA 0 NA 365486.31

DY12 DPH Contra Costa Regional Medical Center 2.1.1 Baby Friendly Hospital designation: Informational Webinar Participation Yes Yes 0 Webinar complete? 0 1 0 0 NA 0 NA 365486.31

DY12 DPH Contra Costa Regional Medical Center 2.1.1 Baby Friendly Hospital designation: BFUSA Designation No No 0 BFUSA Cert? 0 0 0 0 NA 0 NA 365486.31

DY12 DPH Contra Costa Regional Medical Center 2.1.2 Exclusive Breast Milk Feeding (PC-05) 754 0 1098 0 1 0.6867 0 0.5383 0 0.5643 1096458.92

DY12 DPH Contra Costa Regional Medical Center 2.1.3 OB Hemorrhage: Massive Transfusion None 1 1240 0 1 None 1 None 1 0 1096458.92

DY12 DPH Contra Costa Regional Medical Center 2.1.4 OB Hemorrhage: Total Products Transfused 33 0 1240 0 1 0.0266 0 0.0344 0 0 1096458.92

DY12 DPH Contra Costa Regional Medical Center 2.1.5 PC-02 Cesarean Section 75 0 345 0 1 0.2174 0 0.2359 0 0.2308 1096458.92

DY12 DPH Contra Costa Regional Medical Center 2.1.6 Prenatal and Postpartum Care: Prenatal Care 588 0 653 0 1 0.900459418 0 0.9345 0 0.9173 548229.46

DY12 DPH Contra Costa Regional Medical Center 2.1.6 Prenatal and Postpartum Care: Postpartum Care 543 0 653 0 1 0.831546708 0 0.7903 0 0.7243 548229.46

DY12 DPH Contra Costa Regional Medical Center 2.1.7 Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage 23 0 146 0 1 0.1575 0 0.1266 0 0 1096458.92

DY12 DPH Contra Costa Regional Medical Center 2.1.8 Unexpected Newborn Complications (UNC) 58 0 919 0 1 0.0631 0 0.0443 0 0 1096458.91

DY12 DPH Contra Costa Regional Medical Center 2.1.9 OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed)
[Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) 15 0 16 0 1 0 0 NA 0 NA 1096458.91

DY12 DPH Contra Costa Regional Medical Center 2.2.1 DHCS All-Cause Readmissions 125 0 2127 0 1 0.0588 0 0.0885 0 0.1318 1096458.92

DY12 DPH Contra Costa Regional Medical Center 2.2.2 H-CAHPS: Care Transition Metrics (3) 394 0 735 0 1 0.5361 0 0.4398 0 0.48 1096458.91

DY12 DPH Contra Costa Regional Medical Center 2.2.3 Medication Reconciliation 30 days 3019 0 3069 0 1 0.9837 0 0.9805 0 0 1096458.91

DY12 DPH Contra Costa Regional Medical Center 2.2.4 Reconciled Medication List Received by Discharged Patients 4869 0 4975 0 1 0.9787 0 0.9778 0 0 1096458.91

DY12 DPH Contra Costa Regional Medical Center 2.2.5 Timely Transmission of Transition Record 97 0 4231 0 1 0.0229 0 0.0261 0 0 1096458.91

DY12 DPH Contra Costa Regional Medical Center 2.3.1 Care Coordinator Assignment 14500 0 16639 0 1 0.8714 0 0.9892 0 0 1096458.92

DY12 DPH Contra Costa Regional Medical Center 2.3.2 Medication Reconciliation 30 days 1202 0 1236 0 1 0.9725 0 0.9711 0 0 1096458.91

DY12 DPH Contra Costa Regional Medical Center 2.3.3 Prevention Quality Overall Composite #90 335 0 16639 0 1 0.0201 0 0.029 0 0 1096458.91

DY12 DPH Contra Costa Regional Medical Center 2.3.4 Timely Transmission of Transition Record 75 0 1654 0 1 0.0453 0 0.0584 0 0 1096458.91

DY12 DPH Contra Costa Regional Medical Center 2.4.1 Adolescent Well-Care Visit 43 0 48 0 1 0.8958 0 0.7885 0 0.6658 1096458.91

DY12 DPH Contra Costa Regional Medical Center 2.4.2 Developmental Screening in the First Three Years of Life None 1 None 4 0 None 1 None 1 0 501769.33

DY12 DPH Contra Costa Regional Medical Center 2.4.3 Documentation of Current Medications in the Medical Record (0-18 yo) 177 0 177 0 1 1 0 0.1096 0 0 1096458.91

DY12 DPH Contra Costa Regional Medical Center 2.4.4 Screening for Clinical Depression and follow-up 25 0 38 0 1 0.6579 0 0.6667 0 0 1096458.91

DY12 DPH Contra Costa Regional Medical Center 2.4.5 Tobacco Assessment and Counseling (13 yo and older) 20 0 None 4 0 None 4 0.9167 0 0 $-

DY12 DPH Contra Costa Regional Medical Center 2.4.6 Well Child Visits - First 15 months of life None 1 None 4 0 None 1 None 1 0.0427 $-

DY12 DPH Contra Costa Regional Medical Center 2.4.7 Well Child Visits - Third, Fourth, Fifth, and Sixth Years of life 28 0 33 0 1 0.8485 0 None 4 0.8375 1096458.91

DY12 DPH Contra Costa Regional Medical Center 2.6.1 Alcohol and Drug Misuse (SBIRT) 425 0 5535 0 1 0.0768 0 0.0829 0 0 1096458.92

DY12 DPH Contra Costa Regional Medical Center 2.6.2 Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen 946 0 2017 0 1 0.469 0 0.3106 0 0 1096458.91

DY12 DPH Contra Costa Regional Medical Center 2.6.3 Patients with chronic pain on long term opioid therapy checked in PDMPs 1182 0 2194 0 1 0.5387 0 0.4427 0 0 1096458.91

DY12 DPH Contra Costa Regional Medical Center 2.6.4 Screening for Clinical Depression and follow-up 1388 0 3259 0 1 0.4259 0 0.3783 0 0 1096458.91

DY12 DPH Contra Costa Regional Medical Center 2.6.5 Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy 4873 0 6016 0 1 0.81 0 0.8268 0 0 1096458.91

DY12 DPH Contra Costa Regional Medical Center 3.2.1 Imaging for Routine Headaches (Choosing Wisely) 499 0 4455 0 1 0.112 0 0.1376 0 0.17 1881635

DY12 DPH Contra Costa Regional Medical Center 3.2.2 Appropriate Emergency Department Utilization of CT for Pulmonary Embolism 247 0 282 0 1 0.8759 0 0.5685 0 0 1881635

DY12 DPH Contra Costa Regional Medical Center 3.2.3 Use of Imaging Studies for Low Back Pain 2588 0 2979 0 1 0.8687 0 0.8437 0 0.8286 1881635

DY12 DPH Contra Costa Regional Medical Center 3.2.4 Use of Imaging Studies for Low Back Pain (anytime) Variation of HEDIS Use of Imaging Studies for Low Back Pain measures: Appropriate Score 590 0 6835 0 1 0.08632041 0 0 0 NA 940817.5

DY12 DPH Contra Costa Regional Medical Center 3.2.4 Use of Imaging Studies for Low Back Pain (anytime) Variation of HEDIS Use of Imaging Studies for Low Back Pain measures: Inappropriate Score 690 0 6835 0 1 0.100950988 0 0 0 NA 940817.5

DY12 DMPH Eastern Plumas Health Care, Portol 1.1.1.a Alcohol and Drug Misuse (SBIRT) 54 0 751 0 1 0.0719 0 0 0 0 150000

DY12 DMPH Eastern Plumas Health Care, Portol 1.1.2 Care Coordinator Assignment 0 0 None 4 1 None 4 0 0 0 150000

DY12 DMPH Eastern Plumas Health Care, Portol 1.1.3.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 16 0 68 0 1 0.2353 0 0 0 0 150000

DY12 DMPH Eastern Plumas Health Care, Portol 1.1.4 Depression Remission at 12 Months (CMS159v4) 0 0 0 0 1 0 0 0 0 0 150000

DY12 DMPH Eastern Plumas Health Care, Portol 1.1.5.f Screening for Clinical Depression and follow-up None 1 501 0 1 None 1 0 0 0 150000

DY12 DMPH Eastern Plumas Health Care, Portol 1.1.6.t Tobacco Assessment and Counseling 138 0 597 0 1 0.2312 0 0 0 0 150000

DY12 DMPH Eastern Plumas Health Care, Portol None Development of a standardized screening tool and uniform care plan, which includes a behavioral health module None None None None 1 None None None None None 200000

DY12 DMPH Eastern Plumas Health Care, Portol None Implementation of standardized care plan None None None None 1 None None None None None 200000

DY12 DMPH Eastern Plumas Health Care, Portol None Recruit & hire key behavioral health positions None None None None 1 None None None None None 200000

DY12 DMPH El Camino Hospital, Mountain View 1.1.1.a Alcohol and Drug Misuse (SBIRT) 0 0 3003 0 1 0 0 0 0 0 140400

DY12 DMPH El Camino Hospital, Mountain View 1.1.2 Care Coordinator Assignment 0 0 281 0 1 0 0 0 0 0 140400

DY12 DMPH El Camino Hospital, Mountain View 1.1.3.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 54 0 281 0 1 0.1922 0 0 0 0 140400

DY12 DMPH El Camino Hospital, Mountain View 1.1.4 Depression Remission at 12 Months (CMS159v4) None 1 None 4 1 None 1 0 0 0 140400

DY12 DMPH El Camino Hospital, Mountain View 1.1.5.f Screening for Clinical Depression and follow-up 1157 0 2169 0 1 0.5334 0 0 0 0 140400

DY12 DMPH El Camino Hospital, Mountain View 1.1.6.t Tobacco Assessment and Counseling 1945 0 3349 0 1 0.5808 0 0 0 0 140400

DY12 DMPH El Camino Hospital, Mountain View 2.1.1 Baby Friendly Hospital designation: Discovery Phase Complete No No 0 BFUSA Cert? 0 0 0 0 0 0 NA 46800

DY12 DMPH El Camino Hospital, Mountain View 2.1.1 Baby Friendly Hospital designation: Informational Webinar Participation No No 0 Discovery Phase? 0 0 0 0 0 0 NA 46800

DY12 DMPH El Camino Hospital, Mountain View 2.1.1 Baby Friendly Hospital designation: BFUSA Designation No No 0 Webinar complete? 0 0 0 0 0 0 NA 46800

DY12 DMPH El Camino Hospital, Mountain View 2.1.2 Exclusive Breast Milk Feeding (PC-05) 18 0 33 0 1 0.5455 0 0 0 0 140400

DY12 DMPH El Camino Hospital, Mountain View 2.1.3 OB Hemorrhage: Massive Transfusion 0 0 33 0 1 0 0 0 0 0 140400

DY12 DMPH El Camino Hospital, Mountain View 2.1.4 OB Hemorrhage: Total Products Transfused 0 0 33 0 1 0 0 0 0 0 140400

DY12 DMPH El Camino Hospital, Mountain View 2.1.5 PC-02 Cesarean Section None 1 33 0 1 None 1 0 0 0 140400

DY12 DMPH El Camino Hospital, Mountain View 2.1.6 Prenatal and Postpartum Care: Prenatal Care 28 0 33 0 1 0.848484848 0 0 0 0.7744 70200

DY12 DMPH El Camino Hospital, Mountain View 2.1.6 Prenatal and Postpartum Care: Postpartum Care 26 0 33 0 1 0.787878788 0 0 0 0.5547 70200

DY12 DMPH El Camino Hospital, Mountain View 2.1.7 Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage 0 0 33 0 1 0 0 0 0 0 140400

DY12 DMPH El Camino Hospital, Mountain View 2.1.8 Unexpected Newborn Complications (UNC) 0 0 33 0 1 0 0 0 0 0 140400

DY12 DMPH El Camino Hospital, Mountain View 2.1.9 OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed)
[Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) 22 0 32 0 1 0 0 NA 0 NA 140400

DY12 DMPH El Camino Hospital, Mountain View 3.4.1 ePBM-01 Pre-op Anemia Screening, Selected Elective Surgical Patients None 1 None 4 1 None 1 0 0 0 140400

DY12 DMPH El Camino Hospital, Mountain View 3.4.2 ePBM-02 Pre-op Hemoglobin Level, Selected Elective Surgical Patients None 1 None 1 1 None 1 0 0 0 140400

DY12 DMPH El Camino Hospital, Mountain View 3.4.3 ePBM-03 Pre-op Type and Crossmatch, Type and Screen, Selected elective Surgical Patients 20 0 None 4 1 None 4 0 0 0 140400

DY12 DMPH El Camino Hospital, Mountain View 3.4.4 ePBM-04 Initial Transfusion Threshold 99 0 99 0 1 1 0 0 0 0 140400

DY12 DMPH El Camino Hospital, Mountain View 3.4.5 ePBM-05 Outcome of Patient Blood Management, Selected Elective Surgical Patients None 1 None 4 1 None 1 0 0 0 140400

DY12 DMPH El Camino Hospital, Mountain View None Develop a partnership that promotes integration of behavioral health services with primary care for Medi-Cal beneficiaries as demonstrated by a plan to provide appropriate BH interventions that improve performance on Required Metrics for the target population. None None None None 1 None None None None None 374400

DY12 DMPH El Camino Hospital, Mountain View None CMQCC Report developed for OB-Delivery metrics 2.1.5, 2.1.8 by December 2016 None None None None 1 None None None None None 374400

DY12 DMPH El Camino Hospital, Mountain View None Develop a partnership with Primary care partners that promotes integration of behavioral health and perinatal care and improves performance on core metrics for the target population None None None None 1 None None None None None 374400

DY12 DMPH El Camino Hospital, Mountain View None Clinical workflow in place for MayView prenatal referral to ECH OB Hospitalist in Los Gatos and back to MayView Postnatal care by December 31, 2016 None None None None 1 None None None None None 374400

DY12 DMPH El Camino Hospital, Mountain View None Develop processes for evaluating impact of blood product use including appropriateness of use, adequacy of documentation and patient safety None None None None 1 None None None None None 374400

DY12 DMPH El Centro Regional Medical Center, El Centro 1.2.1.a Alcohol and Drug Misuse (SBIRT) 0 0 14882 0 1 0 0 0 0 0 271800

DY12 DMPH El Centro Regional Medical Center, El Centro 1.2.11 REAL data completeness 0 0 14882 0 1 0 0 0 0 0 271800

DY12 DMPH El Centro Regional Medical Center, El Centro 1.2.12.f Screening for Clinical Depression and follow-up 3372 0 14093 0 1 0.2393 0 0 0 0 271800

DY12 DMPH El Centro Regional Medical Center, El Centro 1.2.13 SO/GI data completeness 0 0 14882 0 1 0 0 0 0 0 271800

DY12 DMPH El Centro Regional Medical Center, El Centro 1.2.14.t Tobacco Assessment and Counseling 5786 0 14882 0 1 0.3888 0 0 0 0 271800

DY12 DMPH El Centro Regional Medical Center, El Centro 1.2.2 CG-CAHPS: Provider Rating 563 0 655 0 1 0.8595 0 0 0 0 271800

DY12 DMPH El Centro Regional Medical Center, El Centro 1.2.3.c Colorectal Cancer Screening 322 0 3160 0 1 0.1019 0 0 0 0 271800

DY12 DMPH El Centro Regional Medical Center, El Centro 1.2.4.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 350 0 1914 0 1 0.1829 0 0 0 0 271800

DY12 DMPH El Centro Regional Medical Center, El Centro 1.2.5.b Controlling Blood Pressure 438 0 451 0 1 0.9712 0 0 0 0 271800

DY12 DMPH El Centro Regional Medical Center, El Centro 1.2.6 Documented REAL and/or SO/GI disparity reduction plan: Documented disparity reduction plan? Yes Yes 0 Plan ? 0 1 0 0 NA 0 NA 271800

DY12 DMPH El Centro Regional Medical Center, El Centro 1.2.7.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 572 0 578 0 1 0.9896 0 0 0 0 271800

DY12 DMPH El Centro Regional Medical Center, El Centro 1.2.8 Prevention Quality Overall Composite #90 447 0 14882 0 1 0.03 0 0 0 0 271800

DY12 DMPH El Centro Regional Medical Center, El Centro 1.2.9 Primary Care Redesign metrics stratified by REAL categories and SO/GI: Primary care redesign metrics stratified? No No 0 Stratified ? 0 1 0 0 NA 0 NA 271800

DY12 DMPH El Centro Regional Medical Center, El Centro 1.7.1 BMI Screening and Follow-up 4336 0 14882 0 1 0.2914 0 0 0 0 271800

DY12 DMPH El Centro Regional Medical Center, El Centro 1.7.2 Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Numerator - Criteria Met (If your system has more than one hospital, please enter the sum of all criteria met)
Denominator - Required Criteria (If your system has more than one hospital, multiply the number of hospitals by 2) 2 0 8 0 1 0 0 NA 0 NA 271800

DY12 DMPH El Centro Regional Medical Center, El Centro 1.7.3 Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI 4201 0 4233 0 1 0 0 0 0 0.5127 90600

DY12 DMPH El Centro Regional Medical Center, El Centro 1.7.3 Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition 1477 0 4233 0 1 0 0 0 0 0.5198 90600

DY12 DMPH El Centro Regional Medical Center, El Centro 1.7.3 Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity 1477 0 4233 0 1 0 0 0 0 0.4416 90600

DY12 DMPH El Centro Regional Medical Center, El Centro 3.2.1 Imaging for Routine Headaches (Choosing Wisely) 394 0 1389 0 1 0.2837 0 0.2503 0 0 271800

DY12 DMPH El Centro Regional Medical Center, El Centro 3.2.2 Appropriate Emergency Department Utilization of CT for Pulmonary Embolism 103 0 158 0 1 0.6519 0 0.6031 0 0 271800

DY12 DMPH El Centro Regional Medical Center, El Centro 3.2.3 Use of Imaging Studies for Low Back Pain 378 0 696 0 1 0.5431 0 0.5051 0 0 271800

DY12 DMPH El Centro Regional Medical Center, El Centro 3.2.4 Use of Imaging Studies for Low Back Pain (anytime) Variation of HEDIS Use of Imaging Studies for Low Back Pain measures: Appropriate Score 339 0 1351 0 1 0.250925241 0 0 0 NA 135900

DY12 DMPH El Centro Regional Medical Center, El Centro 3.2.4 Use of Imaging Studies for Low Back Pain (anytime) Variation of HEDIS Use of Imaging Studies for Low Back Pain measures: Inappropriate Score 270 0 1351 0 1 0.199851962 0 0 0 NA 135900

DY12 DMPH El Centro Regional Medical Center, El Centro None Complete PRIME / HEDIS crosswalk None None None None 1 None None None None None 172571.43

DY12 DMPH El Centro Regional Medical Center, El Centro None Analyze and identify primary care needs corresponding with PCMH guidelines None None None None 1 None None None None None 172571.43

DY12 DMPH El Centro Regional Medical Center, El Centro None Develop and Implement agreement of strategy to supplement pediatric needs None None None None 1 None None None None None 172571.43

DY12 DMPH El Centro Regional Medical Center, El Centro None Complete gap analysis to determine needs for Primary Care Services None None None None 1 None None None None None 172571.43

DY12 DMPH El Centro Regional Medical Center, El Centro None Develop a Population Management Task Force Charter outlining goals, objectives and deliverables None None None None 1 None None None None None 172571.43

DY12 DMPH El Centro Regional Medical Center, El Centro None Complete evaluation of IT infrastructure for potential storage capacity expansion None None None None 1 None None None None None 172571.43

DY12 DMPH El Centro Regional Medical Center, El Centro None Analyze and generate PCMH structure including revised policies for PCMH implementation None None None None 1 None None None None None 172571.43

DY12 DMPH El Centro Regional Medical Center, El Centro None Develop and complete protocols for comprehensive disease management throughout the continuum of care None None None None 1 None None None None None 172571.43

DY12 DMPH El Centro Regional Medical Center, El Centro None Complete development of Community Referral & Support System None None None None 1 None None None None None 172571.43

DY12 DMPH El Centro Regional Medical Center, El Centro None Complete and submit PCMH Application None None None None 0 None None None None None 172571.43

DY12 DMPH El Centro Regional Medical Center, El Centro None Create gap analysis between current staffing and staffing to meet PRIME Project requirement None None None None 1 None None None None None 172571.43

DY12 DMPH El Centro Regional Medical Center, El Centro None Develop job descriptions and training curriculum. None None None None 1 None None None None None 172571.43

DY12 DMPH El Centro Regional Medical Center, El Centro None Recruit, Hire and Implement program training. None None None None 1 None None None None None 172571.43

DY12 DMPH El Centro Regional Medical Center, El Centro None Based on findings of gap analysis, complete recruitment, hiring and training of Primary Care Providers None None None None 1 None None None None None 172571.43

DY12 DMPH El Centro Regional Medical Center, El Centro None Develop SO/GI and REAL infrastructure None None None None 1 None None None None None 172571.43

DY12 DMPH El Centro Regional Medical Center, El Centro None Complete the development for data abstraction capabilities for SO/GI and REAL data. None None None None 1 None None None None None 172571.43

DY12 DMPH El Centro Regional Medical Center, El Centro None Develop a Quality Management Plan None None None None 1 None None None None None 172571.43

DY12 DMPH El Centro Regional Medical Center, El Centro None Upgrade and complete infrastructure build in ECW for outpatient metrics None None None None 1 None None None None None 172571.43

DY12 DMPH El Centro Regional Medical Center, El Centro None Complete MIDAS infrastructure build for inpatient specific metrics None None None None 1 None None None None None 172571.42

DY12 DMPH El Centro Regional Medical Center, El Centro None Implement Population Health Management and Care Planning system infrastructure within existing EMR system None None None None 1 None None None None None 172571.42

DY12 DMPH El Centro Regional Medical Center, El Centro None Attain financial approval for IT infrastructure and storage capacity expansion and purchase necessary equipment None None None None 1 None None None None None 172571.42

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister 2.3.1 Care Coordinator Assignment 27 0 72 0 1 0.375 0 0 0 0 393000

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister 2.3.2 Medication Reconciliation 30 days 15 0 72 0 1 0.2083 0 0 0 0 393000

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister 2.3.3 Prevention Quality Overall Composite #90 15 0 629 0 1 0.0238 0 0 0 0 393000

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister 2.3.4 Timely Transmission of Transition Record 22 0 72 0 1 0.3056 0 0 0 0 393000

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Complete Medication Reconciliation Analysis None None None None 1 None None None None None 34933.34

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Develop and pilot medication reconciliation protocols None None None None 1 None None None None None 34933.34

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Implementation of medication reconciliation protocols. None None None None 1 None None None None None 34933.34

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Assemble team and design transition record None None None None 1 None None None None None 34933.34

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Pilot Transition Record Protocols None None None None 1 None None None None None 34933.34

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Implementation of transition record None None None None 1 None None None None None 34933.34

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Establish tools for the performance of Care Coordination None None None None 1 None None None None None 34933.34

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Implement Case Management Protocols None None None None 1 None None None None None 34933.34

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Initiate Review of Target Population admitted to acute care None None None None 1 None None None None None 34933.34

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Measure performance of Care Coordination None None None None 1 None None None None None 34933.34

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Create team to reduce admissions / readmissions None None None None 1 None None None None None 34933.33

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Develop and pilot Project RED (Re-Enginered Discharge) None None None None 1 None None None None None 34933.33

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Implementation of Project RED None None None None 1 None None None None None 34933.33

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Convene team to implement registry None None None None 1 None None None None None 34933.33

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Conduct IT gap analysis for disease registry None None None None 1 None None None None None 34933.33

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Determine functionality of Disease Registry None None None None 1 None None None None None 34933.33

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Implement Disease Registry None None None None 1 None None None None None 34933.33

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Develop Target Population Reports None None None None 1 None None None None None 34933.33

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Develop and Pilot Disease Management Protocols None None None None 1 None None None None None 34933.33

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Implement Disease Management Protocols None None None None 1 None None None None None 34933.33

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Implement and pilot improvement methodologies None None None None 1 None None None None None 34933.33

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Evaluate and Reconstruct data collection systems None None None None 1 None None None None None 34933.33

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Create PRIME Quality Dashboard None None None None 1 None None None None None 34933.33

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Construction of new Chronic Disease Center None None None None 1 None None None None None 34933.33

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Obtain Medical licensing & OSHPD approval of new center None None None None 0 None None None None None 34933.33

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Develop marketing materials/ advertisements None None None None 1 None None None None None 34933.33

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Hire Chronic Disease Center Staff None None None None 1 None None None None None 34933.33

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Prepare personnel, operational provisions, and practices for the center None None None None 1 None None None None None 34933.33

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Pilot protocols None None None None 1 None None None None None 34933.33

DY12 DMPH Hazel Hawkins Memorial Hospital, Hollister None Implement the patient flow model None None None None 1 None None None None None 34933.33

DY12 DMPH Healdsburg District Hospital, Healdsburg 1.5.1.b Controlling Blood Pressure 31 0 679 0 1 0.0457 0 0 0 0 150666.67

DY12 DMPH Healdsburg District Hospital, Healdsburg 1.5.2.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic None 1 None 1 1 None 1 0 0 0 150666.67

DY12 DMPH Healdsburg District Hospital, Healdsburg 1.5.3 PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 0 0 835 0 1 0 0 0 0 0 150666.67

DY12 DMPH Healdsburg District Hospital, Healdsburg 1.5.4.t Tobacco Assessment and Counseling 85 0 835 0 1 0.1018 0 0 0 0 150666.66

DY12 DMPH Healdsburg District Hospital, Healdsburg 1.6.1 BIRADS to Biopsy 0 0 0 0 1 0 0 0 0 0 150666.67

DY12 DMPH Healdsburg District Hospital, Healdsburg 1.6.2 Breast Cancer Screening 27 0 194 0 1 0.1392 0 0 0 0 150666.67

DY12 DMPH Healdsburg District Hospital, Healdsburg 1.6.3 Cervical Cancer Screening 19 0 349 0 1 0.0544 0 0 0 0 150666.67

DY12 DMPH Healdsburg District Hospital, Healdsburg 1.6.4.c Colorectal Cancer Screening 28 0 439 0 1 0.0638 0 0 0 0 150666.66

DY12 DMPH Healdsburg District Hospital, Healdsburg 1.6.5 Receipt of appropriate follow-up for abnormal CRC screening 0 0 50 0 1 0 0 0 0 0 150666.66

DY12 DMPH Healdsburg District Hospital, Healdsburg None Hire care management coordinator None None None None 1 None None None None None 180800

DY12 DMPH Healdsburg District Hospital, Healdsburg None Develop a standardized screening tool for breast cancer in the electronic medical record None None None None 1 None None None None None 180800

DY12 DMPH Healdsburg District Hospital, Healdsburg None Develop a standardized screening tool for Cervical Cancer in HER None None None None 1 None None None None None 180800

DY12 DMPH Healdsburg District Hospital, Healdsburg None Develop a system to follow up on patients with abnormal CRC screening None None None None 1 None None None None None 180800

DY12 DMPH Healdsburg District Hospital, Healdsburg None Develop a referral system for patients with a BIRAD of 4 or greater to receive timely biopsy None None None None 0 None None None None None 180800

DY12 DMPH Jerold Phelps Community Hospital, Garberville 1.5.1.b Controlling Blood Pressure 20 0 None 4 1 None 4 0 0 0 225000

DY12 DMPH Jerold Phelps Community Hospital, Garberville 1.5.2.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic None 1 None 1 1 None 1 0 0 0 225000

DY12 DMPH Jerold Phelps Community Hospital, Garberville 1.5.3 PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 27 0 72 0 1 0.375 0 0 0 0 225000

DY12 DMPH Jerold Phelps Community Hospital, Garberville 1.5.4.t Tobacco Assessment and Counseling 90 0 109 0 1 0.8257 0 0 0 0 225000

DY12 DMPH Jerold Phelps Community Hospital, Garberville None Research and develop cardiovascular health Policies and Procedures None None None None 1 None None None None None 125000

DY12 DMPH Jerold Phelps Community Hospital, Garberville None Present findings to Medical Staff and the Hospital Board None None None None 1 None None None None None 125000

DY12 DMPH Jerold Phelps Community Hospital, Garberville None Formally adopt cardiovascular health Policies and Procedures None None None None 1 None None None None None 125000

DY12 DMPH Jerold Phelps Community Hospital, Garberville None Educate Clinic Providers and other Clinic Healthcare Personnel on newly approved Policies and Procedures None None None None 1 None None None None None 125000

DY12 DMPH Jerold Phelps Community Hospital, Garberville None Implement new ASP Policies and Procedures None None None None 0 None None None None None 50000

DY12 DMPH Jerold Phelps Community Hospital, Garberville None Implement ASP program performance tracking and reporting process None None None None 0 None None None None None 50000

DY12 DMPH John C. Fremont Healthcare District, Mariposa 1.2.1.a Alcohol and Drug Misuse (SBIRT) None 1 1114 0 1 None 1 0 0 0 69230.77

DY12 DMPH John C. Fremont Healthcare District, Mariposa 1.2.11 REAL data completeness 0 0 1237 0 1 0 0 0 0 0 69230.77

DY12 DMPH John C. Fremont Healthcare District, Mariposa 1.2.12.f Screening for Clinical Depression and follow-up 35 0 784 0 1 0.0446 0 0 0 0 69230.77

DY12 DMPH John C. Fremont Healthcare District, Mariposa 1.2.13 SO/GI data completeness 0 0 1237 0 1 0 0 0 0 0 69230.77

DY12 DMPH John C. Fremont Healthcare District, Mariposa 1.2.14.t Tobacco Assessment and Counseling 675 0 1039 0 1 0.6497 0 0 0 0 69230.76

DY12 DMPH John C. Fremont Healthcare District, Mariposa 1.2.2 CG-CAHPS: Provider Rating None 1 None 4 1 None 1 0 0 0 69230.77

DY12 DMPH John C. Fremont Healthcare District, Mariposa 1.2.3.c Colorectal Cancer Screening 129 0 570 0 1 0.2263 0 0 0 0 69230.77

DY12 DMPH John C. Fremont Healthcare District, Mariposa 1.2.4.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 48 0 115 0 1 0.4174 0 0 0 0 69230.77

DY12 DMPH John C. Fremont Healthcare District, Mariposa 1.2.5.b Controlling Blood Pressure 173 0 310 0 1 0.5581 0 0 0 0 69230.77

DY12 DMPH John C. Fremont Healthcare District, Mariposa 1.2.6 Documented REAL and/or SO/GI disparity reduction plan: Documented disparity reduction plan? No No 0 Plan ? 0 1 0 0 NA 0 NA 69230.77

DY12 DMPH John C. Fremont Healthcare District, Mariposa 1.2.7.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 32 0 49 0 1 0.6531 0 0 0 0 69230.77

DY12 DMPH John C. Fremont Healthcare District, Mariposa 1.2.8 Prevention Quality Overall Composite #90 117 0 1039 0 1 0.1126 0 0 0 0 69230.77

DY12 DMPH John C. Fremont Healthcare District, Mariposa 1.2.9 Primary Care Redesign metrics stratified by REAL categories and SO/GI: Primary care redesign metrics stratified? No No 0 Stratified ? 0 1 0 0 NA 0 NA 69230.77

DY12 DMPH John C. Fremont Healthcare District, Mariposa None Prime committee members identified. Meetings started and provider champion identified None None None None 1 None None None None None 60000

DY12 DMPH John C. Fremont Healthcare District, Mariposa None 100% of baseline Medi-cal population for JCFHD will be obtained. None None None None 1 None None None None None 60000

DY12 DMPH John C. Fremont Healthcare District, Mariposa None Complete process of hiring case manager by October 1, 2016. None None None None 1 None None None None None 60000

DY12 DMPH John C. Fremont Healthcare District, Mariposa None Identify the best practice case volume for each case manager. This will determine if more case managers are needed. This is expected to be completed by November 1, 2016. None None None None 1 None None None None None 60000

DY12 DMPH John C. Fremont Healthcare District, Mariposa None Work with EHR vendor to develop process to track and follow up with care needs of clients None None None None 1 None None None None None 60000

DY12 DMPH John C. Fremont Healthcare District, Mariposa None Case management team members identified. None None None None 1 None None None None None 60000

DY12 DMPH John C. Fremont Healthcare District, Mariposa None Develop pre and post assessment modules to determine skill, competency levels and areas requiring additional training. None None None None 1 None None None None None 60000

DY12 DMPH John C. Fremont Healthcare District, Mariposa None Educate staff and clients on procedures for self-scheduling. The staff involved in training are the physicians, mid-levels, medical assistants, front desk staff and the LVNs. None None None None 0 None None None None None 60000

DY12 DMPH John C. Fremont Healthcare District, Mariposa None Develop telemedicine program None None None None 1 None None None None None 60000

DY12 DMPH John C. Fremont Healthcare District, Mariposa None Develop process for home medical monitoring None None None None 1 None None None None None 60000

DY12 DMPH Kaweah Delta Health Care District, Visalia 1.2.1.a Alcohol and Drug Misuse (SBIRT) None 1 434 0 1 None 1 0 0 0 430636.37

DY12 DMPH Kaweah Delta Health Care District, Visalia 1.2.11 REAL data completeness 0 0 18631 0 1 0 0 0 0 0 430636.36

DY12 DMPH Kaweah Delta Health Care District, Visalia 1.2.12.f Screening for Clinical Depression and follow-up 16 0 377 0 1 0.0424 0 0 0 0 430636.36

DY12 DMPH Kaweah Delta Health Care District, Visalia 1.2.13 SO/GI data completeness 971 0 11761 0 1 0.0826 0 0 0 0 430636.36

DY12 DMPH Kaweah Delta Health Care District, Visalia 1.2.14.t Tobacco Assessment and Counseling 334 0 434 0 1 0.7696 0 0 0 0 430636.36

DY12 DMPH Kaweah Delta Health Care District, Visalia 1.2.2 CG-CAHPS: Provider Rating 821 0 1131 0 1 0.7259 0 0 0 0 430636.37

DY12 DMPH Kaweah Delta Health Care District, Visalia 1.2.3.c Colorectal Cancer Screening 69 0 400 0 1 0.1725 0 0 0 0 430636.37

DY12 DMPH Kaweah Delta Health Care District, Visalia 1.2.4.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 225 0 403 0 1 0.5583 0 0 0 0 430636.37

DY12 DMPH Kaweah Delta Health Care District, Visalia 1.2.5.b Controlling Blood Pressure 290 0 421 0 1 0.6888 0 0 0 0 430636.37

DY12 DMPH Kaweah Delta Health Care District, Visalia 1.2.6 Documented REAL and/or SO/GI disparity reduction plan: Documented disparity reduction plan? No No 0 Plan ? 0 1 0 0 NA 0 NA 430636.37

DY12 DMPH Kaweah Delta Health Care District, Visalia 1.2.7.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 186 0 217 0 1 0.8571 0 0 0 0 430636.36

DY12 DMPH Kaweah Delta Health Care District, Visalia 1.2.8 Prevention Quality Overall Composite #90 820 0 22633 0 1 0.0362 0 0 0 0 430636.36

DY12 DMPH Kaweah Delta Health Care District, Visalia 1.2.9 Primary Care Redesign metrics stratified by REAL categories and SO/GI: Primary care redesign metrics stratified? No No 0 Stratified ? 0 1 0 0 NA 0 NA 430636.36

DY12 DMPH Kaweah Delta Health Care District, Visalia 1.3.1 Closing the referral loop: receipt of specialist report (CMS50v3) 194 0 295 0 1 0.6576 0 0 0 0 430636.37

DY12 DMPH Kaweah Delta Health Care District, Visalia 1.3.2 DHCS All-Cause Readmissions 0 0 None 4 1 None 4 0 0 0 430636.37

DY12 DMPH Kaweah Delta Health Care District, Visalia 1.3.3 Influenza Immunization 20 0 395 0 1 0.0506 0 0 0 0 430636.36

DY12 DMPH Kaweah Delta Health Care District, Visalia 1.3.4 Post Procedure ED Visits 12 0 431 0 1 0.0278 0 0 0 0 430636.36

DY12 DMPH Kaweah Delta Health Care District, Visalia 1.3.5 Request for Specialty Care Expertise Turnaround Time 73 0 334 0 1 0.2186 0 0 0 0 430636.36

DY12 DMPH Kaweah Delta Health Care District, Visalia 1.3.6 Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters 0 0 372 0 1 0 0 0 0 0 430636.36

DY12 DMPH Kaweah Delta Health Care District, Visalia 1.3.7 Tobacco Assessment and Counseling 333 0 405 0 1 0.8222 0 0 0 0 430636.36

DY12 DMPH Kaweah Delta Health Care District, Visalia 1.5.1.b Controlling Blood Pressure 290 0 421 0 1 0.6888 0 0 0 0 430636.37

DY12 DMPH Kaweah Delta Health Care District, Visalia 1.5.2.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 186 0 217 0 1 0.8571 0 0 0 0 430636.36

DY12 DMPH Kaweah Delta Health Care District, Visalia 1.5.3 PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 78 0 370 0 1 0.2108 0 0 0 0 430636.36

DY12 DMPH Kaweah Delta Health Care District, Visalia 1.5.4.t Tobacco Assessment and Counseling 334 0 434 0 1 0.7696 0 0 0 0 430636.36

DY12 DMPH Kaweah Delta Health Care District, Visalia 2.2.1 DHCS All-Cause Readmissions 207 0 415 0 1 0.4988 0 0 0 0 430636.37

DY12 DMPH Kaweah Delta Health Care District, Visalia 2.2.2 H-CAHPS: Care Transition Metrics (3) 5071 0 10000 0 1 0.5071 0 0 0 0 430636.36

DY12 DMPH Kaweah Delta Health Care District, Visalia 2.2.3 Medication Reconciliation 30 days 36 0 250 0 1 0.144 0 0 0 0 430636.36

DY12 DMPH Kaweah Delta Health Care District, Visalia 2.2.4 Reconciled Medication List Received by Discharged Patients 0 0 426 0 1 0 0 0 0 0 430636.36

DY12 DMPH Kaweah Delta Health Care District, Visalia 2.2.5 Timely Transmission of Transition Record 0 0 426 0 1 0 0 0 0 0 430636.36

DY12 DMPH Kaweah Delta Health Care District, Visalia 2.3.1 Care Coordinator Assignment 29 0 277 0 1 0.1047 0 0 0 0 430636.37

DY12 DMPH Kaweah Delta Health Care District, Visalia 2.3.2 Medication Reconciliation 30 days 23 0 56 0 1 0.4107 0 0 0 0 430636.36

DY12 DMPH Kaweah Delta Health Care District, Visalia 2.3.3 Prevention Quality Overall Composite #90 186 0 683 0 1 0.2723 0 0 0 0 430636.36

DY12 DMPH Kaweah Delta Health Care District, Visalia 2.3.4 Timely Transmission of Transition Record 0 0 227 0 1 0 0 0 0 0 430636.36

DY12 DMPH Kaweah Delta Health Care District, Visalia 2.6.1 Alcohol and Drug Misuse (SBIRT) 0 0 193 0 1 0 0 0 0 0 430636.37

DY12 DMPH Kaweah Delta Health Care District, Visalia 2.6.2 Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen 22 0 198 0 1 0.1111 0 0 0 0 430636.37

DY12 DMPH Kaweah Delta Health Care District, Visalia 2.6.3 Patients with chronic pain on long term opioid therapy checked in PDMPs 0 0 188 0 1 0 0 0 0 0 430636.36

DY12 DMPH Kaweah Delta Health Care District, Visalia 2.6.4 Screening for Clinical Depression and follow-up None 1 190 0 1 None 1 0 0 0 430636.36

DY12 DMPH Kaweah Delta Health Care District, Visalia 2.6.5 Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy 0 0 208 0 1 0 0 0 0 0 430636.36

DY12 DMPH Kaweah Delta Health Care District, Visalia 2.7.1 Advance Care Plan None 1 370 0 1 None 1 0 0 0 430636.37

DY12 DMPH Kaweah Delta Health Care District, Visalia 2.7.2 Ambulatory Palliative Care Team Established: Ambulatory Palliative Care Team Established? Yes Yes 0 Team Established? 0 1 0 0 NA 0 NA 430636.37

DY12 DMPH Kaweah Delta Health Care District, Visalia 2.7.3 MWM #8: Treatment Preferences (documentation) Inpatient 118 0 181 0 1 0.6519 0 0 0 0 430636.37

DY12 DMPH Kaweah Delta Health Care District, Visalia 2.7.4 MWM #8: Treatment Preferences (documentation) Outpatient 0 0 0 0 1 0 0 0 0 0 430636.36

DY12 DMPH Kaweah Delta Health Care District, Visalia 2.7.5 Palliative Care Service Offered at Time of Diagnosis of Advanced Illness 18 0 99 0 1 0.1818 0 0 0 0 430636.36

DY12 DMPH Kaweah Delta Health Care District, Visalia 2.7.6 Proportion Admitted to Hospice for Less Than 3 Days None 1 None 1 1 None 1 0 0 0 430636.36

DY12 DMPH Kaweah Delta Health Care District, Visalia None 2 New Team Members Hired None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Analyze feedback given and incorporate into specialty care model None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Assess current referral and follow-up processes and identify gaps None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Assess effectiveness of trainings and expand care management coordination None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Collect and Submit data for PCMH recognition None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Conduct survey sample of patient population and analyze results None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Convene a team to develop a process for data collection and reporting of demographic data in this project None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Convene a workgroup to develop a strategy to increase relationships with community based agencies None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Convene workgroup to develop discharge tools for transitions of care program to include engagement of patient/caregivers and families in planning process and education on transition care plan and communication about post-acute care needs None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Create binder for each individual patient to reinforce participation in care plans and support self-management behaviors None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Create Mission/Vision Statement; Long/Short Term Program Goals & Objectives; Community Awareness Plan for Palliative Care Program None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Create Validation and Reporting Structure None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Design patient registry for all projects None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Design workflows and documentation to reinforce patient engagement in plans of care None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop Multidisciplinary Pain Service Team Charter None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop Multidisciplinary Pain Service Team Workflow None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop a Primary Palliative Care Training Program None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop and implement a clinical workflow to identify patients at risk for readmission None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop and implement concierge, meds-to-bed workflow None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop and implement documentation tools to track recommended medication changes None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop and implement plan to collect data in current HER None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop and Implement plan to collect data within new HER None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop and implement procedure for review of patients medication list at risk for readmission None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop and implement processes to ensure preventative screening is consistently performed under Million Hearts initiative None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop and implement standardized workflows for diversified delivery strategies None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop communication/referral processes with hospice partners None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop curricula modules for targeted disease states (i.e. hypertension, aspirin utilization, cholesterol and smoking cessation) and patient engagement and education strategies None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop documentation tools for patient assessment and monitoring None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop education materials for staff around discharge medication reconciliation process and patient education None None None None 1 None None None None None 154048.79

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop Guideline for management of chronic non-malignant Pain None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop patient survey for targeted feedback of service design and implementation None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop patient surveys for targeted feedback of service design and implementation None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop plan for educating community organizations and providers on the services KDHCD provides None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop policies and/or protocols that enable team members to practice at the top of their license None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop Policies for Internal/External Referral Processes None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop process for patient identification and referral of patients to the pain management service None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop process to follow-up on referrals None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop process to provide continual performance feedback to care teams from patients, frontline staff and senior leadership None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop Referral Process for Inpatient; Outpatient; Home Health; Skilled Nursing Facilities None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop roles, responsibilities, policies, reports and workflows for PCMH None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop standardized workflows and protocols for program to include access to PCP, Multidisciplinary involvement, medication reconciliation, discharge planning and arranging post-acute care needs None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop survey tool to assess the needs and utilization patterns of high risk, high-utilizing patients None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop system to communicate to primary care physicians their patients that have been identified as high-risk for targeted disease states to facilitate referral process None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop telehealth training program None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop tool to track referrals for specialty care by referring provider, indication and payer None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop tool to track reimbursement for care provider by payer None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop training module and train staff on care management model None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop training module and train staff on care plan usage None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop training module and train staff on discharge process None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop training module and train staff on transition of care workflows and protocol None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Develop workflow for post-discharge process in patients at high risk of readmission for medication issues None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Development of team based-curriculum for targeted disease state and patient engagement strategies None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Engage primary care, specialist providers, medical groups and local public health departments in the design and implementation of the specialty care model None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Establish process regarding POLST completion and train staff on POLST completion None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Establish workflow that supports telehealth platform with communication modalities that connect between specialty care and primary care (e.g. eConsult/eReferral) None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Evaluate current workflow and develop new workflows around discharge medication reconciliation None None None None 1 None None None None None 154048.79

DY12 DMPH Kaweah Delta Health Care District, Visalia None Hire 4 positions None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Hire PRIME Manager None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Hire team members None None None None 1 None None None None None 154048.79

DY12 DMPH Kaweah Delta Health Care District, Visalia None Hire transitions of care staff for all project components None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Identify cross-functional team required to create and implement telehealth platform None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Identify potential hospice program partners None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Identify smoking cessation services covered by Medi-Cal MCOs, Medi-Cal Medical Groups and FFS (counseling and pharmacotherapy) None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Identify the community based resources available to coordinate care None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Implement and improve team-based care None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Implement care plan in all settings for participating patient population None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Implement ongoing patient surveillance process for signs of potential opioid misuse/diversion None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Implement patient registry None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Incorporate findings into strategy to better manage this population None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Integrate patient survey into workflow None None None None 1 None None None None None 154048.79

DY12 DMPH Kaweah Delta Health Care District, Visalia None Launch telehealth platform None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Meet with PCPs, medical groups and the public health department to determine needs of a specialty care model as well as PCPs capacity to manage higher acuity conditions either independently, or in collaboration with, specialty care None None None None 0 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Obtain criteria needed for prior authorization approval for specialty care services None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Pilot care management model None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Pilot usage of care plan in designated setting to evaluate care plan template None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Regular meetings and communications with local representatives from Health Net and Blue Cross Managed Medi-Cal to discuss transitions of care program and engage in implementing protocols for post acre care needs. None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Schedule and conduct ongoing trainings None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Train all new PC staff & all appropriate CDMC, hospital & medical staff None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Train staff and seek feedback None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Train staff how to use telehealth platform (1 physician, 1 nurse practitioner, 1 Pharmacist, 1 LVN, 1 Medical assistant) None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Train team in team-based care philosophy None None None None 1 None None None None None 154048.78

DY12 DMPH Kaweah Delta Health Care District, Visalia None Work with vendor to evaluate integration of care plan template into HER None None None None 1 None None None None None 154048.78

DY12 DPH Kern Medical Center 1.1.1.a Alcohol and Drug Misuse (SBIRT) 3596 0 8340 0 1 0.4312 0 0.2832 0 0 1093351.73

DY12 DPH Kern Medical Center 1.1.2 Care Coordinator Assignment 594 0 594 0 1 1 0 0.0401 0 0 1093351.73

DY12 DPH Kern Medical Center 1.1.3.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 530 0 1804 0 1 0.2938 0 0.3138 0 0.3121 1093351.72

DY12 DPH Kern Medical Center 1.1.4 Depression Remission at 12 Months (CMS159v4) None 1 181 0 1 None 1 None 1 0 1093351.72

DY12 DPH Kern Medical Center 1.1.5.f Screening for Clinical Depression and follow-up 2678 0 5581 0 1 0.4798 0 0 0 0 1093351.72

DY12 DPH Kern Medical Center 1.1.6.t Tobacco Assessment and Counseling 5075 0 5715 0 1 0.888 0 0.3736 0 0.7237 1093351.72

DY12 DPH Kern Medical Center 1.2.1.a Alcohol and Drug Misuse (SBIRT) 3596 0 8340 0 1 0.4312 0 0.2832 0 0 1093351.73

DY12 DPH Kern Medical Center 1.2.11 REAL data completeness 3264 0 11618 0 1 0.2809 0 0 0 NA 1093351.72

DY12 DPH Kern Medical Center 1.2.12.f Screening for Clinical Depression and follow-up 2678 0 5581 0 1 0.4798 0 0 0 0 1093351.72

DY12 DPH Kern Medical Center 1.2.13 SO/GI data completeness None 1 6140 0 1 None 1 0 0 0 1093351.72

DY12 DPH Kern Medical Center 1.2.14.t Tobacco Assessment and Counseling 5075 0 5715 0 1 0.888 0 0.3736 0 0.7237 1093351.72

DY12 DPH Kern Medical Center 1.2.2 CG-CAHPS: Provider Rating 94 0 144 0 0 0.6528 0 0.6701 0 0.6734 1093351.73

DY12 DPH Kern Medical Center 1.2.3.c Colorectal Cancer Screening 1980 0 3077 0 1 0.6435 0 0.3175 0 0.3515 1093351.73

DY12 DPH Kern Medical Center 1.2.4.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 530 0 1804 0 1 0.2938 0 0.3138 0 0.3121 1093351.73

DY12 DPH Kern Medical Center 1.2.5.b Controlling Blood Pressure 1532 0 2473 0 1 0.6195 0 0.4584 0 0.4988 1093351.73

DY12 DPH Kern Medical Center 1.2.6 Documented REAL and/or SO/GI disparity reduction plan: Documented disparity reduction plan? Yes Yes 0 Plan ? 0 1 0 0 NA 0 NA 1093351.72

DY12 DPH Kern Medical Center 1.2.7.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 387 0 533 0 1 0.7261 0 0.5927 0 0.6808 1093351.72

DY12 DPH Kern Medical Center 1.2.8 Prevention Quality Overall Composite #90 111 0 11168 0 1 0.0099 0 0.018 0 0 1093351.72

DY12 DPH Kern Medical Center 1.2.9 Primary Care Redesign metrics stratified by REAL categories and SO/GI: Primary care redesign metrics stratified? Yes Yes 0 Stratified ? 0 1 0 0 NA 0 NA 1093351.72

DY12 DPH Kern Medical Center 1.3.1 Closing the referral loop: receipt of specialist report (CMS50v3) 18886 0 18886 0 1 1 0 0 0 0 1093351.73

DY12 DPH Kern Medical Center 1.3.2 DHCS All-Cause Readmissions 23 0 258 0 1 0.0891 0 None 1 0.1318 1093351.73

DY12 DPH Kern Medical Center 1.3.3 Influenza Immunization 4299 0 7946 0 1 0.541 0 0.3614 0 0 1093351.73

DY12 DPH Kern Medical Center 1.3.4 Post Procedure ED Visits 253 0 11681 0 1 0.0217 0 0.0763 0 0 1093351.73

DY12 DPH Kern Medical Center 1.3.5 Request for Specialty Care Expertise Turnaround Time None 1 67718 0 1 None 1 0 0 0 1093351.72

DY12 DPH Kern Medical Center 1.3.6 Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters None 1 104088 0 1 None 1 0 0 0 1093351.72

DY12 DPH Kern Medical Center 1.3.7 Tobacco Assessment and Counseling 2524 0 2812 0 1 0.8976 0 0.4578 0 0.7237 1093351.72

DY12 DPH Kern Medical Center 1.4.1 Abnormal Results Follow-Up: Abnormal Potassium Follow-up 1607 0 1814 0 1 0.885887541 0 0.9537 0 NA 364450.58

DY12 DPH Kern Medical Center 1.4.1 Abnormal Results Follow-Up: Abnormal INR Follow-up 33 0 68 0 1 0.485294118 0 0.6962 0 NA 364450.58

DY12 DPH Kern Medical Center 1.4.1 Abnormal Results Follow-Up: Abnormal BIRADS Follow-up 433 0 920 0 1 0.470652174 0 0.1769 0 NA 364450.58

DY12 DPH Kern Medical Center 1.4.2 Annual Monitoring for Patients on Persistent Medications 2478 0 2879 0 1 0.8607 0 0.6116 0 0.8446 1093351.72

DY12 DPH Kern Medical Center 1.4.3 INR Monitoring for Individuals on Warfarin 68 0 103 0 1 0.6602 0 0.3659 0 0 1093351.72

DY12 DPH Kern Medical Center 2.1.1 Baby Friendly Hospital designation: Discovery Phase Complete Yes Yes 0 Discovery Phase? 0 1 0 0 NA 0 NA 367619.71

DY12 DPH Kern Medical Center 2.1.1 Baby Friendly Hospital designation: Informational Webinar Participation Yes Yes 0 Webinar complete? 0 1 0 0 NA 0 NA 367619.71

DY12 DPH Kern Medical Center 2.1.1 Baby Friendly Hospital designation: BFUSA Designation No No 0 BFUSA Cert? 0 0 0 0 NA 0 NA 367619.71

DY12 DPH Kern Medical Center 2.1.2 Exclusive Breast Milk Feeding (PC-05) 378 0 745 0 1 0.5074 0 0.3682 0 0.497 1102859.14

DY12 DPH Kern Medical Center 2.1.3 OB Hemorrhage: Massive Transfusion None 1 1012 0 1 None 1 None 1 0 1102859.13

DY12 DPH Kern Medical Center 2.1.4 OB Hemorrhage: Total Products Transfused 126 0 1012 0 1 0.1245 0 0.1546 0 0 1102859.13

DY12 DPH Kern Medical Center 2.1.5 PC-02 Cesarean Section 38 0 212 0 1 0.1792 0 0.1982 0 0.1969 1102859.13

DY12 DPH Kern Medical Center 2.1.6 Prenatal and Postpartum Care: Prenatal Care 783 0 1073 0 1 0.72972973 0 0.279 0 0.7744 551429.57

DY12 DPH Kern Medical Center 2.1.6 Prenatal and Postpartum Care: Postpartum Care 505 0 1073 0 1 0.470643057 0 0.4283 0 0.5547 551429.57

DY12 DPH Kern Medical Center 2.1.7 Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage 51 0 103 0 1 0.4951 0 0.4348 0 0 1102859.13

DY12 DPH Kern Medical Center 2.1.8 Unexpected Newborn Complications (UNC) 47 0 730 0 1 0.0644 0 0.0625 0 0 1102859.13

DY12 DPH Kern Medical Center 2.1.9 OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed)
[Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) 8 0 16 0 1 0 0 NA 0 NA 1102859.13

DY12 DPH Kern Medical Center 2.2.1 DHCS All-Cause Readmissions 25 0 272 0 1 0.0919 0 0.2337 0 0.177 1102859.13

DY12 DPH Kern Medical Center 2.2.2 H-CAHPS: Care Transition Metrics (3) 4943 0 10000 0 1 0.4943 0 0.4727 0 0.4864 1102859.13

DY12 DPH Kern Medical Center 2.2.3 Medication Reconciliation 30 days 115 0 353 0 1 0.3258 0 0 0 0 1102859.13

DY12 DPH Kern Medical Center 2.2.4 Reconciled Medication List Received by Discharged Patients 901 0 1469 0 1 0.6133 0 0 0 0 1102859.13

DY12 DPH Kern Medical Center 2.2.5 Timely Transmission of Transition Record 623 0 1003 0 1 0.6211 0 0 0 0 1102859.13

DY12 DPH Kern Medical Center 2.3.1 Care Coordinator Assignment 152 0 848 0 1 0.1792 0 0.1189 0 0 1102859.13

DY12 DPH Kern Medical Center 2.3.2 Medication Reconciliation 30 days 38 0 91 0 1 0.4176 0 0 0 0 1102859.13

DY12 DPH Kern Medical Center 2.3.3 Prevention Quality Overall Composite #90 23 0 848 0 1 0.0271 0 0.0442 0 0 1102859.13

DY12 DPH Kern Medical Center 2.3.4 Timely Transmission of Transition Record 157 0 185 0 1 0.8486 0 0 0 0 1102859.13

DY12 DPH Kern Medical Center 2.5.1 Alcohol and Drug Misuse (SBIRT) 73 0 162 0 1 0.4506 0 0.2626 0 0 1102859.13

DY12 DPH Kern Medical Center 2.5.2 Controlling Blood Pressure 27 0 39 0 1 0.6923 0 0.4725 0 0.4988 1102859.13

DY12 DPH Kern Medical Center 2.5.3 Prevention Quality Overall Composite #90 None 1 334 0 1 None 1 0 0 0 1102859.13

DY12 DPH Kern Medical Center 2.5.4 Screening for Clinical Depression and follow-up 60 0 138 0 1 0.4348 0 0 0 0 1102859.13

DY12 DPH Kern Medical Center 2.5.5 Tobacco Assessment and Counseling 108 0 117 0 1 0.9231 0 0.5795 0 0.7237 1102859.13

DY12 DPH Kern Medical Center 3.2.1 Imaging for Routine Headaches (Choosing Wisely) 314 0 1744 0 1 0.18 0 0.1825 0 0.1813 1849586.67

DY12 DPH Kern Medical Center 3.2.2 Appropriate Emergency Department Utilization of CT for Pulmonary Embolism 104 0 182 0 1 0.5714 0 0.7164 0 0 1849586.67

DY12 DPH Kern Medical Center 3.2.3 Use of Imaging Studies for Low Back Pain 857 0 983 0 1 0.8718 0 0.7127 0 0.7243 1849586.66

DY12 DPH Kern Medical Center 3.2.4 Use of Imaging Studies for Low Back Pain (anytime) Variation of HEDIS Use of Imaging Studies for Low Back Pain measures: Appropriate Score 69 0 1578 0 1 0.043726236 0 0.513761468 0 NA 396340

DY12 DPH Kern Medical Center 3.2.4 Use of Imaging Studies for Low Back Pain (anytime) Variation of HEDIS Use of Imaging Studies for Low Back Pain measures: Inappropriate Score 134 0 1523 0 1 0.087984242 0 0.116972477 0 NA 396340

DY12 DMPH Kern Valley Healthcare District, Lake Isabella 1.1.1.a Alcohol and Drug Misuse (SBIRT) 243 0 869 0 1 0.2796 0 0 0 0 150000

DY12 DMPH Kern Valley Healthcare District, Lake Isabella 1.1.2 Care Coordinator Assignment None 1 56 0 1 None 1 0 0 0 150000

DY12 DMPH Kern Valley Healthcare District, Lake Isabella 1.1.3.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 56 0 121 0 1 0.4628 0 0 0 0 150000

DY12 DMPH Kern Valley Healthcare District, Lake Isabella 1.1.4 Depression Remission at 12 Months (CMS159v4) 0 0 96 0 1 0 0 0 0 0 150000

DY12 DMPH Kern Valley Healthcare District, Lake Isabella 1.1.5.f Screening for Clinical Depression and follow-up 257 0 733 0 1 0.3506 0 0 0 0 150000

DY12 DMPH Kern Valley Healthcare District, Lake Isabella 1.1.6.t Tobacco Assessment and Counseling 465 0 788 0 1 0.5901 0 0 0 0 150000

DY12 DMPH Kern Valley Healthcare District, Lake Isabella None Complete consulting privileges for behavioral health providers in both acute care and long-term care units None None None None 1 None None None None None 40000

DY12 DMPH Kern Valley Healthcare District, Lake Isabella None Complete enrollment for behavioral health providers with the Council for Affordable Quality Healthcare (CAQH). None None None None 1 None None None None None 40000

DY12 DMPH Kern Valley Healthcare District, Lake Isabella None Complete development of a behavioral health integration assessment tool. None None None None 1 None None None None None 40000

DY12 DMPH Kern Valley Healthcare District, Lake Isabella None Complete development of architectural plans for improvement of the existing hospital facility to meet SB1953. None None None None 1 None None None None None 40000

DY12 DMPH Kern Valley Healthcare District, Lake Isabella None Complete establishment of staff consult framework for collaboration on evidence based standards of care including medication management for complex needs. None None None None 1 None None None None None 40000

DY12 DMPH Kern Valley Healthcare District, Lake Isabella None Complete recruitment of one Quality Care Coordinator/Project Manager for the behavioral health program. None None None None 1 None None None None None 40000

DY12 DMPH Kern Valley Healthcare District, Lake Isabella None Complete expansion of Rural Health Clinic by adding four additional exam rooms. None None None None 0 None None None None None 40000

DY12 DMPH Kern Valley Healthcare District, Lake Isabella None Complete workgroup convening for development a behavioral health care management model. None None None None 1 None None None None None 40000

DY12 DMPH Kern Valley Healthcare District, Lake Isabella None Complete implementation of behavioral health care management model. None None None None 1 None None None None None 40000

DY12 DMPH Kern Valley Healthcare District, Lake Isabella None Complete development of training materials for behavioral health care management tools, train behavioral healthcare staff and providers on use of tools. None None None None 1 None None None None None 40000

DY12 DMPH Kern Valley Healthcare District, Lake Isabella None Complete integration of multiple populations into treatment plan (e.g., obesity, diabetes, etc.). None None None None 1 None None None None None 40000

DY12 DMPH Kern Valley Healthcare District, Lake Isabella None Complete incorporation of traditional medical interventions into a single treatment plan. None None None None 1 None None None None None 40000

DY12 DMPH Kern Valley Healthcare District, Lake Isabella None Complete recruitment of one clinical staff member for the behavioral health program. None None None None 1 None None None None None 40000

DY12 DMPH Kern Valley Healthcare District, Lake Isabella None Complete needs assessment for additional behavioral health staff and office/treatment space. None None None None 1 None None None None None 40000

DY12 DMPH Kern Valley Healthcare District, Lake Isabella None Complete development of a process to screen for new non-traditional options for inclusion into the single treatment plan. None None None None 1 None None None None None 40000

DY12 DMPH Lompoc Valley Medical Center, Lompoc 1.3.1 Closing the referral loop: receipt of specialist report (CMS50v3) 225 0 494 0 1 0.4555 0 0 0 0 180000

DY12 DMPH Lompoc Valley Medical Center, Lompoc 1.3.2 DHCS All-Cause Readmissions None 1 143 0 1 None 1 0 0 0 180000

DY12 DMPH Lompoc Valley Medical Center, Lompoc 1.3.3 Influenza Immunization 80 0 223 0 1 0.3587 0 0 0 0 180000

DY12 DMPH Lompoc Valley Medical Center, Lompoc 1.3.4 Post Procedure ED Visits 109 0 3693 0 1 0.0295 0 0 0 0 180000

DY12 DMPH Lompoc Valley Medical Center, Lompoc 1.3.5 Request for Specialty Care Expertise Turnaround Time 225 0 494 0 1 0.4555 0 0 0 0 180000

DY12 DMPH Lompoc Valley Medical Center, Lompoc 1.3.6 Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters 0 0 494 0 1 0 0 0 0 0 180000

DY12 DMPH Lompoc Valley Medical Center, Lompoc 1.3.7 Tobacco Assessment and Counseling 100 0 185 0 1 0.5405 0 0 0 0 180000

DY12 DMPH Lompoc Valley Medical Center, Lompoc 1.5.1.b Controlling Blood Pressure 81 0 97 0 1 0.8351 0 0 0 0 180000

DY12 DMPH Lompoc Valley Medical Center, Lompoc 1.5.2.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic None 1 None 4 1 None 1 0 0 0 180000

DY12 DMPH Lompoc Valley Medical Center, Lompoc 1.5.3 PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 162 0 301 0 1 0.5382 0 0 0 0 180000

DY12 DMPH Lompoc Valley Medical Center, Lompoc 1.5.4.t Tobacco Assessment and Counseling 208 0 362 0 1 0.5746 0 0 0 0 180000

DY12 DMPH Lompoc Valley Medical Center, Lompoc 1.7.1 BMI Screening and Follow-up 110 0 457 0 1 0.2407 0 0 0 0 180000

DY12 DMPH Lompoc Valley Medical Center, Lompoc 1.7.2 Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Numerator - Criteria Met (If your system has more than one hospital, please enter the sum of all criteria met)
Denominator - Required Criteria (If your system has more than one hospital, multiply the number of hospitals by 2) 2 0 8 0 1 0 0 NA 0 NA 180000

DY12 DMPH Lompoc Valley Medical Center, Lompoc 1.7.3 Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition 83 0 152 0 1 0 0 0 0 0.5198 60000

DY12 DMPH Lompoc Valley Medical Center, Lompoc 1.7.3 Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity 81 0 152 0 1 0 0 0 0 0.4416 60000

DY12 DMPH Lompoc Valley Medical Center, Lompoc 1.7.3 Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI 181 0 245 0 1 0 0 0 0 0.5127 60000

DY12 DMPH Lompoc Valley Medical Center, Lompoc 2.2.1 DHCS All-Cause Readmissions 166 0 669 0 1 0.2481 0 0 0 0 180000

DY12 DMPH Lompoc Valley Medical Center, Lompoc 2.2.2 H-CAHPS: Care Transition Metrics (3) 48 0 100 0 1 0.48 0 0 0 0 180000

DY12 DMPH Lompoc Valley Medical Center, Lompoc 2.2.3 Medication Reconciliation 30 days None 1 None 4 1 None 1 0 0 0 180000

DY12 DMPH Lompoc Valley Medical Center, Lompoc 2.2.4 Reconciled Medication List Received by Discharged Patients 116 0 831 0 1 0.1396 0 0 0 0 180000

DY12 DMPH Lompoc Valley Medical Center, Lompoc 2.2.5 Timely Transmission of Transition Record 460 0 872 0 1 0.5275 0 0 0 0 180000

DY12 DMPH Lompoc Valley Medical Center, Lompoc None Clinic Relocation to New Building for General Surgery completed None None None None 1 None None None None None 126666.67

DY12 DMPH Lompoc Valley Medical Center, Lompoc None Develop and Implement Clinical Reporting Systems in Specialty Care Clinics None None None None 1 None None None None None 126666.66

DY12 DMPH Lompoc Valley Medical Center, Lompoc None Establish Clinic Systems for Data Collection for Obesity Prevention None None None None 1 None None None None None 126666.67

DY12 DMPH Lompoc Valley Medical Center, Lompoc None Establish Clinic Systems for Data Collection on Million Hearts Initiative None None None None 1 None None None None None 126666.67

DY12 DMPH Lompoc Valley Medical Center, Lompoc None Establish Operational Orthopedic Practice None None None None 1 None None None None None 126666.67

DY12 DMPH Lompoc Valley Medical Center, Lompoc None Establish Operational Otorhinolaryngology Practice None None None None 1 None None None None None 126666.66

DY12 DMPH Lompoc Valley Medical Center, Lompoc None Establish Policy and Procedures for Care Transitions Project None None None None 0 None None None None None 126666.66

DY12 DMPH Lompoc Valley Medical Center, Lompoc None Family Caregiver Support Network operational None None None None 0 None None None None None 126666.66

DY12 DMPH Lompoc Valley Medical Center, Lompoc None Hire Caregiver Support Coordinator to run the Family Caregiver Support Network None None None None 0 None None None None None 126666.66

DY12 DMPH Lompoc Valley Medical Center, Lompoc None Implement Post-Discharge Follow-Up Program None None None None 0 None None None None None 126666.67

DY12 DMPH Lompoc Valley Medical Center, Lompoc None Licensing Requirements Met None None None None 1 None None None None None 126666.67

DY12 DMPH Lompoc Valley Medical Center, Lompoc None Perform a Gap Analysis and Needs Assessment of Hospital Food Services None None None None 1 None None None None None 126666.66

DY12 DMPH Lompoc Valley Medical Center, Lompoc None Provide Education and Training on Project Requirements for the Metric Reporting at Outpatient Clinics None None None None 0 None None None None None 126666.67

DY12 DMPH Lompoc Valley Medical Center, Lompoc None Provide Education and Training to Clinic Staff on Obesity Prevention Project None None None None 0 None None None None None 126666.67

DY12 DMPH Lompoc Valley Medical Center, Lompoc None Provide Physician Collaborators with PRIME Project Overview Information and Training None None None None 0 None None None None None 126666.67

DY12 DMPH Lompoc Valley Medical Center, Lompoc None Provide PRIME Overview and Education to Case Management Staff None None None None 0 None None None None None 126666.67

DY12 DMPH Lompoc Valley Medical Center, Lompoc None Recruit Orthopedist None None None None 0 None None None None None 126666.67

DY12 DMPH Lompoc Valley Medical Center, Lompoc None Recruit Otorhinolaryngologist None None None None 1 None None None None None 126666.67

DY12 DPH Los Angeles County Health System 1.1.1.a Alcohol and Drug Misuse (SBIRT) 18 0 377 0 1 0.0477 0 0.0317 0 0 6046183.73

DY12 DPH Los Angeles County Health System 1.1.2 Care Coordinator Assignment 0 0 377 0 1 0 0 0 0 0 6046183.73

DY12 DPH Los Angeles County Health System 1.1.3.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 9343 0 34126 0 1 0.2738 0 0.2934 0 0.2968 6046183.73

DY12 DPH Los Angeles County Health System 1.1.4 Depression Remission at 12 Months (CMS159v4) 434 0 1650 0 1 0.263 0 None 1 0 6046183.73

DY12 DPH Los Angeles County Health System 1.1.5.f Screening for Clinical Depression and follow-up 80543 0 101530 0 1 0.7933 0 0.8435 0 0 6046183.73

DY12 DPH Los Angeles County Health System 1.1.6.t Tobacco Assessment and Counseling 92439 0 105667 0 1 0.8748 0 0.7057 0 0.7309 6046183.73

DY12 DPH Los Angeles County Health System 1.2.1.a Alcohol and Drug Misuse (SBIRT) 18 0 377 0 1 0.0477 0 0.0317 0 0 6046183.73

DY12 DPH Los Angeles County Health System 1.2.11 REAL data completeness 94034 0 129402 0 1 0.7267 0 0 0 NA 6046183.73

DY12 DPH Los Angeles County Health System 1.2.12.f Screening for Clinical Depression and follow-up 80543 0 101530 0 1 0.7933 0 0.8435 0 0 6046183.73

DY12 DPH Los Angeles County Health System 1.2.13 SO/GI data completeness 0 0 106518 0 1 0 0 0 0 0 6046183.73

DY12 DPH Los Angeles County Health System 1.2.14.t Tobacco Assessment and Counseling 92439 0 105667 0 1 0.8748 0 0.7057 0 0.7309 6046183.72

DY12 DPH Los Angeles County Health System 1.2.2 CG-CAHPS: Provider Rating 6127 0 8279 0 1 0.7401 0 0.6091 0 0.6185 6046183.73

DY12 DPH Los Angeles County Health System 1.2.3.c Colorectal Cancer Screening 41969 0 62509 0 1 0.6714 0 0.6222 0 0.6257 6046183.73

DY12 DPH Los Angeles County Health System 1.2.4.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 9343 0 34126 0 1 0.2738 0 0.2934 0 0.2968 6046183.73

DY12 DPH Los Angeles County Health System 1.2.5.b Controlling Blood Pressure 31017 0 44577 0 1 0.6958 0 0.6393 0 0.6457 6046183.73

DY12 DPH Los Angeles County Health System 1.2.6 Documented REAL and/or SO/GI disparity reduction plan: Documented disparity reduction plan? Yes Yes 0 Plan ? 0 1 0 0 NA 0 NA 6046183.73

DY12 DPH Los Angeles County Health System 1.2.7.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 5488 0 6547 0 1 0.8382 0 0.8112 0 0.8229 6046183.73

DY12 DPH Los Angeles County Health System 1.2.8 Prevention Quality Overall Composite #90 1336 0 222279 0 1 0.006 0 0.0312 0 0 6046183.73

DY12 DPH Los Angeles County Health System 1.2.9 Primary Care Redesign metrics stratified by REAL categories and SO/GI: Primary care redesign metrics stratified? Yes Yes 0 Stratified ? 0 1 0 0 NA 0 NA 6046183.73

DY12 DPH Los Angeles County Health System 1.3.1 Closing the referral loop: receipt of specialist report (CMS50v3) 68604 0 93308 0 1 0.7352 0 0.8761 0 0 6046183.73

DY12 DPH Los Angeles County Health System 1.3.2 DHCS All-Cause Readmissions 856 0 6711 0 1 0.1276 0 0.1308 0 0.1318 6046183.73

DY12 DPH Los Angeles County Health System 1.3.3 Influenza Immunization 27424 0 48235 0 1 0.5685 0 0.3633 0 0 6046183.73

DY12 DPH Los Angeles County Health System 1.3.4 Post Procedure ED Visits 1708 0 69959 0 1 0.0244 0 0.0173 0 0 6046183.73

DY12 DPH Los Angeles County Health System 1.3.5 Request for Specialty Care Expertise Turnaround Time 138962 0 165210 0 1 0.8411 0 0.7882 0 0 6046183.73

DY12 DPH Los Angeles County Health System 1.3.6 Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters 37847 0 169699 0 1 0.223 0 0.2301 0 0 6046183.73

DY12 DPH Los Angeles County Health System 1.3.7 Tobacco Assessment and Counseling 44420 0 49018 0 1 0.9062 0 0.7773 0 0.7954 6046183.73

DY12 DPH Los Angeles County Health System 1.4.1 Abnormal Results Follow-Up: Abnormal Potassium Follow-up 75228 0 79189 0 1 0.949980427 0 0.9521 0 NA 2015394.58

DY12 DPH Los Angeles County Health System 1.4.1 Abnormal Results Follow-Up: Abnormal INR Follow-up 23609 0 25250 0 1 0.935009901 0 0.9396 0 NA 2015394.58

DY12 DPH Los Angeles County Health System 1.4.1 Abnormal Results Follow-Up: Abnormal BIRADS Follow-up 10177 0 15787 0 1 0.644644328 0 0.5604 0 NA 2015394.58

DY12 DPH Los Angeles County Health System 1.4.2 Annual Monitoring for Patients on Persistent Medications 48113 0 51571 0 1 0.9329 0 0.8251 0 0.8446 6046183.73

DY12 DPH Los Angeles County Health System 1.4.3 INR Monitoring for Individuals on Warfarin 2021 0 2287 0 1 0.8837 0 0.6101 0 0 6046183.73

DY12 DPH Los Angeles County Health System 1.6.1 BIRADS to Biopsy 329 0 691 0 1 0.4761 0 0.4396 0 0 6046183.73

DY12 DPH Los Angeles County Health System 1.6.2 Breast Cancer Screening 31960 0 46567 0 1 0.6863 0 0.6031 0 0.6142 6046183.73

DY12 DPH Los Angeles County Health System 1.6.3 Cervical Cancer Screening 38778 0 81419 0 0 0.4763 0 0.3424 0 0.5433 6046183.73

DY12 DPH Los Angeles County Health System 1.6.4.c Colorectal Cancer Screening 41969 0 62509 0 1 0.6714 0 0.6222 0 0.6257 6046183.73

DY12 DPH Los Angeles County Health System 1.6.5 Receipt of appropriate follow-up for abnormal CRC screening 313 0 910 0 1 0.344 0 0.3148 0 0 6046183.73

DY12 DPH Los Angeles County Health System 1.7.1 BMI Screening and Follow-up 57505 0 109343 0 1 0.5259 0 0.3249 0 0.4009 6046183.73

DY12 DPH Los Angeles County Health System 1.7.2 Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Numerator - Criteria Met (If your system has more than one hospital, please enter the sum of all criteria met)
Denominator - Required Criteria (If your system has more than one hospital, multiply the number of hospitals by 2) 30 0 40 0 1 0 0 NA 0 NA 6046183.73

DY12 DPH Los Angeles County Health System 1.7.3 Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI 17069 0 17919 0 1 0 0 0.4556 0 0.5127 2015394.58

DY12 DPH Los Angeles County Health System 1.7.3 Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition 12133 0 17919 0 1 0 0 0.0454 0 0.5198 2015394.58

DY12 DPH Los Angeles County Health System 1.7.3 Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity 11793 0 17919 0 1 0 0 0.0769 0 0.4416 2015394.58

DY12 DPH Los Angeles County Health System 2.1.1 Baby Friendly Hospital designation: BFUSA Designation Yes Yes 0 BFUSA Cert? 0 1 0 0 NA 0 NA 6171277.21

DY12 DPH Los Angeles County Health System 2.1.2 Exclusive Breast Milk Feeding (PC-05) 637 0 1267 0 1 0.5028 0 0.4152 0 0.497 6171277.21

DY12 DPH Los Angeles County Health System 2.1.3 OB Hemorrhage: Massive Transfusion 23 0 2010 0 1 0.0114 0 None 1 0 6171277.21

DY12 DPH Los Angeles County Health System 2.1.4 OB Hemorrhage: Total Products Transfused 339 0 2010 0 1 0.1687 0 0.0788 0 0 6171277.21

DY12 DPH Los Angeles County Health System 2.1.5 PC-02 Cesarean Section 172 0 714 0 1 0.2409 0 0.2476 0 0.2413 6171277.21

DY12 DPH Los Angeles County Health System 2.1.6 Prenatal and Postpartum Care: Prenatal Care 1433 0 1657 0 1 0.864815932 0 0.492 0 0.7744 3085638.61

DY12 DPH Los Angeles County Health System 2.1.6 Prenatal and Postpartum Care: Postpartum Care 954 0 1657 0 1 0.575739288 0 0.3635 0 0.5547 3085638.61

DY12 DPH Los Angeles County Health System 2.1.7 Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage 87 0 218 0 1 0.3991 0 0.4355 0 0 6171277.2

DY12 DPH Los Angeles County Health System 2.1.8 Unexpected Newborn Complications (UNC) 101 0 1044 0 1 0.0967 0 0.1173 0 0 6171277.2

DY12 DPH Los Angeles County Health System 2.1.9 OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed)
[Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) 33 0 48 0 1 0 0 NA 0 NA 6171277.2

DY12 DPH Los Angeles County Health System 2.2.1 DHCS All-Cause Readmissions 933 0 7400 0 1 0.1261 0 0.1277 0 0.1318 6171277.21

DY12 DPH Los Angeles County Health System 2.2.2 H-CAHPS: Care Transition Metrics (3) 4045 0 7033 0 1 0.5751 0 0.5605 0 0.5655 6171277.21

DY12 DPH Los Angeles County Health System 2.2.3 Medication Reconciliation 30 days 5336 0 9767 0 1 0.5463 0 0.2891 0 0 6171277.21

DY12 DPH Los Angeles County Health System 2.2.4 Reconciled Medication List Received by Discharged Patients 293 0 377 0 1 0.7772 0 0.586 0 0 6171277.2

DY12 DPH Los Angeles County Health System 2.2.5 Timely Transmission of Transition Record 2597 0 13448 0 1 0.1931 0 0 0 0 6171277.2

DY12 DPH Los Angeles County Health System 2.3.1 Care Coordinator Assignment 0 0 370 0 1 0 0 0 0 0 6171277.21

DY12 DPH Los Angeles County Health System 2.3.2 Medication Reconciliation 30 days 4034 0 6962 0 1 0.5794 0 0.2546 0 0 6171277.21

DY12 DPH Los Angeles County Health System 2.3.3 Prevention Quality Overall Composite #90 1124 0 60951 0 1 0.0184 0 0.1196 0 0 6171277.21

DY12 DPH Los Angeles County Health System 2.3.4 Timely Transmission of Transition Record 1806 0 9210 0 1 0.1961 0 0 0 0 6171277.2

DY12 DPH Los Angeles County Health System 2.5.1 Alcohol and Drug Misuse (SBIRT) 11 0 260 0 1 0.0423 0 None 1 0 6171277.21

DY12 DPH Los Angeles County Health System 2.5.2 Controlling Blood Pressure 133 0 214 0 1 0.6215 0 None 1 0.4988 6171277.21

DY12 DPH Los Angeles County Health System 2.5.3 Prevention Quality Overall Composite #90 37 0 1203 0 1 0.0308 0 0.0764 0 0 6171277.21

DY12 DPH Los Angeles County Health System 2.5.4 Screening for Clinical Depression and follow-up 442 0 676 0 1 0.6538 0 0.7097 0 0 6171277.2

DY12 DPH Los Angeles County Health System 2.5.5 Tobacco Assessment and Counseling 531 0 670 0 1 0.7925 0 0.5873 0 0.7237 6171277.2

DY12 DPH Los Angeles County Health System 2.7.1 Advance Care Plan 15847 0 16027 0 1 0.9888 0 0.9748 0 0 6171277.21

DY12 DPH Los Angeles County Health System 2.7.2 Ambulatory Palliative Care Team Established: Ambulatory Palliative Care Team Established? Yes Yes 0 Team Established? 0 1 0 0 NA 0 NA 6171277.21

DY12 DPH Los Angeles County Health System 2.7.3 MWM #8: Treatment Preferences (documentation) Inpatient 91 0 115 0 1 0.7913 0 0.36 0 0 6171277.21

DY12 DPH Los Angeles County Health System 2.7.4 MWM #8: Treatment Preferences (documentation) Outpatient 103 0 147 0 1 0.7007 0 None 1 0 6171277.21

DY12 DPH Los Angeles County Health System 2.7.5 Palliative Care Service Offered at Time of Diagnosis of Advanced Illness 120 0 269 0 1 0.4461 0 0.192 0 0 6171277.21

DY12 DPH Los Angeles County Health System 2.7.6 Proportion Admitted to Hospice for Less Than 3 Days 65 0 448 0 1 0.1451 0 None 1 0 6171277.2

DY12 DPH Los Angeles County Health System 3.1.1 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis 345 0 832 0 1 0.4147 0 0.3427 0 0.3488 5992199.98

DY12 DPH Los Angeles County Health System 3.1.2 Avoidance of Antibiotic Treatment with Low Colony Urinary Cultures 0 0 0 0 0 0 0 0.4112 0 NA 2796360.19

DY12 DPH Los Angeles County Health System 3.1.3 National Healthcare Safety Network (NHSN) Antimicrobial Use Measure 71344 0 347474 0 1 0.2053 0 0.1933 0 0 5992199.97

DY12 DPH Los Angeles County Health System 3.1.4 Peri-operative Prophylactic Antibiotics Administered after Surgical Closure 278 0 377 0 1 0.7374 0 0.2894 0 0 5992199.97

DY12 DPH Los Angeles County Health System 3.1.5 Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR No 8498 0 10000 0 1 0.8498 0 0 0 0 5992199.97

DY12 DPH Los Angeles County Health System 3.3.1 Adherence to Medications: Rate 1 81 0 83 0 1 0.975903614 0 0.902 0 NA 5992199.98

DY12 DPH Los Angeles County Health System 3.3.3 High-Cost Pharmaceuticals Ordering Protocols: Rate 1 67 0 90 0 1 0.744444444 0 0.5882 0 NA 5992199.97

DY12 DPH Los Angeles County Health System 3.3.4 Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 1 401 0 1300 0 1 0.308461538 0 NA 0 NA 5992199.97

DY12 DMPH Mammoth Hospital, Mammoth Lakes 1.1.1.a Alcohol and Drug Misuse (SBIRT) 114 0 1268 0 1 0.0899 0 0 0 0 126545.46

DY12 DMPH Mammoth Hospital, Mammoth Lakes 1.1.2 Care Coordinator Assignment None 1 None 4 1 None 1 0 0 0 126545.46

DY12 DMPH Mammoth Hospital, Mammoth Lakes 1.1.3.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 16 0 60 0 1 0.2667 0 0 0 0 126545.46

DY12 DMPH Mammoth Hospital, Mammoth Lakes 1.1.4 Depression Remission at 12 Months (CMS159v4) 0 0 0 0 1 0 0 0 0 0 126545.45

DY12 DMPH Mammoth Hospital, Mammoth Lakes 1.1.5.f Screening for Clinical Depression and follow-up 110 0 874 0 1 0.1259 0 0 0 0 126545.45

DY12 DMPH Mammoth Hospital, Mammoth Lakes 1.1.6.t Tobacco Assessment and Counseling 117 0 889 0 1 0.1316 0 0 0 0 126545.45

DY12 DMPH Mammoth Hospital, Mammoth Lakes 2.6.1 Alcohol and Drug Misuse (SBIRT) 27 0 47 0 1 0.5745 0 0 0 0 126545.46

DY12 DMPH Mammoth Hospital, Mammoth Lakes 2.6.2 Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen None 1 30 0 1 None 1 0 0 0 126545.46

DY12 DMPH Mammoth Hospital, Mammoth Lakes 2.6.3 Patients with chronic pain on long term opioid therapy checked in PDMPs None 1 30 0 1 None 1 0 0 0 126545.45

DY12 DMPH Mammoth Hospital, Mammoth Lakes 2.6.4 Screening for Clinical Depression and follow-up 18 0 30 0 1 0.6 0 0 0 0 126545.45

DY12 DMPH Mammoth Hospital, Mammoth Lakes 2.6.5 Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy 41 0 47 0 1 0.8723 0 0 0 0 126545.45

DY12 DMPH Mammoth Hospital, Mammoth Lakes None Establish workflows and processes for implementing assessment tools None None None None 1 None None None None None 116000

DY12 DMPH Mammoth Hospital, Mammoth Lakes None Train RN Care Coordinator None None None None 1 None None None None None 116000

DY12 DMPH Mammoth Hospital, Mammoth Lakes None Train providers and staff on behavioral health screening assessment tools None None None None 1 None None None None None 116000

DY12 DMPH Mammoth Hospital, Mammoth Lakes None Create patient registries for Mono County Medi-Cal and uninsured patients with BMH diagnoses None None None None 1 None None None None None 116000

DY12 DMPH Mammoth Hospital, Mammoth Lakes None Establish workflows for providers to follow when treating chronic non-malignant pain patients None None None None 1 None None None None None 116000

DY12 DMPH Mammoth Hospital, Mammoth Lakes None Establish 1st level multi-modal treatment protocols/algorithms for treatment of chronic non-malignant pain None None None None 1 None None None None None 116000

DY12 DMPH Mammoth Hospital, Mammoth Lakes None Create patient registries for Mono County Medi-Cal and uninsured patients with Chronic Non-Malignant Pain diagnoses None None None None 1 None None None None None 116000

DY12 DMPH Mammoth Hospital, Mammoth Lakes None Develop and implement a system or manual process for capturing metric data None None None None 1 None None None None None 116000

DY12 DMPH Marin General Hospital, Greenbrae 2.3.1 Care Coordinator Assignment 0 0 1080 0 1 0 0 0 0 0 146400

DY12 DMPH Marin General Hospital, Greenbrae 2.3.2 Medication Reconciliation 30 days 0 0 0 0 1 0 0 0 0 0 146400

DY12 DMPH Marin General Hospital, Greenbrae 2.3.3 Prevention Quality Overall Composite #90 111 0 1080 0 1 0.1028 0 0 0 0 146400

DY12 DMPH Marin General Hospital, Greenbrae 2.3.4 Timely Transmission of Transition Record 0 0 1630 0 1 0 0 0 0 0 146400

DY12 DMPH Marin General Hospital, Greenbrae 2.7.1 Advance Care Plan 0 0 366 0 1 0 0 0 0 0 146400

DY12 DMPH Marin General Hospital, Greenbrae 2.7.2 Ambulatory Palliative Care Team Established: Ambulatory Palliative Care Team Established? No Yes 0 Team Established? 0 1 0 0 NA 0 NA 146400

DY12 DMPH Marin General Hospital, Greenbrae 2.7.3 MWM #8: Treatment Preferences (documentation) Inpatient 0 0 122 0 1 0 0 0 0 0 146400

DY12 DMPH Marin General Hospital, Greenbrae 2.7.4 MWM #8: Treatment Preferences (documentation) Outpatient 0 0 0 0 1 0 0 0 0 0 146400

DY12 DMPH Marin General Hospital, Greenbrae 2.7.5 Palliative Care Service Offered at Time of Diagnosis of Advanced Illness 0 0 0 0 1 0 0 0 0 0 146400

DY12 DMPH Marin General Hospital, Greenbrae 2.7.6 Proportion Admitted to Hospice for Less Than 3 Days 0 0 0 0 1 0 0 0 0 0 146400

DY12 DMPH Marin General Hospital, Greenbrae None Assess existing data system infrastructure None None None None 1 None None None None None 28705.89

DY12 DMPH Marin General Hospital, Greenbrae None Assess the existing inpatient and outpatient PC referral process and identify gaps None None None None 1 None None None None None 28705.88

DY12 DMPH Marin General Hospital, Greenbrae None Conduct a gap analysis of current transitions of care process for CCM patients moving from inpatient to outpatient None None None None 1 None None None None None 28705.89

DY12 DMPH Marin General Hospital, Greenbrae None Conduct a needs assessment for telehealth in Marin County None None None None 1 None None None None None 28705.89

DY12 DMPH Marin General Hospital, Greenbrae None Conduct a qualitative assessment of high-risk, high-utilizing patients to determine program needs None None None None 1 None None None None None 28705.88

DY12 DMPH Marin General Hospital, Greenbrae None Conduct an analysis of existing performance feedback and rapid cycle improvement systems None None None None 1 None None None None None 28705.89

DY12 DMPH Marin General Hospital, Greenbrae None Create set of educational materials to support telehealth services None None None None 1 None None None None None 28705.88

DY12 DMPH Marin General Hospital, Greenbrae None Develop a risk stratification tool to identify patients at risk for re-admission and in need of care coordination None None None None 1 None None None None None 28705.88

DY12 DMPH Marin General Hospital, Greenbrae None Develop and distribute PC resources to staff and community network to support selected PC model None None None None 1 None None None None None 28705.88

DY12 DMPH Marin General Hospital, Greenbrae None Develop and implement a report template for ongoing monitoring of target population and required PRIME metrics None None None None 1 None None None None None 28705.88

DY12 DMPH Marin General Hospital, Greenbrae None Develop and implement outreach and referral process for community providers about referral to care coordination program None None None None 1 None None None None None 28705.88

DY12 DMPH Marin General Hospital, Greenbrae None Develop and implement process to secure patients and referral sources None None None None 1 None None None None None 28705.88

DY12 DMPH Marin General Hospital, Greenbrae None Develop or update care transitions process and workflows for CCM None None None None 1 None None None None None 28705.88

DY12 DMPH Marin General Hospital, Greenbrae None Develop plan to address data infrastructure assessment findings None None None None 1 None None None None None 28705.89

DY12 DMPH Marin General Hospital, Greenbrae None Develop system for regular communication and data sharing with hospice programs in Marin None None None None 1 None None None None None 28705.88

DY12 DMPH Marin General Hospital, Greenbrae None Develop tools and protocols for advance care planning None None None None 1 None None None None None 28705.88

DY12 DMPH Marin General Hospital, Greenbrae None Develop workforce strategy for PC program None None None None 1 None None None None None 28705.89

DY12 DMPH Marin General Hospital, Greenbrae None Development and deployment of clinical and staff education on complex care management model None None None None 1 None None None None None 28705.88

DY12 DMPH Marin General Hospital, Greenbrae None Educate and train at least 50% of hospital clinical staff about PC None None None None 1 None None None None None 28705.88

DY12 DMPH Marin General Hospital, Greenbrae None Establish process and workflows to ensure qualitative feedback is collected on an ongoing basis None None None None 1 None None None None None 28705.88

DY12 DMPH Marin General Hospital, Greenbrae None Hire new staff for PC program None None None None 1 None None None None None 28705.88

DY12 DMPH Marin General Hospital, Greenbrae None Identify at least 1 hub site for telehealth and draft an MOU None None None None 1 None None None None None 28705.88

DY12 DMPH Marin General Hospital, Greenbrae None Identify network of providers in the community None None None None 1 None None None None None 28705.88

DY12 DMPH Marin General Hospital, Greenbrae None Implement plan to expand or improve data infrastructure None None None None 1 None None None None None 28705.88

DY12 DMPH Marin General Hospital, Greenbrae None Install equipment and implement telehealth services None None None None 1 None None None None None 28705.88

DY12 DMPH Marin General Hospital, Greenbrae None Integrate PRIME metric data collection modules into EMR None None None None 1 None None None None None 28705.88

DY12 DMPH Marin General Hospital, Greenbrae None Plan and implement updates to existing performance feedback and rapid-cycle improvement systems for PRIME programs None None None None 1 None None None None None 28705.88

DY12 DMPH Marin General Hospital, Greenbrae None Recruit and hire staff for CCM program None None None None 1 None None None None None 28705.88

DY12 DMPH Marin General Hospital, Greenbrae None Research and select a PC program model None None None None 1 None None None None None 28705.89

DY12 DMPH Marin General Hospital, Greenbrae None Research telehealth infrastructure (hardware, software), and billing needs None None None None 1 None None None None None 28705.89

DY12 DMPH Marin General Hospital, Greenbrae None Select a CCM program for patients with multiple chronic conditions None None None None 1 None None None None None 28705.88

DY12 DMPH Marin General Hospital, Greenbrae None Train 50% of clinical staff on advanced care planning process None None None None 1 None None None None None 28705.88

DY12 DMPH Marin General Hospital, Greenbrae None Train new CCM clinical staff on care model None None None None 1 None None None None None 28705.88

DY12 DMPH Marin General Hospital, Greenbrae None Update the inpatient PC referral process, including planned extension of services to the outpatient setting None None None None 1 None None None None None 28705.88

DY12 DMPH Mayers Memorial Hospital District, Fall River Mills 1.5.1.b Controlling Blood Pressure 14 0 41 0 1 0.3415 0 0 0 0 225000

DY12 DMPH Mayers Memorial Hospital District, Fall River Mills 1.5.2.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 0 0 0 0 0 0 0 0 0 0 225000

DY12 DMPH Mayers Memorial Hospital District, Fall River Mills 1.5.3 PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 0 0 0 0 0 0 0 0 0 0 225000

DY12 DMPH Mayers Memorial Hospital District, Fall River Mills 1.5.4.t Tobacco Assessment and Counseling None 1 None 1 1 None 1 0 0 0 225000

DY12 DMPH Mayers Memorial Hospital District, Fall River Mills None Acquire necessary technology to perform quality metrics extraction None None None None 0 None None None None None 120000

DY12 DMPH Mayers Memorial Hospital District, Fall River Mills None Develop cardiovascular health protocols specific to our facility None None None None 1 None None None None None 120000

DY12 DMPH Mayers Memorial Hospital District, Fall River Mills None Educate Medical Staff on newly approved policies and procedures None None None None 1 None None None None None 120000

DY12 DMPH Mayers Memorial Hospital District, Fall River Mills None Formally adopt policies and procedures for cardiovascular health protocols None None None None 1 None None None None None 120000

DY12 DMPH Mayers Memorial Hospital District, Fall River Mills None Present findings to Medical Staff and BOD Quality None None None None 1 None None None None None 120000

DY12 DMPH Mendocino Coast District Hospital, Fort Bragg 1.6.1 BIRADS to Biopsy None 1 None 1 1 None 1 0 0 0 180000

DY12 DMPH Mendocino Coast District Hospital, Fort Bragg 1.6.2 Breast Cancer Screening 209 0 463 0 1 0.4514 0 0 0 0 180000

DY12 DMPH Mendocino Coast District Hospital, Fort Bragg 1.6.3 Cervical Cancer Screening 110 0 888 0 1 0.1239 0 0 0 0 180000

DY12 DMPH Mendocino Coast District Hospital, Fort Bragg 1.6.4.c Colorectal Cancer Screening 349 0 924 0 1 0.3777 0 0 0 0 180000

DY12 DMPH Mendocino Coast District Hospital, Fort Bragg 1.6.5 Receipt of appropriate follow-up for abnormal CRC screening 0 0 None 1 1 None 1 0 0 0 180000

DY12 DMPH Mendocino Coast District Hospital, Fort Bragg None Complete implementation of cancer screening tools and CDS alerts into EHR None None None None 1 None None None None None 100000

DY12 DMPH Mendocino Coast District Hospital, Fort Bragg None Complete implementation of cancer screening tools into clinic workflow None None None None 1 None None None None None 100000

DY12 DMPH Mendocino Coast District Hospital, Fort Bragg None Consult with the Advisory Board for guidance on community outreach targeting the Hispanic community for early detection of cancer screening. None None None None 1 None None None None None 100000

DY12 DMPH Mendocino Coast District Hospital, Fort Bragg None Establish and meet with an Advisory Board who can partner with MCDH in reaching the Hispanic community The Hispanic population in Mendocino County receives early detection of breast, cervical and colorectal cancers at a lower rate than the rest of the population (see Section 2.1 of the MCDH PRIME application). The purpose of this Advisory Board is to assist MCDH with efforts to increase timely cancer screenings in a culturally sensitive and effective manner. None None None None 1 None None None None None 100000

DY12 DMPH Mendocino Coast District Hospital, Fort Bragg None Recruit and hire staff to fill vacancies identified in the workforce gap analysis None None None None 1 None None None None None 100000

DY12 DMPH Mendocino Coast District Hospital, Fort Bragg None Train and implement the Patient Care Teams None None None None 1 None None None None None 100000

DY12 DMPH Modoc Medical Center, Alturas 1.2.1.a Alcohol and Drug Misuse (SBIRT) 0 0 648 0 1 0 0 0 0 0 69230.77

DY12 DMPH Modoc Medical Center, Alturas 1.2.11 REAL data completeness 783 0 831 0 1 0.9422 0 0 0 0 69230.77

DY12 DMPH Modoc Medical Center, Alturas 1.2.12.f Screening for Clinical Depression and follow-up 94 0 235 0 1 0.4 0 0 0 0 69230.77

DY12 DMPH Modoc Medical Center, Alturas 1.2.13 SO/GI data completeness 0 0 831 0 1 0 0 0 0 0 69230.77

DY12 DMPH Modoc Medical Center, Alturas 1.2.14.t Tobacco Assessment and Counseling 367 0 373 0 1 0.9839 0 0 0 0 69230.76

DY12 DMPH Modoc Medical Center, Alturas 1.2.2 CG-CAHPS: Provider Rating 68 0 90 0 1 0.7556 0 0 0 0 69230.77

DY12 DMPH Modoc Medical Center, Alturas 1.2.3.c Colorectal Cancer Screening 90 0 317 0 1 0.2839 0 0 0 0 69230.77

DY12 DMPH Modoc Medical Center, Alturas 1.2.4.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 11 0 35 0 1 0.3143 0 0 0 0 69230.77

DY12 DMPH Modoc Medical Center, Alturas 1.2.5.b Controlling Blood Pressure 37 0 71 0 1 0.5211 0 0 0 0 69230.77

DY12 DMPH Modoc Medical Center, Alturas 1.2.6 Documented REAL and/or SO/GI disparity reduction plan: Documented disparity reduction plan? No No 0 Plan ? 0 1 0 0 NA 0 NA 69230.77

DY12 DMPH Modoc Medical Center, Alturas 1.2.7.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 24 0 None 4 1 None 4 0 0 0 69230.77

DY12 DMPH Modoc Medical Center, Alturas 1.2.8 Prevention Quality Overall Composite #90 24 0 571 0 1 0.042 0 0 0 0 69230.77

DY12 DMPH Modoc Medical Center, Alturas 1.2.9 Primary Care Redesign metrics stratified by REAL categories and SO/GI: Primary care redesign metrics stratified? No No 0 Stratified ? 0 1 0 0 NA 0 NA 69230.77

DY12 DMPH Modoc Medical Center, Alturas None Develop and document final plan to expand access to care None None None None 1 None None None None None 23076.92

DY12 DMPH Modoc Medical Center, Alturas None Develop care coordinator job description None None None None 1 None None None None None 23076.93

DY12 DMPH Modoc Medical Center, Alturas None Develop policies and procedures for team delivery model None None None None 1 None None None None None 23076.92

DY12 DMPH Modoc Medical Center, Alturas None Engage consultant to perform gap analysis of steps needed to become PCMH None None None None 1 None None None None None 23076.92

DY12 DMPH Modoc Medical Center, Alturas None Establish members of a workgroup to develop an access to care strategy None None None None 1 None None None None None 23076.92

DY12 DMPH Modoc Medical Center, Alturas None Establish selection committee and complete demonstrations of at least 3 new EMR vendors to determine best system to support PRIME objectives None None None None 1 None None None None None 23076.92

DY12 DMPH Modoc Medical Center, Alturas None Evaluate at least three software products capable of producing the data necessary to conduct population health management and care coordination activities None None None None 1 None None None None None 23076.93

DY12 DMPH Modoc Medical Center, Alturas None Hire appropriate number of care coordinators to support proper care coordination of patient panel and ensure successful transition to PCMH and achievement of PRIME objectives. None None None None 1 None None None None None 23076.93

DY12 DMPH Modoc Medical Center, Alturas None Identify and implement population health management and care coordination tasks None None None None 1 None None None None None 23076.93

DY12 DMPH Modoc Medical Center, Alturas None Identify and procure necessary hardware to support selected software. None None None None 1 None None None None None 23076.93

DY12 DMPH Modoc Medical Center, Alturas None Identify appropriate training to implement team delivery model None None None None 1 None None None None None 23076.92

DY12 DMPH Modoc Medical Center, Alturas None Identify opportunities to expand access to care None None None None 1 None None None None None 23076.92

DY12 DMPH Modoc Medical Center, Alturas None Implement selected EMR None None None None 0 None None None None None 23076.92

DY12 DMPH Modoc Medical Center, Alturas None Implement team delivery model None None None None 1 None None None None None 23076.92

DY12 DMPH Modoc Medical Center, Alturas None Implement technology None None None None 0 None None None None None 23076.93

DY12 DMPH Modoc Medical Center, Alturas None Incorporate PRIME metrics into Quality Assurance/Performance Improvement (QAPI) Program None None None None 1 None None None None None 23076.92

DY12 DMPH Modoc Medical Center, Alturas None Level 2 PCMH status recognized by NCQA for clinic None None None None 0 None None None None None 23076.92

DY12 DMPH Modoc Medical Center, Alturas None Present draft team delivery model to providers and staff and finalize model None None None None 1 None None None None None 23076.92

DY12 DMPH Modoc Medical Center, Alturas None Procure Hardware to support selected EMR None None None None 1 None None None None None 23076.92

DY12 DMPH Modoc Medical Center, Alturas None Select and secure the best-suited software product None None None None 1 None None None None None 23076.93

DY12 DMPH Modoc Medical Center, Alturas None Select best EMR solution for Modoc Medical Center None None None None 1 None None None None None 23076.92

DY12 DMPH Modoc Medical Center, Alturas None Select vendor for CG-CAHPS None None None None 1 None None None None None 23076.92

DY12 DMPH Modoc Medical Center, Alturas None Select vendor to expand/remodel existing clinic space and initiate remodel None None None None 1 None None None None None 23076.92

DY12 DMPH Modoc Medical Center, Alturas None Train care coordinators None None None None 1 None None None None None 23076.93

DY12 DMPH Modoc Medical Center, Alturas None Transition to PCMH None None None None 0 None None None None None 23076.92

DY12 DMPH Modoc Medical Center, Alturas None Visit at least two sites that have implemented successful models for team delivery of care to determine appropriate team delivery model None None None None 1 None None None None None 23076.92

DY12 DPH Natividad Medical Center 1.1.1.a Alcohol and Drug Misuse (SBIRT) 487 0 6965 0 1 0.0699 0 0.5056 0 0 529993.34

DY12 DPH Natividad Medical Center 1.1.2 Care Coordinator Assignment 160 0 234 0 1 0.6838 0 0 0 0 529993.34

DY12 DPH Natividad Medical Center 1.1.3.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 404 0 1022 0 1 0.3953 0 0.4234 0 0.4107 529993.33

DY12 DPH Natividad Medical Center 1.1.4 Depression Remission at 12 Months (CMS159v4) None 1 291 0 1 None 1 0 0 0 529993.33

DY12 DPH Natividad Medical Center 1.1.5.f Screening for Clinical Depression and follow-up 2801 0 4313 0 1 0.6494 0 0.5691 0 0 529993.33

DY12 DPH Natividad Medical Center 1.1.6.t Tobacco Assessment and Counseling 5326 0 5503 0 1 0.9678 0 0.9458 0 0.947 529993.33

DY12 DPH Natividad Medical Center 1.2.1.a Alcohol and Drug Misuse (SBIRT) 487 0 6965 0 1 0.0699 0 0.5056 0 0 529993.34

DY12 DPH Natividad Medical Center 1.2.11 REAL data completeness 9274 0 10406 0 1 0.8912 0 0.8975 0 NA 529993.33

DY12 DPH Natividad Medical Center 1.2.12.f Screening for Clinical Depression and follow-up 2801 0 4313 0 1 0.6494 0 0.5691 0 0 529993.33

DY12 DPH Natividad Medical Center 1.2.13 SO/GI data completeness 3856 0 7043 0 1 0.5475 0 0 0 0 529993.33

DY12 DPH Natividad Medical Center 1.2.14.t Tobacco Assessment and Counseling 5326 0 5503 0 1 0.9678 0 0.9458 0 0.947 529993.33

DY12 DPH Natividad Medical Center 1.2.2 CG-CAHPS: Provider Rating 7108 0 10000 0 1 0.7108 0 0.7 0 0.7003 529993.34

DY12 DPH Natividad Medical Center 1.2.3.c Colorectal Cancer Screening 1052 0 1803 0 1 0.5835 0 0.5282 0 0.5411 529993.34

DY12 DPH Natividad Medical Center 1.2.4.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 404 0 1022 0 1 0.3953 0 0.4234 0 0.4107 529993.34

DY12 DPH Natividad Medical Center 1.2.5.b Controlling Blood Pressure 1174 0 1700 0 1 0.6906 0 0.6599 0 0.6642 529993.34

DY12 DPH Natividad Medical Center 1.2.6 Documented REAL and/or SO/GI disparity reduction plan: Documented disparity reduction plan? Yes Yes 0 Plan ? 0 1 0 0 NA 0 NA 529993.33

DY12 DPH Natividad Medical Center 1.2.7.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 199 0 222 0 1 0.8964 0 0.8824 0 0.887 529993.33

DY12 DPH Natividad Medical Center 1.2.8 Prevention Quality Overall Composite #90 67 0 9346 0 1 0.0072 0 0.0084 0 0 529993.33

DY12 DPH Natividad Medical Center 1.2.9 Primary Care Redesign metrics stratified by REAL categories and SO/GI: Primary care redesign metrics stratified? Yes Yes 0 Stratified ? 0 1 0 0 NA 0 NA 529993.33

DY12 DPH Natividad Medical Center 1.3.1 Closing the referral loop: receipt of specialist report (CMS50v3) 1109 0 1190 0 1 0.9319 0 0.9594 0 0 529993.34

DY12 DPH Natividad Medical Center 1.3.2 DHCS All-Cause Readmissions 25 0 250 0 1 0.1 0 0.1474 0 0.1458 529993.34

DY12 DPH Natividad Medical Center 1.3.3 Influenza Immunization 594 0 1115 0 1 0.5327 0 0.4566 0 0 529993.33

DY12 DPH Natividad Medical Center 1.3.4 Post Procedure ED Visits 154 0 5878 0 1 0.0262 0 0.0272 0 0 529993.33

DY12 DPH Natividad Medical Center 1.3.5 Request for Specialty Care Expertise Turnaround Time 1229 0 5253 0 1 0.234 0 0.2455 0 0 529993.33

DY12 DPH Natividad Medical Center 1.3.6 Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters None 1 5277 0 1 None 1 0 0 0 529993.33

DY12 DPH Natividad Medical Center 1.3.7 Tobacco Assessment and Counseling 1411 0 1453 0 1 0.9711 0 0.9567 0 0.9568 529993.33

DY12 DPH Natividad Medical Center 1.5.1.b Controlling Blood Pressure 1174 0 1700 0 1 0.6906 0 0.6599 0 0.6642 529993.34

DY12 DPH Natividad Medical Center 1.5.2.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 199 0 222 0 1 0.8964 0 0.8824 0 0.887 529993.33

DY12 DPH Natividad Medical Center 1.5.3 PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 2073 0 4199 0 1 0.4937 0 0.4895 0 0 529993.33

DY12 DPH Natividad Medical Center 1.5.4.t Tobacco Assessment and Counseling 5326 0 5503 0 1 0.9678 0 0.9458 0 0.947 529993.33

DY12 DPH Natividad Medical Center 2.1.1 Baby Friendly Hospital designation: BFUSA Designation Yes Yes 0 BFUSA Cert? 0 1 0 0 NA 0 NA 553036.53

DY12 DPH Natividad Medical Center 2.1.2 Exclusive Breast Milk Feeding (PC-05) 283 0 540 0 1 0.5241 0 0.4007 0 0.497 553036.53

DY12 DPH Natividad Medical Center 2.1.3 OB Hemorrhage: Massive Transfusion 0 0 615 0 1 0 0 None 1 0 553036.52

DY12 DPH Natividad Medical Center 2.1.4 OB Hemorrhage: Total Products Transfused None 1 615 0 1 None 1 0.0654 0 0 553036.52

DY12 DPH Natividad Medical Center 2.1.5 PC-02 Cesarean Section 26 0 132 0 1 0.197 0 0.2222 0 0.2185 553036.52

DY12 DPH Natividad Medical Center 2.1.6 Prenatal and Postpartum Care: Prenatal Care 341 0 789 0 1 0.432192649 0 0.2366 0 0.7744 276518.26

DY12 DPH Natividad Medical Center 2.1.6 Prenatal and Postpartum Care: Postpartum Care 607 0 789 0 1 0.769328264 0 0.5573 0 0.574 276518.26

DY12 DPH Natividad Medical Center 2.1.7 Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage 12 0 72 0 1 0.1667 0 None 1 0 553036.52

DY12 DPH Natividad Medical Center 2.1.8 Unexpected Newborn Complications (UNC) 42 0 481 0 1 0.0873 0 0.0361 0 0 553036.52

DY12 DPH Natividad Medical Center 2.1.9 OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed)
[Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) 12 0 16 0 1 0 0 NA 0 NA 553036.52

DY12 DPH Natividad Medical Center 2.2.1 DHCS All-Cause Readmissions 32 0 428 0 1 0.0748 0 0.13 0 0.1318 553036.53

DY12 DPH Natividad Medical Center 2.2.2 H-CAHPS: Care Transition Metrics (3) 4571 0 10000 0 0 0.4571 0 0.39 0 0.48 553036.52

DY12 DPH Natividad Medical Center 2.2.3 Medication Reconciliation 30 days 237 0 368 0 1 0.644 0 0.6685 0 0 553036.52

DY12 DPH Natividad Medical Center 2.2.4 Reconciled Medication List Received by Discharged Patients 443 0 493 0 1 0.8986 0 0.894 0 0 553036.52

DY12 DPH Natividad Medical Center 2.2.5 Timely Transmission of Transition Record 466 0 519 0 1 0.8979 0 0.8734 0 0 553036.52

DY12 DPH Natividad Medical Center 2.3.1 Care Coordinator Assignment 230 0 397 0 1 0.5793 0 0 0 0 553036.53

DY12 DPH Natividad Medical Center 2.3.2 Medication Reconciliation 30 days 44 0 48 0 1 0.9167 0 0.7188 0 0 553036.52

DY12 DPH Natividad Medical Center 2.3.3 Prevention Quality Overall Composite #90 17 0 169 0 1 0.1006 0 0.0721 0 0 553036.52

DY12 DPH Natividad Medical Center 2.3.4 Timely Transmission of Transition Record 61 0 71 0 1 0.8592 0 0.8842 0 0 553036.52

DY12 DPH Natividad Medical Center 2.6.1 Alcohol and Drug Misuse (SBIRT) 27 0 322 0 1 0.0839 0 0.6191 0 0 553036.52

DY12 DPH Natividad Medical Center 2.6.2 Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen 89 0 343 0 1 0.2595 0 0.3097 0 0 553036.52

DY12 DPH Natividad Medical Center 2.6.3 Patients with chronic pain on long term opioid therapy checked in PDMPs 119 0 399 0 1 0.2982 0 0 0 0 553036.52

DY12 DPH Natividad Medical Center 2.6.4 Screening for Clinical Depression and follow-up 173 0 257 0 1 0.6732 0 0.6244 0 0 553036.52

DY12 DPH Natividad Medical Center 2.6.5 Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy 597 0 673 0 1 0.8871 0 0.9524 0 0 553036.52

DY12 DPH Natividad Medical Center 3.4.1 ePBM-01 Pre-op Anemia Screening, Selected Elective Surgical Patients 17 0 150 0 1 0.1133 0 0.1339 0 0 1059986.67

DY12 DPH Natividad Medical Center 3.4.2 ePBM-02 Pre-op Hemoglobin Level, Selected Elective Surgical Patients None 1 None 1 0 None 1 None 1 0 $-

DY12 DPH Natividad Medical Center 3.4.3 ePBM-03 Pre-op Type and Crossmatch, Type and Screen, Selected elective Surgical Patients 58 0 91 0 1 0.6374 0 0.6711 0 0 1059986.67

DY12 DPH Natividad Medical Center 3.4.4 ePBM-04 Initial Transfusion Threshold 201 0 201 0 1 1 0 1 0 0 1059986.67

DY12 DPH Natividad Medical Center 3.4.5 ePBM-05 Outcome of Patient Blood Management, Selected Elective Surgical Patients None 1 None 4 0 None 1 None 1 0 $-

DY12 DMPH Northern Inyo Hospital, Bishop 3.1.1 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis 17 0 None 4 1 None 4 0 0 0 792000

DY12 DMPH Northern Inyo Hospital, Bishop 3.1.3 National Healthcare Safety Network (NHSN) Antimicrobial Use Measure 57 0 609 0 1 0.0936 0 0 0 0 792000

DY12 DMPH Northern Inyo Hospital, Bishop 3.1.4 Peri-operative Prophylactic Antibiotics Administered after Surgical Closure None 1 None 1 1 None 1 0 0 0 792000

DY12 DMPH Northern Inyo Hospital, Bishop 3.1.5 Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR No 0 0 0 0 0 0 0 0 0 0 $-

DY12 DMPH Northern Inyo Hospital, Bishop None Conduct gap analysis of current data systems None None None None 1 None None None None None 93176.48

DY12 DMPH Northern Inyo Hospital, Bishop None Configure IT system and/or abstract data to meet DHCS reporting requirements for avoiding treatment of antibiotics in adults with acute bronchitis None None None None 1 None None None None None 93176.47

DY12 DMPH Northern Inyo Hospital, Bishop None Configure IT system and/or abstract data to meet DHCS reporting requirements for avoiding treatment of antibiotics with low colony urinary cultures None None None None 1 None None None None None 93176.47

DY12 DMPH Northern Inyo Hospital, Bishop None Configure IT system and/or abstract data to meet DHCS reporting requirements for discontinuing prophylactic antibiotics at time of surgical closure. None None None None 1 None None None None None 93176.47

DY12 DMPH Northern Inyo Hospital, Bishop None Design and implement EMR and analytics changes to support meeting PRIME reporting requirements None None None None 1 None None None None None 93176.47

DY12 DMPH Northern Inyo Hospital, Bishop None Develop a process to assess performance and distribute ASP scorecard/dashboard None None None None 1 None None None None None 93176.47

DY12 DMPH Northern Inyo Hospital, Bishop None Develop a strategy to populate the ASP scorecard/dashboard template None None None None 1 None None None None None 93176.47

DY12 DMPH Northern Inyo Hospital, Bishop None Develop a template for an Antibiotic Stewardship (ASP) scorecard/dashboard to include PRIME and non PRIME measures None None None None 1 None None None None None 93176.47

DY12 DMPH Northern Inyo Hospital, Bishop None Develop process(es), systems and/or interventions to avoid treatment of antibiotics in adults with acute bronchitis None None None None 0 None None None None None 93176.47

DY12 DMPH Northern Inyo Hospital, Bishop None Develop process(es), systems and/or interventions to avoid treatment of antibiotics with low colony urinary cultures None None None None 0 None None None None None 93176.47

DY12 DMPH Northern Inyo Hospital, Bishop None Develop process(es), systems and/or interventions to discontinue prophylactic antibiotics at time of surgical closure None None None None 0 None None None None None 93176.47

DY12 DMPH Northern Inyo Hospital, Bishop None Develop reports and queries to identify target population None None None None 1 None None None None None 93176.47

DY12 DMPH Northern Inyo Hospital, Bishop None Establish reporting schedule and distribution process None None None None 1 None None None None None 93176.47

DY12 DMPH Northern Inyo Hospital, Bishop None Train at least 75% of relevant staff on clinical documentation needs None None None None 0 None None None None None 93176.47

DY12 DMPH Northern Inyo Hospital, Bishop None Train at least 75% of relevant staff on interventions developed to prevent treatment of adult patients with acute bronchitis with antibiotics on or 3 days after episode None None None None 0 None None None None None 93176.47

DY12 DMPH Northern Inyo Hospital, Bishop None Train at least 75% of relevant staff on interventions to discontinue prophylactic antibiotics at time of surgical closure None None None None 0 None None None None None 93176.47

DY12 DMPH Northern Inyo Hospital, Bishop None Train at least 75% of relevant staff on utilizing order sets and diagnostic testing for low colony urinary cultures None None None None 0 None None None None None 93176.47

DY12 DMPH Oak Valley Hospital District, Oakdale 1.2.1.a Alcohol and Drug Misuse (SBIRT) 182 0 6789 0 1 0.0268 0 0 0 0 133500

DY12 DMPH Oak Valley Hospital District, Oakdale 1.2.11 REAL data completeness 9094 0 9325 0 1 0.9752 0 0 0 0 133500

DY12 DMPH Oak Valley Hospital District, Oakdale 1.2.12.f Screening for Clinical Depression and follow-up 321 0 5724 0 1 0.0561 0 0 0 0 133500

DY12 DMPH Oak Valley Hospital District, Oakdale 1.2.13 SO/GI data completeness 7406 0 9325 0 1 0.7942 0 0 0 0 133500

DY12 DMPH Oak Valley Hospital District, Oakdale 1.2.14.t Tobacco Assessment and Counseling 4300 0 5110 0 1 0.8415 0 0 0 0 133500

DY12 DMPH Oak Valley Hospital District, Oakdale 1.2.2 CG-CAHPS: Provider Rating 419 0 633 0 1 0.6619 0 0 0 0 133500

DY12 DMPH Oak Valley Hospital District, Oakdale 1.2.3.c Colorectal Cancer Screening 587 0 1677 0 1 0.35 0 0 0 0 133500

DY12 DMPH Oak Valley Hospital District, Oakdale 1.2.4.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 665 0 907 0 1 0.7332 0 0 0 0 133500

DY12 DMPH Oak Valley Hospital District, Oakdale 1.2.5.b Controlling Blood Pressure 962 0 1806 0 1 0.5327 0 0 0 0 133500

DY12 DMPH Oak Valley Hospital District, Oakdale 1.2.6 Documented REAL and/or SO/GI disparity reduction plan: Documented disparity reduction plan? Yes Yes 0 Plan ? 0 1 0 0 NA 0 NA 133500

DY12 DMPH Oak Valley Hospital District, Oakdale 1.2.7.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 123 0 195 0 1 0.6308 0 0 0 0 133500

DY12 DMPH Oak Valley Hospital District, Oakdale 1.2.8 Prevention Quality Overall Composite #90 92 0 5724 0 1 0.0161 0 0 0 0 133500

DY12 DMPH Oak Valley Hospital District, Oakdale 1.2.9 Primary Care Redesign metrics stratified by REAL categories and SO/GI: Primary care redesign metrics stratified? Yes Yes 0 Stratified ? 0 1 0 0 NA 0 NA 133500

DY12 DMPH Oak Valley Hospital District, Oakdale 1.4.1 Abnormal Results Follow-Up: Abnormal BIRADS Follow-up 1896 0 1929 0 1 0.982892691 0 0 0 NA 44500

DY12 DMPH Oak Valley Hospital District, Oakdale 1.4.1 Abnormal Results Follow-Up: Abnormal INR Follow-up 1422 0 1643 0 1 0.865489957 0 0 0 NA 44500

DY12 DMPH Oak Valley Hospital District, Oakdale 1.4.1 Abnormal Results Follow-Up: Abnormal Potassium Follow-up 1419 0 1640 0 1 0.865243902 0 0 0 NA 44500

DY12 DMPH Oak Valley Hospital District, Oakdale 1.4.2 Annual Monitoring for Patients on Persistent Medications 761 0 1694 0 1 0.4492 0 0 0 0 133500

DY12 DMPH Oak Valley Hospital District, Oakdale 1.4.3 INR Monitoring for Individuals on Warfarin None 1 None 4 1 None 1 0 0 0 133500

DY12 DMPH Oak Valley Hospital District, Oakdale None Develop a plan to transform clinics into PCMH model of care delivery None None None None 1 None None None None None 158222.23

DY12 DMPH Oak Valley Hospital District, Oakdale None Develop goals and process to improve monitoring and/or tracking of patients on persistent meds and warfarin None None None None 1 None None None None None 158222.22

DY12 DMPH Oak Valley Hospital District, Oakdale None Educate and train 80% of clinic staff on the concept of the PCMH model of care and the associated workflows/policies/ procedures to support the transformation to the PCMH model of care delivery None None None None 1 None None None None None 158222.23

DY12 DMPH Oak Valley Hospital District, Oakdale None Educate, Train and Deploy Staff on the concept of the PCMH model of care, and specific job-related competencies and changes in workflows/processes required to support the PCMH model of care None None None None 1 None None None None None 158222.22

DY12 DMPH Oak Valley Hospital District, Oakdale None Establish new systems and procedures for monitoring and/or tracking of patients on persistent meds and warfarin None None None None 0 None None None None None 158222.22

DY12 DMPH Oak Valley Hospital District, Oakdale None Evaluate alternative options and finalize contract for selected Population Health Software solutions None None None None 1 None None None None None 158222.22

DY12 DMPH Oak Valley Hospital District, Oakdale None Hire a minimum of 3 Staff members to support the transition to the PCMH model of care None None None None 1 None None None None None 158222.22

DY12 DMPH Oak Valley Hospital District, Oakdale None Implement Population Health Software solution None None None None 1 None None None None None 158222.22

DY12 DMPH Oak Valley Hospital District, Oakdale None Test and evaluate the PCMH Transformation plan in clinic settings None None None None 1 None None None None None 158222.22

DY12 DMPH Palo Verde Hospital, Blythe 1.1.1.a Alcohol and Drug Misuse (SBIRT) 16 0 206 0 1 0.0777 0 0 0 0 140000

DY12 DMPH Palo Verde Hospital, Blythe 1.1.2 Care Coordinator Assignment None 1 105 0 1 None 1 0 0 0 140000

DY12 DMPH Palo Verde Hospital, Blythe 1.1.3.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 105 0 1256 0 1 0.0836 0 0 0 0 140000

DY12 DMPH Palo Verde Hospital, Blythe 1.1.4 Depression Remission at 12 Months (CMS159v4) 0 0 62 0 1 0 0 0 0 0 140000

DY12 DMPH Palo Verde Hospital, Blythe 1.1.5.f Screening for Clinical Depression and follow-up 13 0 125 0 1 0.104 0 0 0 0 140000

DY12 DMPH Palo Verde Hospital, Blythe 1.1.6.t Tobacco Assessment and Counseling 46 0 416 0 1 0.1106 0 0 0 0 140000

DY12 DMPH Palo Verde Hospital, Blythe 2.2.1 DHCS All-Cause Readmissions 71 0 317 0 1 0.224 0 0 0 0 140000

DY12 DMPH Palo Verde Hospital, Blythe 2.2.2 H-CAHPS: Care Transition Metrics (3) 283 0 946 0 1 0.2992 0 0 0 0 140000

DY12 DMPH Palo Verde Hospital, Blythe 2.2.3 Medication Reconciliation 30 days 71 0 996 0 1 0.0713 0 0 0 0 140000

DY12 DMPH Palo Verde Hospital, Blythe 2.2.4 Reconciled Medication List Received by Discharged Patients 34 0 601 0 1 0.0566 0 0 0 0 140000

DY12 DMPH Palo Verde Hospital, Blythe 2.2.5 Timely Transmission of Transition Record 35 0 996 0 1 0.0351 0 0 0 0 140000

DY12 DMPH Palo Verde Hospital, Blythe 2.3.1 Care Coordinator Assignment 17 0 95 0 1 0.1789 0 0 0 0 140000

DY12 DMPH Palo Verde Hospital, Blythe 2.3.2 Medication Reconciliation 30 days 17 0 996 0 1 0.0171 0 0 0 0 140000

DY12 DMPH Palo Verde Hospital, Blythe 2.3.3 Prevention Quality Overall Composite #90 17 0 71 0 1 0.2394 0 0 0 0 140000

DY12 DMPH Palo Verde Hospital, Blythe 2.3.4 Timely Transmission of Transition Record 17 0 201 0 1 0.0846 0 0 0 0 140000

DY12 DMPH Palo Verde Hospital, Blythe None Develop a plan to improve access in primary care clinic by the addition of 3 to exam rooms None None None None 1 None None None None None 140000

DY12 DMPH Palo Verde Hospital, Blythe None Develop and train 3 departments on documentation protocols in the clinical E.H.R. and/or with the use of mobile devices None None None None 1 None None None None None 140000

DY12 DMPH Palo Verde Hospital, Blythe None Develop strategies/modules to support clinical documentation for quality reporting for 3 departments (A: Outpatient Clinic, B: PVH-ED, C: PVH-Labor and deliver) None None None None 1 None None None None None 140000

DY12 DMPH Palo Verde Hospital, Blythe None E.H.R. Integration/Implementation in 3 departments for outpatient home health integrated clinic, would care, and prenatal services; implantation of 1 module in each area (3 in total) None None None None 1 None None None None None 140000

DY12 DMPH Palo Verde Hospital, Blythe None Expansion of community based programs, community integration/collaboration of care/protocols/ coordination None None None None 1 None None None None None 140000

DY12 DMPH Palo Verde Hospital, Blythe None Implement of behavior health care integration templates, referral management tools and advance care planning in 3 departments (A-C). None None None None 1 None None None None None 140000

DY12 DMPH Palo Verde Hospital, Blythe None Implementation and practice of PRIME Plan integrated care management in 3 departments None None None None 1 None None None None None 140000

DY12 DMPH Palo Verde Hospital, Blythe None Implementation of referral outreach protocols in 3 department for integrated care coordination None None None None 1 None None None None None 140000

DY12 DMPH Palo Verde Hospital, Blythe None Improve access to care by training 3 departments on time management skills None None None None 1 None None None None None 140000

DY12 DMPH Palo Verde Hospital, Blythe None Training for 3 staff: 7 modules, 2 face to face clinical health coach trainings (TCPI) None None None None 1 None None None None None 140000

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 1.4.1 Abnormal Results Follow-Up: Abnormal BIRADS Follow-up 48 0 77 0 1 0.623376623 0 0 0 NA 112222.22

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 1.4.1 Abnormal Results Follow-Up: Abnormal INR Follow-up 47 0 50 0 1 0.94 0 0 0 NA 112222.22

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 1.4.1 Abnormal Results Follow-Up: Abnormal Potassium Follow-up 233 0 262 0 1 0.889312977 0 0 0 NA 112222.22

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 1.4.2 Annual Monitoring for Patients on Persistent Medications 0 0 0 0 1 0 0 0 0 0.8446 336666.67

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 1.4.3 INR Monitoring for Individuals on Warfarin 12 0 43 0 1 0.2791 0 0 0 0 336666.67

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 1.5.1.b Controlling Blood Pressure 0 0 0 0 1 0 0 0 0 0.4988 336666.66

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 1.5.2.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 0 0 0 0 1 0 0 0 0 0.6808 336666.67

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 1.5.3 PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 3465 0 6191 0 1 0.5597 0 0 0 0 336666.67

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 1.5.4.t Tobacco Assessment and Counseling 888 0 1180 0 1 0.7525 0 0 0 0.7237 336666.67

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 1.7.1 BMI Screening and Follow-up None 1 112 0 1 None 1 0 0 0.4009 336666.66

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 1.7.2 Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Numerator - Criteria Met (If your system has more than one hospital, please enter the sum of all criteria met)
Denominator - Required Criteria (If your system has more than one hospital, multiply the number of hospitals by 2) 4 0 8 0 1 0 0 NA 0 NA 336666.67

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 1.7.3 Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition 0 0 0 0 1 0 0 0 0 0.5198 112222.22

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 1.7.3 Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity 0 0 0 0 1 0 0 0 0 0.4416 112222.22

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 1.7.3 Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI 0 0 0 0 1 0 0 0 0 0.5127 112222.22

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 2.2.1 DHCS All-Cause Readmissions 76 0 303 0 1 0.2508 0 0 0 0.1318 336666.66

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 2.2.2 H-CAHPS: Care Transition Metrics (3) 5485 0 10000 0 1 0.5485 0 0 0 0.48 336666.66

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 2.2.3 Medication Reconciliation 30 days 22 0 38 0 1 0.5789 0 0 0 0 336666.67

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 2.2.4 Reconciled Medication List Received by Discharged Patients 363 0 372 0 1 0.9758 0 0 0 0 336666.67

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 2.2.5 Timely Transmission of Transition Record 0 0 4019 0 1 0 0 0 0 0 336666.67

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 2.3.1 Care Coordinator Assignment None 1 5087 0 1 None 1 0 0 0 336666.66

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 2.3.2 Medication Reconciliation 30 days 22 0 34 0 1 0.6471 0 0 0 0 336666.66

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 2.3.3 Prevention Quality Overall Composite #90 2604 0 5087 0 1 0.5119 0 0 0 0 336666.67

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 2.3.4 Timely Transmission of Transition Record 0 0 3616 0 1 0 0 0 0 0 336666.67

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 2.7.1 Advance Care Plan 178 0 271 0 1 0.6568 0 0 0 0 336666.66

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 2.7.2 Ambulatory Palliative Care Team Established: Ambulatory Palliative Care Team Established? Yes Yes 0 Team Established? 0 1 0 0 NA 0 NA 336666.66

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 2.7.3 MWM #8: Treatment Preferences (documentation) Inpatient 33 0 40 0 1 0.825 0 0 0 0 336666.67

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 2.7.4 MWM #8: Treatment Preferences (documentation) Outpatient 0 0 0 0 1 0 0 0 0 0 336666.67

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 2.7.5 Palliative Care Service Offered at Time of Diagnosis of Advanced Illness None 1 137 0 1 None 1 0 0 0 336666.67

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 2.7.6 Proportion Admitted to Hospice for Less Than 3 Days None 1 None 1 1 None 1 0 0 0 336666.67

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 3.1.1 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis 106 0 151 0 1 0.702 0 0 0 0.22 336666.66

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 3.1.3 National Healthcare Safety Network (NHSN) Antimicrobial Use Measure 27550 0 186836 0 1 0.1475 0 0 0 0 336666.67

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 3.1.4 Peri-operative Prophylactic Antibiotics Administered after Surgical Closure 323 0 337 0 1 0.9585 0 0 0 0 336666.67

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 3.1.5 Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR No 7640 0 10000 0 1 0.764 0 0 0 0 336666.67

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 3.2.1 Imaging for Routine Headaches (Choosing Wisely) 4764 0 13510 0 1 0.3526 0 0 0 0.17 336666.66

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 3.2.2 Appropriate Emergency Department Utilization of CT for Pulmonary Embolism 673 0 3216 0 1 0.2093 0 0 0 0 336666.67

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 3.2.3 Use of Imaging Studies for Low Back Pain 895 0 4102 0 1 0.2182 0 0 0 0.7182 336666.67

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 3.2.4 Use of Imaging Studies for Low Back Pain (anytime) Variation of HEDIS Use of Imaging Studies for Low Back Pain measures: Appropriate Score 441 0 11645 0 1 0.037870331 0 0 0 NA 168333.34

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 3.2.4 Use of Imaging Studies for Low Back Pain (anytime) Variation of HEDIS Use of Imaging Studies for Low Back Pain measures: Inappropriate Score 2708 0 11204 0 1 0.241699393 0 0 0 NA 168333.34

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 3.3.1 Adherence to Medications: Rate 1 38 0 56 0 1 0.678571429 0 0 0 NA 336666.66

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 3.3.3 High-Cost Pharmaceuticals Ordering Protocols: Rate 1 0 0 89 0 1 0 0 0 0 NA 336666.67

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) 3.3.4 Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 1 0 0 None 4 1 None 4 0 0 NA 336666.67

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Conduct a qualitative assessment of high-risk, high-utilizing patients None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Conduct a workforce gap analysis to support PRIME project None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Contract with FQHC to create pharmacist-run clinic None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Convene inter-professional workgroup to review current imaging clinical workflow None None None None 1 None None None None None 124307.7

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Convene recurring quality workgroup to address abnormal test results None None None None 1 None None None None None 124307.7

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Convene recurring quality workgroup to address patients on persistent medications and warfarin None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Create new policy and procedure for the BMI screening and referral process None None None None 1 None None None None None 124307.7

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Create or revise data reporting system for PRIME None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Design high cost pharmaceutical strategies and protocols None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Design Process Changes for Abnormal Test Results None None None None 1 None None None None None 124307.7

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Design process changes for monitoring of patients on persistent medications and warfarin None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Design utilization strategies and tactics None None None None 1 None None None None None 124307.7

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Develop a report on the current state of each criteria within the initiative and develop mechanism to track and make improvements None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Develop a strategy to decrease imaging overutilization None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Develop a template to create a quarterly report to evaluate performance None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Develop and implement population health strategy None None None None 1 None None None None None 124307.7

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Develop and Implement structure for obtaining best possible medication history and assessing accuracy of list for care transitions program None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Develop and/or provide patient/family education tool or educational resources to identify alternatives to imaging None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Develop communication and referral process with community Hospice programs None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Develop criteria to identify high-risk patient populations who may benefit from care management None None None None 1 None None None None None 124307.7

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Develop education modules and curricula on care model for project None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Develop educational curricula on complex care management None None None None 1 None None None None None 124307.7

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Develop infrastructure for additional Community-Based Care Transition Program (CCTP) patients None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Develop infrastructure for Community-Based Care Transitions Program (CCTP) patients None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Develop job descriptions and hire team members None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Develop palliative care training program None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Develop partnership with Federally funded clinics None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Develop partnership with Palomar Health Express Care clinics for patient follow up post discharge from the hospital None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Develop process for updating and evaluating staff competencies None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Develop process to identify patients and potential referral for program None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Develop process to provide continual performance feedback to care teams from patients, frontline staff and senior leadership None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Develop referral network for patients with community partners and services listed None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Develop referral process for inpatient, outpatient, home health, Skilled Nursing Facilities and train 90% of Clinical Resource Management (CRM) staff. None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Develop staffing plan to support PRIME project None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Develop standardized workflow for transitions of care team None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Develop strategy on managing high-risk, high utilizing population None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Develop system to support care transitions program including discharge process None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Develop template for hospice staff to track patients who expire with less than 3 days on hospice None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Develop tools, protocols, and modules for advanced care planning in palliative care None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Develop/revise discharge medication reconciliation standards for PRIME patients and subsequent patient education about medications for care transitions program None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Development of a multidisciplinary complex care management team None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None ED Committee approval of BMI workflow screening and referral process None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Establish inpatient and outpatient subcommittees to palliative care program None None None None 1 None None None None None 124307.7

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Establish partnerships with stakeholders to identify patient populations None None None None 1 None None None None None 124307.7

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Establish space and clinical agreements for pharmacist-run clinic None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Establish transitions of care team None None None None 1 None None None None None 124307.7

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Evaluate existing data reporting systems None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Identify best practices for clinical pathways None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Identify high cost pharmaceuticals None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Identify leading imaging practices and train 90% of imaging-related staff on practices None None None None 1 None None None None None 124307.7

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Identify utilization targets None None None None 1 None None None None None 124307.7

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Implement CPOE and education for clinical pathways None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Integrate pharmacist into FQHC None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Modify risk stratification tool to identify PRIME patients at risk for readmission for the care transitions program. None None None None 1 None None None None None 124307.7

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Obtain prescription utilization data for high cost pharmaceuticals None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Perform workforce gap analysis of palliative care needs None None None None 1 None None None None None 124307.7

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Revise clinical workflow and train staff None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Train 75% of ED staff (RN and Providers) on proposed changes to EMR system for PRIME reporting system None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Train 75% of Transition Nurse Specialists (RN) staff on project interventions None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Train 90 % ED staff (RNs and Providers) and other hospital staff on BMI screening and referral process None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Train 90% of Clinical Resource Management (CRM) staff on complex care management process and models to be used None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Train 90% of Clinical Resource Management (CRM) staff on the advanced care planning process and implement advanced care planning and documentation None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Train and educate 60% of staff (Pharmacists, Providers and Medical Assistants) on process for monitoring of patients on persistent medications and warfarin None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Train and educate 60% of staff (Pharmacists, Providers and Medical Assistants) on workflow process for Abnormal Test Results None None None None 1 None None None None None 124307.69

DY12 DMPH Palomar Medical Center, Escondido (including Pomerado Hospital, Poway) None Train staff on the advanced care planning process and implement advanced care planning in palliative care None None None None 1 None None None None None 124307.69

DY12 DMPH Pioneers Memorial Healthcare District, Brawley 1.4.1 Abnormal Results Follow-Up: Abnormal BIRADS Follow-up 34 0 53 0 1 0.641509434 0 0 0 NA 72470.59

DY12 DMPH Pioneers Memorial Healthcare District, Brawley 1.4.1 Abnormal Results Follow-Up: Abnormal INR Follow-up 28 0 38 0 1 0.736842105 0 0 0 NA 72470.59

DY12 DMPH Pioneers Memorial Healthcare District, Brawley 1.4.1 Abnormal Results Follow-Up: Abnormal Potassium Follow-up 11 0 78 0 1 0.141025641 0 0 0 NA 72470.59

DY12 DMPH Pioneers Memorial Healthcare District, Brawley 1.4.2 Annual Monitoring for Patients on Persistent Medications 659 0 889 0 1 0.7413 0 0 0 0 217411.76

DY12 DMPH Pioneers Memorial Healthcare District, Brawley 1.4.3 INR Monitoring for Individuals on Warfarin None 1 None 4 1 None 1 0 0 0 217411.77

DY12 DMPH Pioneers Memorial Healthcare District, Brawley 1.6.1 BIRADS to Biopsy None 1 None 1 1 None 1 0 0 0 217411.76

DY12 DMPH Pioneers Memorial Healthcare District, Brawley 1.6.2 Breast Cancer Screening 255 0 549 0 1 0.4645 0 0 0 0 217411.76

DY12 DMPH Pioneers Memorial Healthcare District, Brawley 1.6.3 Cervical Cancer Screening 155 0 1452 0 1 0.1067 0 0 0 0 217411.77

DY12 DMPH Pioneers Memorial Healthcare District, Brawley 1.6.4.c Colorectal Cancer Screening 79 0 853 0 1 0.0926 0 0 0 0 217411.77

DY12 DMPH Pioneers Memorial Healthcare District, Brawley 1.6.5 Receipt of appropriate follow-up for abnormal CRC screening None 1 None 1 1 None 1 0 0 0 217411.77

DY12 DMPH Pioneers Memorial Healthcare District, Brawley 2.2.1 DHCS All-Cause Readmissions 61 0 450 0 1 0.1356 0 0 0 0 217411.76

DY12 DMPH Pioneers Memorial Healthcare District, Brawley 2.2.2 H-CAHPS: Care Transition Metrics (3) 758 0 1399 0 1 0.5418 0 0 0 0 217411.76

DY12 DMPH Pioneers Memorial Healthcare District, Brawley 2.2.3 Medication Reconciliation 30 days None 1 230 0 1 None 1 0 0 0 217411.76

DY12 DMPH Pioneers Memorial Healthcare District, Brawley 2.2.4 Reconciled Medication List Received by Discharged Patients 309 0 612 0 1 0.5049 0 0 0 0 217411.77

DY12 DMPH Pioneers Memorial Healthcare District, Brawley 2.2.5 Timely Transmission of Transition Record None 1 496 0 1 None 1 0 0 0 217411.77

DY12 DMPH Pioneers Memorial Healthcare District, Brawley 3.1.1 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis None 1 None 4 1 None 1 0 0 0 217411.76

DY12 DMPH Pioneers Memorial Healthcare District, Brawley 3.1.3 National Healthcare Safety Network (NHSN) Antimicrobial Use Measure 4444 0 23295 0 1 0.1908 0 0 0 0 217411.76

DY12 DMPH Pioneers Memorial Healthcare District, Brawley 3.1.4 Peri-operative Prophylactic Antibiotics Administered after Surgical Closure 620 0 4135 0 1 0.1499 0 0 0 0 217411.77

DY12 DMPH Pioneers Memorial Healthcare District, Brawley 3.1.5 Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR No 10750 0 10000 0 1 1.075 0 0 0 0 217411.77

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Create a database to collect transition of care data for reporting None None None None 1 None None None None None 82133.34

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Create and implement community education program for appropriate antibiotic use None None None None 1 None None None None None 82133.33

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Create and implement community outreach for antimicrobial stewardship program None None None None 1 None None None None None 82133.33

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Create and implement community outreach for cancer screening None None None None 1 None None None None None 82133.33

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Create and implement community outreach for patients on long term medication None None None None 1 None None None None None 82133.33

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Create and implement community outreach for transition of care None None None None 1 None None None None None 82133.33

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Create and implement provider education program for appropriate antibiotic use None None None None 1 None None None None None 82133.33

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Create workflow for managing patients on cancer screening None None None None 1 None None None None None 82133.33

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Create workflow for managing patients on long term medication None None None None 1 None None None None None 82133.33

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Develop order sets, protocols and algorithms to support ASP None None None None 1 None None None None None 82133.33

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Develop process to identify patients at risk for readmission None None None None 1 None None None None None 82133.33

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Develop processes and procedures for post discharge follow up None None None None 1 None None None None None 82133.34

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Develop protocol to reduce antimicrobial Days of Therapy and for De-escalation of Antimicrobial Therapy None None None None 1 None None None None None 82133.34

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Develop standard protocols for cancer screening None None None None 1 None None None None None 82133.34

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Develop standard protocols for patients on long term medication None None None None 1 None None None None None 82133.34

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Establish a process to collect, analyze and report data for monitoring timely patient notification and appropriate follow-up of abnormal and normal tests. None None None None 1 None None None None None 82133.33

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Establish a process to collect, analyze and report data on long term medications None None None None 1 None None None None None 82133.33

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Establish an Antibiotic Stewardship Program None None None None 1 None None None None None 82133.34

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Improve Discharge Process using data system None None None None 1 None None None None None 82133.33

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Review and revise current policy and procedures for cancer screening None None None None 1 None None None None None 82133.34

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Review and revise current policy and procedures for patients on long term medication None None None None 1 None None None None None 82133.34

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Train 50 % of care providers and implement protocols, policy and procedures, workflows, and electronic medical record regarding long term medications None None None None 1 None None None None None 82133.33

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Train 50% of care providers and implement follow up processes for transitions of care. None None None None 1 None None None None None 82133.33

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Train 50% of care providers and implement Transition of Care program None None None None 1 None None None None None 82133.34

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Train 50% of care providers and implement protocols, policy and procedures, workflows, and electronic medical record None None None None 1 None None None None None 82133.33

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Train 50% of care providers and implement risk for readmission process None None None None 1 None None None None None 82133.33

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Train 50% of care providers on new discharge documentation process and transition of care program. 50% of care providers will be trained on identification of potential high risk patients using the LACE risk assessment tool and new transition of care program. None None None None 1 None None None None None 82133.33

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Train 75 % of care providers and implement protocol for De-escalation of Antimicrobial Therapy None None None None 1 None None None None None 82133.33

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Train 75% of care providers and ancillary staff and implement order sets, protocols and algorithms for ASP None None None None 1 None None None None None 82133.33

DY12 DMPH Pioneers Memorial Healthcare District, Brawley None Train 75% of care providers and implementation of antimicrobial DOT protocol None None None None 1 None None None None None 82133.34

DY12 DMPH Plumas District Hospital, Quincy 2.6.1 Alcohol and Drug Misuse (SBIRT) 0 0 258 0 1 0 0 0 0 0 180000

DY12 DMPH Plumas District Hospital, Quincy 2.6.2 Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen 37 0 258 0 1 0.1434 0 0 0 0 180000

DY12 DMPH Plumas District Hospital, Quincy 2.6.3 Patients with chronic pain on long term opioid therapy checked in PDMPs 57 0 258 0 1 0.2209 0 0 0 0 180000

DY12 DMPH Plumas District Hospital, Quincy 2.6.4 Screening for Clinical Depression and follow-up 0 0 75 0 1 0 0 0 0 0 180000

DY12 DMPH Plumas District Hospital, Quincy 2.6.5 Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy 204 0 258 0 1 0.7907 0 0 0 0 180000

DY12 DMPH Plumas District Hospital, Quincy None Analyze staff training needs for chronic non-malignant pain management None None None None 1 None None None None None 40000

DY12 DMPH Plumas District Hospital, Quincy None Assess community resources (External) None None None None 1 None None None None None 40000

DY12 DMPH Plumas District Hospital, Quincy None Assess current facility resources (Internal) None None None None 1 None None None None None 40000

DY12 DMPH Plumas District Hospital, Quincy None Collaborate with Northern Sierra Opioid Coalition None None None None 1 None None None None None 40000

DY12 DMPH Plumas District Hospital, Quincy None Develop Training material for chronic non-malignant Pain Management None None None None 1 None None None None None 40000

DY12 DMPH Plumas District Hospital, Quincy None Hire a staff coordination person None None None None 1 None None None None None 40000

DY12 DMPH Plumas District Hospital, Quincy None Hire IT staff position None None None None 1 None None None None None 40000

DY12 DMPH Plumas District Hospital, Quincy None Implement the Care Plan None None None None 1 None None None None None 40000

DY12 DMPH Plumas District Hospital, Quincy None Pilot Care Phase Analysis None None None None 1 None None None None None 40000

DY12 DMPH Plumas District Hospital, Quincy None Pilot Care Plan None None None None 1 None None None None None 40000

DY12 DMPH Plumas District Hospital, Quincy None Submit request for project metric reporting capabilities within EHR None None None None 1 None None None None None 40000

DY12 DMPH Plumas District Hospital, Quincy None Submit request to the vendor for the care plan into the EHR by developing a template None None None None 1 None None None None None 40000

DY12 DMPH Plumas District Hospital, Quincy None Train a staff coordination person None None None None 1 None None None None None 40000

DY12 DMPH Plumas District Hospital, Quincy None Train new IT staff None None None None 1 None None None None None 40000

DY12 DMPH Plumas District Hospital, Quincy None Train staff on chronic non-malignant pain management None None None None 1 None None None None None 40000

DY12 DPH Riverside University Health System 1.1.1.a Alcohol and Drug Misuse (SBIRT) 185 0 19291 0 1 0.0096 0 None 1 0 1112650

DY12 DPH Riverside University Health System 1.1.2 Care Coordinator Assignment 204 0 1011 0 1 0.2018 0 None 1 0 1112650

DY12 DPH Riverside University Health System 1.1.3.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 1300 0 3529 0 1 0.3684 0 0.5092 0 0.4989 1112650

DY12 DPH Riverside University Health System 1.1.4 Depression Remission at 12 Months (CMS159v4) 0 0 32 0 1 0 0 0 0 0 1112650

DY12 DPH Riverside University Health System 1.1.5.f Screening for Clinical Depression and follow-up 199 0 400 0 1 0.4975 0 0.0691 0 0 1112650

DY12 DPH Riverside University Health System 1.1.6.t Tobacco Assessment and Counseling 8588 0 10570 0 1 0.8125 0 0.41 0 0.7237 1112650

DY12 DPH Riverside University Health System 1.2.1.a Alcohol and Drug Misuse (SBIRT) 185 0 19291 0 1 0.0096 0 None 1 0 1112650

DY12 DPH Riverside University Health System 1.2.11 REAL data completeness 16686 0 19567 0 1 0.8528 0 0 0 NA 1112650

DY12 DPH Riverside University Health System 1.2.12.f Screening for Clinical Depression and follow-up 199 0 400 0 1 0.4975 0 0.0691 0 0 1112650

DY12 DPH Riverside University Health System 1.2.13 SO/GI data completeness 11306 0 18335 0 1 0.6166 0 0 0 0 1112650

DY12 DPH Riverside University Health System 1.2.14.t Tobacco Assessment and Counseling 8588 0 10570 0 1 0.8125 0 0.41 0 0.7237 1112650

DY12 DPH Riverside University Health System 1.2.2 CG-CAHPS: Provider Rating 70 0 100 0 1 0.7 0 0.62 0 0.6283 1112650

DY12 DPH Riverside University Health System 1.2.3.c Colorectal Cancer Screening 4123 0 8413 0 1 0.4901 0 0.0675 0 0.2669 1112650

DY12 DPH Riverside University Health System 1.2.4.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 1300 0 3529 0 1 0.3684 0 0.5092 0 0.4989 1112650

DY12 DPH Riverside University Health System 1.2.5.b Controlling Blood Pressure 248 0 400 0 1 0.62 0 0.4636 0 0.4988 1112650

DY12 DPH Riverside University Health System 1.2.6 Documented REAL and/or SO/GI disparity reduction plan: Documented disparity reduction plan? Yes Yes 0 Plan ? 0 1 0 0 NA 0 NA 1112650

DY12 DPH Riverside University Health System 1.2.7.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 945 0 1370 0 1 0.6898 0 0.6324 0 0.6808 1112650

DY12 DPH Riverside University Health System 1.2.8 Prevention Quality Overall Composite #90 180 0 43234 0 1 0.0042 0 0.0066 0 0 1112650

DY12 DPH Riverside University Health System 1.2.9 Primary Care Redesign metrics stratified by REAL categories and SO/GI: Primary care redesign metrics stratified? Yes Yes 0 Stratified ? 0 1 0 0 NA 0 NA 1112650

DY12 DPH Riverside University Health System 1.3.1 Closing the referral loop: receipt of specialist report (CMS50v3) 3411 0 3489 0 1 0.9776 0 0.1915 0 0 1112650

DY12 DPH Riverside University Health System 1.3.2 DHCS All-Cause Readmissions 27 0 243 0 1 0.1111 0 0.1757 0 0.1713 1112650

DY12 DPH Riverside University Health System 1.3.3 Influenza Immunization 603 0 1324 0 1 0.4554 0 0 0 0 1112650

DY12 DPH Riverside University Health System 1.3.4 Post Procedure ED Visits 230 0 5238 0 1 0.0439 0 0.0185 0 0 1112650

DY12 DPH Riverside University Health System 1.3.5 Request for Specialty Care Expertise Turnaround Time 3383 0 12280 0 1 0.2755 0 0.4271 0 0 1112650

DY12 DPH Riverside University Health System 1.3.6 Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters 18 0 400 0 1 0.045 0 0 0 0 1112650

DY12 DPH Riverside University Health System 1.3.7 Tobacco Assessment and Counseling 2556 0 2763 0 1 0.9251 0 0 0 0.7237 1112650

DY12 DPH Riverside University Health System 1.5.1.b Controlling Blood Pressure 248 0 400 0 1 0.62 0 0.4636 0 0.4988 1112650

DY12 DPH Riverside University Health System 1.5.2.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 945 0 1370 0 1 0.6898 0 0.6324 0 0.6808 1112650

DY12 DPH Riverside University Health System 1.5.3 PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 204 0 550 0 1 0.3709 0 0.5528 0 0 1112650

DY12 DPH Riverside University Health System 1.5.4.t Tobacco Assessment and Counseling 8588 0 10570 0 1 0.8125 0 0.41 0 0.7237 1112650

DY12 DPH Riverside University Health System 2.1.1 Baby Friendly Hospital designation: BFUSA Designation Yes Yes 0 BFUSA Cert? 0 1 0 0 NA 0 NA 1213800

DY12 DPH Riverside University Health System 2.1.2 Exclusive Breast Milk Feeding (PC-05) 151 0 239 0 1 0.6318 0 0.6079 0 0.6269 1213800

DY12 DPH Riverside University Health System 2.1.3 OB Hemorrhage: Massive Transfusion None 1 293 0 1 None 1 None 1 0 1213800

DY12 DPH Riverside University Health System 2.1.4 OB Hemorrhage: Total Products Transfused 18 0 293 0 1 0.0614 0 0.162 0 0 1213800

DY12 DPH Riverside University Health System 2.1.5 PC-02 Cesarean Section 13 0 87 0 1 0.1494 0 0.1931 0 0.1923 1213800

DY12 DPH Riverside University Health System 2.1.6 Prenatal and Postpartum Care: Prenatal Care 163 0 271 0 1 0.601476015 0 0.5526 0 0.7744 606900

DY12 DPH Riverside University Health System 2.1.6 Prenatal and Postpartum Care: Postpartum Care 99 0 271 0 1 0.365313653 0 0.4211 0 0.5547 606900

DY12 DPH Riverside University Health System 2.1.7 Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage None 1 None 4 0 None 1 0.4444 0 0 $-

DY12 DPH Riverside University Health System 2.1.8 Unexpected Newborn Complications (UNC) 13 0 221 0 1 0.0588 0 0.0693 0 0 1213800

DY12 DPH Riverside University Health System 2.1.9 OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed)[Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) 8 0 16 0 1 0 0 NA 0 NA 1213800

DY12 DPH Riverside University Health System 2.2.1 DHCS All-Cause Readmissions 50 0 404 0 1 0.1238 0 0.068 0 0.1318 1213800

DY12 DPH Riverside University Health System 2.2.2 H-CAHPS: Care Transition Metrics (3) 4395 0 10000 0 0 0.4395 0 0.46 0 0.48 1213800

DY12 DPH Riverside University Health System 2.2.3 Medication Reconciliation 30 days 174 0 210 0 1 0.8286 0 0.1279 0 0 1213800

DY12 DPH Riverside University Health System 2.2.4 Reconciled Medication List Received by Discharged Patients 2147 0 2635 0 1 0.8148 0 0.4876 0 0 1213800

DY12 DPH Riverside University Health System 2.2.5 Timely Transmission of Transition Record 315 0 388 0 1 0.8119 0 0 0 0 1213800

DY12 DPH Riverside University Health System 2.3.1 Care Coordinator Assignment 717 0 1299 0 1 0.552 0 0 0 0 1213800

DY12 DPH Riverside University Health System 2.3.2 Medication Reconciliation 30 days 58 0 63 0 1 0.9206 0 None 1 0 1213800

DY12 DPH Riverside University Health System 2.3.3 Prevention Quality Overall Composite #90 72 0 1298 0 1 0.0555 0 0.0448 0 0 1213800

DY12 DPH Riverside University Health System 2.3.4 Timely Transmission of Transition Record 241 0 259 0 1 0.9305 0 0 0 0 1213800

DY12 DPH Riverside University Health System 2.6.1 Alcohol and Drug Misuse (SBIRT) None 1 2151 0 1 None 1 None 1 0 1213800

DY12 DPH Riverside University Health System 2.6.2 Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen None 1 1905 0 1 None 1 0 0 0 1213800

DY12 DPH Riverside University Health System 2.6.3 Patients with chronic pain on long term opioid therapy checked in PDMPs 125 0 4211 0 1 0.0297 0 None 1 0 1213800

DY12 DPH Riverside University Health System 2.6.4 Screening for Clinical Depression and follow-up 208 0 347 0 1 0.5994 0 0.0965 0 0 1213800

DY12 DPH Riverside University Health System 2.6.5 Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy 3632 0 5723 0 1 0.6346 0 0.1963 0 0 1213800

DY12 DPH Riverside University Health System 3.3.1 Adherence to Medications: Rate 1 291 0 375 0 1 0.776 0 0 0 NA 2225300

DY12 DPH Riverside University Health System 3.3.3 High-Cost Pharmaceuticals Ordering Protocols: Rate 1 130 0 332 0 1 0.391566265 0 0 0 NA 2225300

DY12 DPH Riverside University Health System 3.3.4 Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 1 463 0 1036 0 1 0.446911197 0 0 0 NA 2225300

DY12 DMPH Salinas Valley Memorial Healthcare System 1.4.1 Abnormal Results Follow-Up: Abnormal BIRADS Follow-up 862 0 1074 0 1 0.802607076 0 0 0 NA 56555.55

DY12 DMPH Salinas Valley Memorial Healthcare System 1.4.1 Abnormal Results Follow-Up: Abnormal INR Follow-up 624 0 768 0 1 0.8125 0 0 0 NA 56555.55

DY12 DMPH Salinas Valley Memorial Healthcare System 1.4.1 Abnormal Results Follow-Up: Abnormal Potassium Follow-up 367 0 420 0 1 0.873809524 0 0 0 NA 56555.55

DY12 DMPH Salinas Valley Memorial Healthcare System 1.4.2 Annual Monitoring for Patients on Persistent Medications 294 0 502 0 1 0.5857 0 0 0 0 169666.66

DY12 DMPH Salinas Valley Memorial Healthcare System 1.4.3 INR Monitoring for Individuals on Warfarin 47 0 63 0 1 0.746 0 0 0 0 169666.67

DY12 DMPH Salinas Valley Memorial Healthcare System 1.5.1.b Controlling Blood Pressure 185 0 473 0 1 0.3911 0 0 0 0 169666.66

DY12 DMPH Salinas Valley Memorial Healthcare System 1.5.2.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 200 0 296 0 1 0.6757 0 0 0 0 169666.66

DY12 DMPH Salinas Valley Memorial Healthcare System 1.5.3 PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 2520 0 6251 0 1 0.4031 0 0 0 0 169666.67

DY12 DMPH Salinas Valley Memorial Healthcare System 1.5.4.t Tobacco Assessment and Counseling 6037 0 6812 0 1 0.8862 0 0 0 0 169666.67

DY12 DMPH Salinas Valley Memorial Healthcare System 1.6.1 BIRADS to Biopsy 61 0 70 0 1 0.8714 0 0 0 0 169666.66

DY12 DMPH Salinas Valley Memorial Healthcare System 1.6.2 Breast Cancer Screening 380 0 868 0 1 0.4378 0 0 0 0 169666.66

DY12 DMPH Salinas Valley Memorial Healthcare System 1.6.3 Cervical Cancer Screening 751 0 2543 0 1 0.2953 0 0 0 0 169666.67

DY12 DMPH Salinas Valley Memorial Healthcare System 1.6.4.c Colorectal Cancer Screening 411 0 1598 0 1 0.2572 0 0 0 0 169666.67

DY12 DMPH Salinas Valley Memorial Healthcare System 1.6.5 Receipt of appropriate follow-up for abnormal CRC screening 0 0 None 4 1 None 4 0 0 0 169666.67

DY12 DMPH Salinas Valley Memorial Healthcare System 2.2.1 DHCS All-Cause Readmissions 366 0 2883 0 1 0.127 0 0 0 0 169666.66

DY12 DMPH Salinas Valley Memorial Healthcare System 2.2.2 H-CAHPS: Care Transition Metrics (3) 2049 0 3819 0 1 0.5365 0 0 0 0 169666.67

DY12 DMPH Salinas Valley Memorial Healthcare System 2.2.3 Medication Reconciliation 30 days 62 0 296 0 1 0.2095 0 0 0 0 169666.67

DY12 DMPH Salinas Valley Memorial Healthcare System 2.2.4 Reconciled Medication List Received by Discharged Patients 506 0 627 0 1 0.807 0 0 0 0 169666.67

DY12 DMPH Salinas Valley Memorial Healthcare System 2.2.5 Timely Transmission of Transition Record None 1 404 0 1 None 1 0 0 0 169666.67

DY12 DMPH Salinas Valley Memorial Healthcare System 2.3.1 Care Coordinator Assignment 20 0 3430 0 1 0.0058 0 0 0 0 169666.66

DY12 DMPH Salinas Valley Memorial Healthcare System 2.3.2 Medication Reconciliation 30 days 13 0 56 0 1 0.2321 0 0 0 0 169666.67

DY12 DMPH Salinas Valley Memorial Healthcare System 2.3.3 Prevention Quality Overall Composite #90 63 0 3430 0 1 0.0184 0 0 0 0 169666.67

DY12 DMPH Salinas Valley Memorial Healthcare System 2.3.4 Timely Transmission of Transition Record None 1 392 0 1 None 1 0 0 0 169666.67

DY12 DMPH Salinas Valley Memorial Healthcare System 2.7.1 Advance Care Plan 277 0 675 0 1 0.4104 0 0 0 0 169666.66

DY12 DMPH Salinas Valley Memorial Healthcare System 2.7.2 Ambulatory Palliative Care Team Established: Ambulatory Palliative Care Team Established? Yes Yes 0 Team Established? 0 1 0 0 NA 0 NA 169666.66

DY12 DMPH Salinas Valley Memorial Healthcare System 2.7.3 MWM #8: Treatment Preferences (documentation) Inpatient 35 0 55 0 1 0.6364 0 0 0 0 169666.67

DY12 DMPH Salinas Valley Memorial Healthcare System 2.7.4 MWM #8: Treatment Preferences (documentation) Outpatient 34 0 197 0 1 0.1726 0 0 0 0 169666.67

DY12 DMPH Salinas Valley Memorial Healthcare System 2.7.5 Palliative Care Service Offered at Time of Diagnosis of Advanced Illness 52 0 511 0 1 0.1018 0 0 0 0 169666.67

DY12 DMPH Salinas Valley Memorial Healthcare System 2.7.6 Proportion Admitted to Hospice for Less Than 3 Days 0 0 0 0 1 0 0 0 0 0 169666.67

DY12 DMPH Salinas Valley Memorial Healthcare System 3.1.1 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis 123 0 188 0 1 0.6543 0 0 0 0 169666.66

DY12 DMPH Salinas Valley Memorial Healthcare System 3.1.3 National Healthcare Safety Network (NHSN) Antimicrobial Use Measure 6524 0 16586 0 1 0.3933 0 0 0 0 169666.67

DY12 DMPH Salinas Valley Memorial Healthcare System 3.1.4 Peri-operative Prophylactic Antibiotics Administered after Surgical Closure 305 0 479 0 1 0.6367 0 0 0 0 169666.67

DY12 DMPH Salinas Valley Memorial Healthcare System 3.1.5 Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR No 10400 0 10000 0 1 1.04 0 0 0 0 169666.67

DY12 DMPH Salinas Valley Memorial Healthcare System 3.4.1 ePBM-01 Pre-op Anemia Screening, Selected Elective Surgical Patients 25 0 105 0 1 0.2381 0 0 0 0 169666.66

DY12 DMPH Salinas Valley Memorial Healthcare System 3.4.2 ePBM-02 Pre-op Hemoglobin Level, Selected Elective Surgical Patients None 1 None 1 1 None 1 0 0 0 169666.67

DY12 DMPH Salinas Valley Memorial Healthcare System 3.4.3 ePBM-03 Pre-op Type and Crossmatch, Type and Screen, Selected elective Surgical Patients 46 0 103 0 1 0.4466 0 0 0 0 169666.67

DY12 DMPH Salinas Valley Memorial Healthcare System 3.4.4 ePBM-04 Initial Transfusion Threshold 164 0 164 0 1 1 0 0 0 0 169666.67

DY12 DMPH Salinas Valley Memorial Healthcare System 3.4.5 ePBM-05 Outcome of Patient Blood Management, Selected Elective Surgical Patients None 1 None 4 1 None 1 0 0 0 169666.67

DY12 DMPH Salinas Valley Memorial Healthcare System None Create a dashboard for sharing clinical metric outcomes None None None None 1 None None None None None 116342.86

DY12 DMPH Salinas Valley Memorial Healthcare System None Create a summary report of data collection process for Patient Safety in the Ambulatory Setting None None None None 1 None None None None None 116342.86

DY12 DMPH Salinas Valley Memorial Healthcare System None Create report of adherence to updated protocols None None None None 1 None None None None None 116342.85

DY12 DMPH Salinas Valley Memorial Healthcare System None Create summary report of adherence to recommended cancer screening protocols None None None None 1 None None None None None 116342.86

DY12 DMPH Salinas Valley Memorial Healthcare System None Create summary report of adherence to recommended protocols for heart disease interventions None None None None 1 None None None None None 116342.85

DY12 DMPH Salinas Valley Memorial Healthcare System None Create summary report of adherence to updated patient safety protocols None None None None 1 None None None None None 116342.85

DY12 DMPH Salinas Valley Memorial Healthcare System None Create summary report of adherence to updated patient safety protocols. None None None None 1 None None None None None 116342.86

DY12 DMPH Salinas Valley Memorial Healthcare System None Define the flow of data for all Patient Safety in the Ambulatory Safety metrics based on specifications None None None None 1 None None None None None 116342.86

DY12 DMPH Salinas Valley Memorial Healthcare System None Develop a dashboard for sharing clinical metric outcomes None None None None 1 None None None None None 116342.86

DY12 DMPH Salinas Valley Memorial Healthcare System None Develop a project charter for PRIME project 2.3 team responsible for updating and implementing clinical protocols None None None None 1 None None None None None 116342.86

DY12 DMPH Salinas Valley Memorial Healthcare System None Develop a project charter for the Project 1.5 PRIME team responsible for leading and implementing clinical protocols None None None None 1 None None None None None 116342.86

DY12 DMPH Salinas Valley Memorial Healthcare System None Develop a project plan with current and future state workflows for discussion of advanced illness planning None None None None 1 None None None None None 116342.85

DY12 DMPH Salinas Valley Memorial Healthcare System None Develop a summary report of risk stratification methodology for prioritizing care transition outreach of admitted patients None None None None 1 None None None None None 116342.86

DY12 DMPH Salinas Valley Memorial Healthcare System None Develop document of lessons learned and distribute with best practices in heart disease intervention report to project stakeholders None None None None 1 None None None None None 116342.86

DY12 DMPH Salinas Valley Memorial Healthcare System None Develop list of recommended strategies to improve adherence to cancer screening protocols None None None None 1 None None None None None 116342.86

DY12 DMPH Salinas Valley Memorial Healthcare System None Develop list of recommended strategies to improve adherence to heart disease intervention protocols None None None None 1 None None None None None 116342.85

DY12 DMPH Salinas Valley Memorial Healthcare System None Develop relationships with at least three community resources None None None None 1 None None None None None 116342.86

DY12 DMPH Salinas Valley Memorial Healthcare System None Distribute care management protocols and train staff in updates None None None None 1 None None None None None 116342.85

DY12 DMPH Salinas Valley Memorial Healthcare System None Distribute new protocols and train staff in updated heart disease intervention protocols None None None None 1 None None None None None 116342.86

DY12 DMPH Salinas Valley Memorial Healthcare System None Distribute new protocols and train staff in updated patient safety protocols None None None None 1 None None None None None 116342.85

DY12 DMPH Salinas Valley Memorial Healthcare System None Distribute updated antibiotic protocols, train staff in updates and perform analysis of adherence None None None None 1 None None None None None 116342.86

DY12 DMPH Salinas Valley Memorial Healthcare System None Distribute updated blood products protocols, train staff in updates and perform analysis of adherence None None None None 1 None None None None None 116342.86

DY12 DMPH Salinas Valley Memorial Healthcare System None Distribute updated care transitions protocols and train staff in updated protocols None None None None 1 None None None None None 116342.85

DY12 DMPH Salinas Valley Memorial Healthcare System None Distribute updated palliative care protocols and train staff in updated protocols None None None None 1 None None None None None 116342.86

DY12 DMPH Salinas Valley Memorial Healthcare System None Engage community partners and create a partnership plan None None None None 1 None None None None None 116342.85

DY12 DMPH Salinas Valley Memorial Healthcare System None Hire a palliative care coordinator None None None None 1 None None None None None 116342.86

DY12 DMPH Salinas Valley Memorial Healthcare System None Perform gap analysis on heart disease clinical metrics related to PRIME and develop associated action items for initial next steps to initiate clinical protocol improvement None None None None 1 None None None None None 116342.86

DY12 DMPH Salinas Valley Memorial Healthcare System None Research best practices for complex care management and update existing protocols including short term action items for clinical improvements None None None None 1 None None None None None 116342.86

DY12 DMPH Salinas Valley Memorial Healthcare System None Train staff in updated blood products protocols None None None None 1 None None None None None 116342.86

DY12 DMPH Salinas Valley Memorial Healthcare System None Update clinical protocols for heart disease intervention in the ambulatory setting None None None None 1 None None None None None 116342.86

DY12 DMPH Salinas Valley Memorial Healthcare System None Update clinical protocols for patient safety in the ambulatory setting None None None None 1 None None None None None 116342.86

DY12 DMPH Salinas Valley Memorial Healthcare System None Update existing antibiotic stewardship protocols None None None None 1 None None None None None 116342.86

DY12 DMPH Salinas Valley Memorial Healthcare System None Update existing care management protocols None None None None 1 None None None None None 116342.86

DY12 DMPH Salinas Valley Memorial Healthcare System None Update existing palliative care protocols for clinical improvements None None None None 1 None None None None None 116342.86

DY12 DMPH Salinas Valley Memorial Healthcare System None Update existing protocols based on care transitions best practices report None None None None 1 None None None None None 116342.85

DY12 DMPH San Bernardino Mountains Community Hospital, Lake Arrowhead 1.4.1 Abnormal Results Follow-Up: Abnormal BIRADS Follow-up 105 0 207 0 1 0.507246377 0 0 0 NA 100000

DY12 DMPH San Bernardino Mountains Community Hospital, Lake Arrowhead 1.4.1 Abnormal Results Follow-Up: Abnormal INR Follow-up 50 0 65 0 1 0.769230769 0 0 0 NA 100000

DY12 DMPH San Bernardino Mountains Community Hospital, Lake Arrowhead 1.4.1 Abnormal Results Follow-Up: Abnormal Potassium Follow-up 120 0 132 0 1 0.909090909 0 0 0 NA 100000

DY12 DMPH San Bernardino Mountains Community Hospital, Lake Arrowhead 1.4.2 Annual Monitoring for Patients on Persistent Medications 95 0 116 0 1 0.819 0 0 0 0 300000

DY12 DMPH San Bernardino Mountains Community Hospital, Lake Arrowhead 1.4.3 INR Monitoring for Individuals on Warfarin 59 0 75 0 1 0.7867 0 0 0 0 300000

DY12 DMPH San Bernardino Mountains Community Hospital, Lake Arrowhead None Develop and pilot persistent medication-related testing and abnormal test follow-up protocols None None None None 1 None None None None None 150000

DY12 DMPH San Bernardino Mountains Community Hospital, Lake Arrowhead None Develop patient compliance enhancement system None None None None 1 None None None None None 150000

DY12 DMPH San Bernardino Mountains Community Hospital, Lake Arrowhead None Establish data collection system None None None None 1 None None None None None 150000

DY12 DMPH San Bernardino Mountains Community Hospital, Lake Arrowhead None Train Rural Health Clinic staff on persistent medication management and abnormal test follow-up protocols None None None None 1 None None None None None 150000

DY12 DPH San Francisco General Hospital 1.1.1.a Alcohol and Drug Misuse (SBIRT) None 1 38177 0 1 None 1 None 1 0 1140533.34

DY12 DPH San Francisco General Hospital 1.1.2 Care Coordinator Assignment 90 0 1714 0 1 0.0525 0 0.7475 0 0 1140533.34

DY12 DPH San Francisco General Hospital 1.1.3.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 1683 0 6634 0 1 0.2537 0 0.2491 0 0.2968 1140533.33

DY12 DPH San Francisco General Hospital 1.1.4 Depression Remission at 12 Months (CMS159v4) 18 0 1162 0 1 0.0155 0 0.0377 0 0 1140533.33

DY12 DPH San Francisco General Hospital 1.1.5.f Screening for Clinical Depression and follow-up 11630 0 28863 0 1 0.4029 0 0.3872 0 0 1140533.33

DY12 DPH San Francisco General Hospital 1.1.6.t Tobacco Assessment and Counseling 31509 0 32688 0 1 0.9639 0 0.9364 0 0.9386 1140533.33

DY12 DPH San Francisco General Hospital 1.2.1.a Alcohol and Drug Misuse (SBIRT) None 1 38177 0 1 None 1 None 1 0 1140533.34

DY12 DPH San Francisco General Hospital 1.2.11 REAL data completeness 24835 0 41187 0 1 0.603 0 0 0 NA 1140533.33

DY12 DPH San Francisco General Hospital 1.2.12.f Screening for Clinical Depression and follow-up 11630 0 28863 0 1 0.4029 0 0.3872 0 0 1140533.33

DY12 DPH San Francisco General Hospital 1.2.13 SO/GI data completeness 0 0 34353 0 1 0 0 0 0 0 1140533.33

DY12 DPH San Francisco General Hospital 1.2.14.t Tobacco Assessment and Counseling 31509 0 32688 0 1 0.9639 0 0.9364 0 0.9386 1140533.33

DY12 DPH San Francisco General Hospital 1.2.2 CG-CAHPS: Provider Rating 2142 0 2852 0 1 0.7511 0 0.71 0 0.7029 1140533.34

DY12 DPH San Francisco General Hospital 1.2.3.c Colorectal Cancer Screening 13873 0 19658 0 1 0.7057 0 0.6719 0 0.6571 1140533.34

DY12 DPH San Francisco General Hospital 1.2.4.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 1683 0 6634 0 1 0.2537 0 0.2491 0 0.2968 1140533.34

DY12 DPH San Francisco General Hospital 1.2.5.b Controlling Blood Pressure 9729 0 12356 0 1 0.7874 0 0.7593 0 0.7032 1140533.33

DY12 DPH San Francisco General Hospital 1.2.6 Documented REAL and/or SO/GI disparity reduction plan: Documented disparity reduction plan? Yes Yes 0 Plan ? 0 1 0 0 NA 0 NA 1140533.33

DY12 DPH San Francisco General Hospital 1.2.7.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 1846 0 2016 0 1 0.9157 0 0.9085 0 0.9105 1140533.33

DY12 DPH San Francisco General Hospital 1.2.8 Prevention Quality Overall Composite #90 396 0 48027 0 1 0.0082 0 0.016 0 0 1140533.33

DY12 DPH San Francisco General Hospital 1.2.9 Primary Care Redesign metrics stratified by REAL categories and SO/GI: Primary care redesign metrics stratified? Yes Yes 0 Stratified ? 0 1 0 0 NA 0 NA 1140533.33

DY12 DPH San Francisco General Hospital 1.3.1 Closing the referral loop: receipt of specialist report (CMS50v3) 101029 0 147441 0 1 0.6852 0 0.452 0 0 1140533.34

DY12 DPH San Francisco General Hospital 1.3.2 DHCS All-Cause Readmissions 322 0 2325 0 1 0.1385 0 0.1568 0 0.1543 1140533.34

DY12 DPH San Francisco General Hospital 1.3.3 Influenza Immunization 8015 0 11221 0 1 0.7143 0 0.5426 0 0 1140533.33

DY12 DPH San Francisco General Hospital 1.3.4 Post Procedure ED Visits 504 0 27685 0 1 0.0182 0 0.0182 0 0 1140533.33

DY12 DPH San Francisco General Hospital 1.3.5 Request for Specialty Care Expertise Turnaround Time 54552 0 59284 0 1 0.9202 0 0.9062 0 0 1140533.33

DY12 DPH San Francisco General Hospital 1.3.6 Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters 12494 0 59284 0 1 0.2107 0 0.196 0 0 1140533.33

DY12 DPH San Francisco General Hospital 1.3.7 Tobacco Assessment and Counseling 12155 0 12589 0 1 0.9655 0 0.9422 0 0.9438 1140533.33

DY12 DPH San Francisco General Hospital 1.5.1.b Controlling Blood Pressure 9729 0 12356 0 1 0.7874 0 0.7593 0 0.7032 1140533.34

DY12 DPH San Francisco General Hospital 1.5.2.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 1846 0 2016 0 1 0.9157 0 0.9085 0 0.9105 1140533.34

DY12 DPH San Francisco General Hospital 1.5.3 PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 17562 0 20936 0 1 0.8388 0 0.486 0 0 1140533.33

DY12 DPH San Francisco General Hospital 1.5.4.t Tobacco Assessment and Counseling 31509 0 32688 0 1 0.9639 0 0.9364 0 0.9386 1140533.33

DY12 DPH San Francisco General Hospital 2.1.1 Baby Friendly Hospital designation: BFUSA Designation Yes Yes 0 BFUSA Cert? 0 1 0 0 NA 0 NA 1190121.74

DY12 DPH San Francisco General Hospital 2.1.2 Exclusive Breast Milk Feeding (PC-05) 150 0 205 0 1 0.7317 0 0.7239 0 0.7313 1190121.74

DY12 DPH San Francisco General Hospital 2.1.3 OB Hemorrhage: Massive Transfusion None 1 922 0 1 None 1 None 1 0 1190121.74

DY12 DPH San Francisco General Hospital 2.1.4 OB Hemorrhage: Total Products Transfused 161 0 922 0 1 0.1746 0 0.0942 0 0 1190121.74

DY12 DPH San Francisco General Hospital 2.1.5 PC-02 Cesarean Section 49 0 297 0 1 0.165 0 0.1831 0 0.185 1190121.74

DY12 DPH San Francisco General Hospital 2.1.6 Prenatal and Postpartum Care: Prenatal Care 780 0 830 0 1 0.939759036 0 0.7506 0 0.7744 595060.87

DY12 DPH San Francisco General Hospital 2.1.6 Prenatal and Postpartum Care: Postpartum Care 498 0 830 0 1 0.6 0 0.5039 0 0.5547 595060.87

DY12 DPH San Francisco General Hospital 2.1.7 Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage 33 0 142 0 1 0.2324 0 0.2449 0 0 1190121.74

DY12 DPH San Francisco General Hospital 2.1.8 Unexpected Newborn Complications (UNC) 83 0 632 0 1 0.1313 0 0.1533 0 0 1190121.74

DY12 DPH San Francisco General Hospital 2.1.9 OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed)
[Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) 10 0 16 0 1 0 0 NA 0 NA 1190121.73

DY12 DPH San Francisco General Hospital 2.2.1 DHCS All-Cause Readmissions 421 0 2911 0 1 0.1446 0 0.1525 0 0.1504 1190121.74

DY12 DPH San Francisco General Hospital 2.2.2 H-CAHPS: Care Transition Metrics (3) 5120 0 10000 0 1 0.512 0 0.49 0 0.502 1190121.74

DY12 DPH San Francisco General Hospital 2.2.3 Medication Reconciliation 30 days 2840 0 3693 0 1 0.769 0 0.8054 0 0 1190121.74

DY12 DPH San Francisco General Hospital 2.2.4 Reconciled Medication List Received by Discharged Patients 2783 0 2925 0 1 0.9515 0 0 0 0 1190121.74

DY12 DPH San Francisco General Hospital 2.2.5 Timely Transmission of Transition Record 2832 0 4241 0 1 0.6678 0 0.7776 0 0 1190121.74

DY12 DPH San Francisco General Hospital 2.3.1 Care Coordinator Assignment 150 0 742 0 1 0.2022 0 0.0803 0 0 1190121.74

DY12 DPH San Francisco General Hospital 2.3.2 Medication Reconciliation 30 days 751 0 932 0 1 0.8058 0 0.8459 0 0 1190121.74

DY12 DPH San Francisco General Hospital 2.3.3 Prevention Quality Overall Composite #90 177 0 742 0 1 0.2385 0 0.1216 0 0 1190121.74

DY12 DPH San Francisco General Hospital 2.3.4 Timely Transmission of Transition Record 824 0 1111 0 1 0.7417 0 0.8542 0 0 1190121.73

DY12 DPH San Francisco General Hospital 2.6.1 Alcohol and Drug Misuse (SBIRT) None 1 3325 0 1 None 1 None 1 0 1190121.74

DY12 DPH San Francisco General Hospital 2.6.2 Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen 1015 0 2177 0 1 0.4662 0 0.4196 0 0 1190121.74

DY12 DPH San Francisco General Hospital 2.6.3 Patients with chronic pain on long term opioid therapy checked in PDMPs 1149 0 1857 0 1 0.6187 0 0.1702 0 0 1190121.74

DY12 DPH San Francisco General Hospital 2.6.4 Screening for Clinical Depression and follow-up 714 0 2053 0 1 0.3478 0 0.3091 0 0 1190121.74

DY12 DPH San Francisco General Hospital 2.6.5 Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy 3174 0 3376 0 1 0.9402 0 0.9037 0 0 1190121.74

DY12 DPH San Francisco General Hospital 3.3.1 Adherence to Medications: Rate 1 21 0 None 4 0 None 4 0.725 0 NA $-

DY12 DPH San Francisco General Hospital 3.3.3 High-Cost Pharmaceuticals Ordering Protocols: Rate 1 15 0 None 4 0 None 4 0 0 NA 1140533.33

DY12 DPH San Francisco General Hospital 3.3.4 Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 1 380 0 612 0 1 0.620915033 0 0 0 NA 5702666.67

DY12 DMPH San Gorgonio Memorial Hospital, Banning 1.7.1 BMI Screening and Follow-up 18 0 37 0 1 0.4865 0 0 0 0 175000

DY12 DMPH San Gorgonio Memorial Hospital, Banning 1.7.2 Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Numerator - Criteria Met (If your system has more than one hospital, please enter the sum of all criteria met)
Denominator - Required Criteria (If your system has more than one hospital, multiply the number of hospitals by 2) 2 0 8 0 1 0 0 NA 0 NA 175000

DY12 DMPH San Gorgonio Memorial Hospital, Banning 1.7.3 Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition 0 0 0 0 1 0 0 0 0 0.5198 58333.33

DY12 DMPH San Gorgonio Memorial Hospital, Banning 1.7.3 Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity 0 0 0 0 1 0 0 0 0 0.4416 58333.33

DY12 DMPH San Gorgonio Memorial Hospital, Banning 1.7.3 Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI 0 0 0 0 1 0 0 0 0 0.5127 58333.33

DY12 DMPH San Gorgonio Memorial Hospital, Banning 2.2.1 DHCS All-Cause Readmissions 50 0 73 0 1 0.6849 0 0 0 0 175000

DY12 DMPH San Gorgonio Memorial Hospital, Banning 2.2.2 H-CAHPS: Care Transition Metrics (3) 446 0 1050 0 1 0.4248 0 0 0 0 175000

DY12 DMPH San Gorgonio Memorial Hospital, Banning 2.2.3 Medication Reconciliation 30 days 21 0 43 0 1 0.4884 0 0 0 0 175000

DY12 DMPH San Gorgonio Memorial Hospital, Banning 2.2.4 Reconciled Medication List Received by Discharged Patients 39 0 43 0 1 0.907 0 0 0 0 175000

DY12 DMPH San Gorgonio Memorial Hospital, Banning 2.2.5 Timely Transmission of Transition Record None 1 43 0 1 None 1 0 0 0 175000

DY12 DMPH San Gorgonio Memorial Hospital, Banning 3.1.1 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis 33 0 76 0 1 0.4342 0 0 0 0 175000

DY12 DMPH San Gorgonio Memorial Hospital, Banning 3.1.2 Avoidance of Antibiotic Treatment with Low Colony Urinary Cultures 0 0 0 0 0 0 0 0 0 NA $-

DY12 DMPH San Gorgonio Memorial Hospital, Banning 3.1.3 National Healthcare Safety Network (NHSN) Antimicrobial Use Measure 6857 0 15541 0 1 0.4412 0 0 0 0 175000

DY12 DMPH San Gorgonio Memorial Hospital, Banning 3.1.4 Peri-operative Prophylactic Antibiotics Administered after Surgical Closure 97 0 141 0 1 0.6879 0 0 0 0 175000

DY12 DMPH San Gorgonio Memorial Hospital, Banning 3.1.5 Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR No 14000 0 10000 0 1 1.4 0 0 0 0 175000

DY12 DMPH San Gorgonio Memorial Hospital, Banning None Appoint ASP Pharmacist None None None None 1 None None None None None 66666.67

DY12 DMPH San Gorgonio Memorial Hospital, Banning None Conduct Referral Source Training None None None None 1 None None None None None 66666.67

DY12 DMPH San Gorgonio Memorial Hospital, Banning None Convene workgroup with clinical staff and IT to determine capabilities of current Cardiopulmonary Department None None None None 1 None None None None None 66666.67

DY12 DMPH San Gorgonio Memorial Hospital, Banning None Create Job Descriptions for A Healthy Children and Families Program None None None None 1 None None None None None 66666.66

DY12 DMPH San Gorgonio Memorial Hospital, Banning None Create Job Descriptions for Care Transitions Personnel None None None None 1 None None None None None 66666.67

DY12 DMPH San Gorgonio Memorial Hospital, Banning None Create Job Descriptions for Tiered Weight Management Program Personnel None None None None 1 None None None None None 66666.67

DY12 DMPH San Gorgonio Memorial Hospital, Banning None Develop education and outreach tactics to educate hospital on ASP None None None None 1 None None None None None 66666.66

DY12 DMPH San Gorgonio Memorial Hospital, Banning None Develop Policies and Procedures for a Healthy Children and Families Program None None None None 1 None None None None None 66666.67

DY12 DMPH San Gorgonio Memorial Hospital, Banning None Develop Policies and Procedures for Tiered Weight Management Program for Adults None None None None 1 None None None None None 66666.67

DY12 DMPH San Gorgonio Memorial Hospital, Banning None Develop training material and train staff and providers on patients self management model None None None None 1 None None None None None 66666.67

DY12 DMPH San Gorgonio Memorial Hospital, Banning None Develop Workflows for Cardiopulmonary Program Staff None None None None 1 None None None None None 66666.67

DY12 DMPH San Gorgonio Memorial Hospital, Banning None Evaluate Data Mining Software to Collect ASP Data None None None None 1 None None None None None 66666.67

DY12 DMPH San Gorgonio Memorial Hospital, Banning None Evaluation of Current Informatics Resources None None None None 1 None None None None None 66666.67

DY12 DMPH San Gorgonio Memorial Hospital, Banning None Identify prescribing trends that need improvement None None None None 1 None None None None None 66666.66

DY12 DMPH San Gorgonio Memorial Hospital, Banning None Implement a Healthy Children and Families Program None None None None 1 None None None None None 66666.66

DY12 DMPH San Gorgonio Memorial Hospital, Banning None Implement ASP Policies and Procedures None None None None 1 None None None None None 66666.67

DY12 DMPH San Gorgonio Memorial Hospital, Banning None Implement self management model with patient population None None None None 1 None None None None None 66666.67

DY12 DMPH San Gorgonio Memorial Hospital, Banning None Implement Tiered Weight Management Program for Adults None None None None 1 None None None None None 66666.67

DY12 DMPH San Gorgonio Memorial Hospital, Banning None Incorporate Healthier Choices into Hospital Cafeteria Menus None None None None 1 None None None None None 66666.66

DY12 DMPH San Gorgonio Memorial Hospital, Banning None Launch telehealth program after training of clinical staff as well as primary care physicians staff has been completed None None None None 1 None None None None None 66666.66

DY12 DMPH San Gorgonio Memorial Hospital, Banning None Monitor effectiveness of model None None None None 1 None None None None None 66666.66

DY12 DPH San Joaquin General Hospital 1.1.1.a Alcohol and Drug Misuse (SBIRT) 30 0 9877 0 1 0.003 0 0 0 0 647319.36

DY12 DPH San Joaquin General Hospital 1.1.2 Care Coordinator Assignment 0 0 411 0 1 0 0 0 0 0 647319.36

DY12 DPH San Joaquin General Hospital 1.1.3.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 565 0 2544 0 1 0.2221 0 0.3215 0 0.319 647319.36

DY12 DPH San Joaquin General Hospital 1.1.4 Depression Remission at 12 Months (CMS159v4) None 1 457 0 1 None 1 0.2836 0 0 647319.35

DY12 DPH San Joaquin General Hospital 1.1.5.f Screening for Clinical Depression and follow-up 329 0 377 0 1 0.8727 0 0.7956 0 0 647319.35

DY12 DPH San Joaquin General Hospital 1.1.6.t Tobacco Assessment and Counseling 9755 0 11371 0 1 0.8579 0 0.7672 0 0.7863 647319.35

DY12 DPH San Joaquin General Hospital 1.2.1.a Alcohol and Drug Misuse (SBIRT) 30 0 9877 0 1 0.003 0 0 0 0 647319.36

DY12 DPH San Joaquin General Hospital 1.2.11 REAL data completeness 13188 0 20875 0 1 0.6318 0 0 0 NA 647319.35

DY12 DPH San Joaquin General Hospital 1.2.12.f Screening for Clinical Depression and follow-up 329 0 377 0 1 0.8727 0 0.7956 0 0 647319.35

DY12 DPH San Joaquin General Hospital 1.2.13 SO/GI data completeness 0 0 15255 0 1 0 0 0 0 0 647319.35

DY12 DPH San Joaquin General Hospital 1.2.14.t Tobacco Assessment and Counseling 9755 0 11371 0 1 0.8579 0 0.7672 0 0.7863 647319.35

DY12 DPH San Joaquin General Hospital 1.2.2 CG-CAHPS: Provider Rating 674 0 952 0 1 0.708 0 0.7363 0 0.7029 647319.36

DY12 DPH San Joaquin General Hospital 1.2.3.c Colorectal Cancer Screening 170 0 370 0 1 0.4595 0 0.4216 0 0.4452 647319.36

DY12 DPH San Joaquin General Hospital 1.2.4.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 565 0 2544 0 1 0.2221 0 0.3215 0 0.319 647319.36

DY12 DPH San Joaquin General Hospital 1.2.5.b Controlling Blood Pressure 246 0 370 0 1 0.6649 0 0.6265 0 0.6342 647319.36

DY12 DPH San Joaquin General Hospital 1.2.6 Documented REAL and/or SO/GI disparity reduction plan: Documented disparity reduction plan? Yes Yes 0 Plan ? 0 1 0 0 NA 0 NA 647319.36

DY12 DPH San Joaquin General Hospital 1.2.7.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 711 0 818 0 1 0.8692 0 0.6868 0 0.711 647319.35

DY12 DPH San Joaquin General Hospital 1.2.8 Prevention Quality Overall Composite #90 614 0 21003 0 1 0.0292 0 0.0065 0 0 647319.35

DY12 DPH San Joaquin General Hospital 1.2.9 Primary Care Redesign metrics stratified by REAL categories and SO/GI: Primary care redesign metrics stratified? Yes Yes 0 Stratified ? 0 1 0 0 NA 0 NA 647319.35

DY12 DPH San Joaquin General Hospital 1.3.1 Closing the referral loop: receipt of specialist report (CMS50v3) 246 0 323 0 1 0.7616 0 0.1989 0 0 647319.36

DY12 DPH San Joaquin General Hospital 1.3.2 DHCS All-Cause Readmissions 97 0 736 0 1 0.1318 0 0.1124 0 0.1318 647319.36

DY12 DPH San Joaquin General Hospital 1.3.3 Influenza Immunization 130 0 341 0 1 0.3812 0 0.423 0 0 647319.36

DY12 DPH San Joaquin General Hospital 1.3.4 Post Procedure ED Visits 44 0 3291 0 1 0.0134 0 0.0282 0 0 647319.35

DY12 DPH San Joaquin General Hospital 1.3.5 Request for Specialty Care Expertise Turnaround Time 160 0 370 0 1 0.4324 0 None 1 0 647319.35

DY12 DPH San Joaquin General Hospital 1.3.6 Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters None 1 377 0 1 None 1 0.0221 0 0 647319.35

DY12 DPH San Joaquin General Hospital 1.3.7 Tobacco Assessment and Counseling 306 0 323 0 1 0.9474 0 0.9239 0 0.9273 647319.35

DY12 DPH San Joaquin General Hospital 1.6.1 BIRADS to Biopsy 14 0 60 0 1 0.2333 0 None 1 0 647319.36

DY12 DPH San Joaquin General Hospital 1.6.2 Breast Cancer Screening 207 0 351 0 1 0.5897 0 0.5392 0 0.5567 647319.36

DY12 DPH San Joaquin General Hospital 1.6.3 Cervical Cancer Screening 177 0 370 0 0 0.4784 0 0.3528 0 0.5433 647319.36

DY12 DPH San Joaquin General Hospital 1.6.4.c Colorectal Cancer Screening 170 0 370 0 1 0.4595 0 0.4216 0 0.4452 647319.35

DY12 DPH San Joaquin General Hospital 1.6.5 Receipt of appropriate follow-up for abnormal CRC screening 32 0 64 0 1 0.5 0 None 1 0 647319.35

DY12 DPH San Joaquin General Hospital 2.1.1 Baby Friendly Hospital designation: BFUSA Designation Yes Yes 0 BFUSA Cert? 0 1 0 0 NA 0 NA 683437.9

DY12 DPH San Joaquin General Hospital 2.1.2 Exclusive Breast Milk Feeding (PC-05) 195 0 274 0 0.75 0.7117 0 0.7037 0 0.7131 683437.9

DY12 DPH San Joaquin General Hospital 2.1.3 OB Hemorrhage: Massive Transfusion None 1 762 0 1 None 1 None 1 0 683437.9

DY12 DPH San Joaquin General Hospital 2.1.4 OB Hemorrhage: Total Products Transfused 75 0 762 0 1 0.0984 0 0.0906 0 0 683437.9

DY12 DPH San Joaquin General Hospital 2.1.5 PC-02 Cesarean Section 56 0 175 0 0 0.32 0 0.2931 0 0.285 683437.9

DY12 DPH San Joaquin General Hospital 2.1.6 Prenatal and Postpartum Care: Prenatal Care 451 0 601 0 1 0.750415973 0 0.4492 0 0.7744 341718.95

DY12 DPH San Joaquin General Hospital 2.1.6 Prenatal and Postpartum Care: Postpartum Care 371 0 601 0 1 0.617304493 0 0.1856 0 0.5547 341718.95

DY12 DPH San Joaquin General Hospital 2.1.7 Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage 27 0 55 0 1 0.4909 0 0.2885 0 0 683437.9

DY12 DPH San Joaquin General Hospital 2.1.8 Unexpected Newborn Complications (UNC) 25 0 511 0 1 0.0489 0 0.0602 0 0 683437.89

DY12 DPH San Joaquin General Hospital 2.1.9 OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed)
[Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) 10 0 16 0 1 0 0 NA 0 NA 683437.89

DY12 DPH San Joaquin General Hospital 2.2.1 DHCS All-Cause Readmissions 142 0 1508 0 1 0.0942 0 0.1192 0 0.1318 683437.9

DY12 DPH San Joaquin General Hospital 2.2.2 H-CAHPS: Care Transition Metrics (3) 4961 0 10000 0 0 0.4961 0 0.5265 0 0.5349 683437.9

DY12 DPH San Joaquin General Hospital 2.2.3 Medication Reconciliation 30 days 142 0 323 0 1 0.4396 0 None 1 0 683437.9

DY12 DPH San Joaquin General Hospital 2.2.4 Reconciled Medication List Received by Discharged Patients 233 0 323 0 1 0.7214 0 0.9267 0 0 683437.9

DY12 DPH San Joaquin General Hospital 2.2.5 Timely Transmission of Transition Record None 1 341 0 1 None 1 0 0 0 683437.89

DY12 DPH San Joaquin General Hospital 2.3.1 Care Coordinator Assignment 0 0 3913 0 1 0 0 0 0 0 683437.9

DY12 DPH San Joaquin General Hospital 2.3.2 Medication Reconciliation 30 days 73 0 451 0 1 0.1619 0 None 1 0 683437.9

DY12 DPH San Joaquin General Hospital 2.3.3 Prevention Quality Overall Composite #90 203 0 3376 0 1 0.0601 0 0.0158 0 0 683437.9

DY12 DPH San Joaquin General Hospital 2.3.4 Timely Transmission of Transition Record None 1 249 0 1 None 1 0 0 0 683437.9

DY12 DPH San Joaquin General Hospital 2.7.1 Advance Care Plan 12 0 341 0 1 0.0352 0 0.1115 0 0 683437.9

DY12 DPH San Joaquin General Hospital 2.7.2 Ambulatory Palliative Care Team Established: Ambulatory Palliative Care Team Established? Yes Yes 0 Team Established? 0 1 0 0 NA 0 NA 683437.9

DY12 DPH San Joaquin General Hospital 2.7.3 MWM #8: Treatment Preferences (documentation) Inpatient 44 0 66 0 1 0.6667 0 None 1 0 683437.9

DY12 DPH San Joaquin General Hospital 2.7.4 MWM #8: Treatment Preferences (documentation) Outpatient 28 0 30 0 1 0.9333 0 0 0 0 683437.9

DY12 DPH San Joaquin General Hospital 2.7.5 Palliative Care Service Offered at Time of Diagnosis of Advanced Illness 26 0 302 0 1 0.0861 0 0 0 0 683437.9

DY12 DPH San Joaquin General Hospital 2.7.6 Proportion Admitted to Hospice for Less Than 3 Days None 1 None 4 0 None 1 None 1 0 334448.33

DY12 DPH San Joaquin General Hospital 3.2.1 Imaging for Routine Headaches (Choosing Wisely) 33 0 260 0 1 0.1269 0 0.1424 0 0.17 1003345

DY12 DPH San Joaquin General Hospital 3.2.2 Appropriate Emergency Department Utilization of CT for Pulmonary Embolism 72 0 121 0 1 0.595 0 None 1 0 1003345

DY12 DPH San Joaquin General Hospital 3.2.3 Use of Imaging Studies for Low Back Pain 845 0 944 0 1 0.8951 0 0.8821 0 0.8286 1003345

DY12 DPH San Joaquin General Hospital 3.2.4 Use of Imaging Studies for Low Back Pain (anytime) Variation of HEDIS Use of Imaging Studies for Low Back Pain measures: Appropriate Score 46 0 1501 0 1 0.030646236 0 0 0 NA 501672.5

DY12 DPH San Joaquin General Hospital 3.2.4 Use of Imaging Studies for Low Back Pain (anytime) Variation of HEDIS Use of Imaging Studies for Low Back Pain measures: Inappropriate Score 260 0 1452 0 1 0.179063361 0 0 0 NA 501672.5

DY12 DPH San Mateo Medical Center 1.1.1.a Alcohol and Drug Misuse (SBIRT) 638 0 27635 0 1 0.0231 0 0.0267 0 0 674822.58

DY12 DPH San Mateo Medical Center 1.1.2 Care Coordinator Assignment 240 0 1266 0 1 0.1896 0 0.1451 0 0 674822.58

DY12 DPH San Mateo Medical Center 1.1.3.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 1266 0 4855 0 1 0.2608 0 0.27 0 0.2968 674822.58

DY12 DPH San Mateo Medical Center 1.1.4 Depression Remission at 12 Months (CMS159v4) None 1 51 0 1 None 1 None 4 0 674822.58

DY12 DPH San Mateo Medical Center 1.1.5.f Screening for Clinical Depression and follow-up 648 0 24438 0 1 0.0265 0 0.0238 0 0 674822.58

DY12 DPH San Mateo Medical Center 1.1.6.t Tobacco Assessment and Counseling 20577 0 21421 0 1 0.9606 0 0.9735 0 0.9579 674822.58

DY12 DPH San Mateo Medical Center 1.2.1.a Alcohol and Drug Misuse (SBIRT) 638 0 27635 0 1 0.0231 0 0.0267 0 0 674822.59

DY12 DPH San Mateo Medical Center 1.2.11 REAL data completeness 39097 0 39236 0 1 0.9965 0 0.9961 0 NA 674822.58

DY12 DPH San Mateo Medical Center 1.2.12.f Screening for Clinical Depression and follow-up 648 0 24438 0 1 0.0265 0 0.0238 0 0 674822.58

DY12 DPH San Mateo Medical Center 1.2.13 SO/GI data completeness 0 0 39236 0 1 0 0 0 0 0 674822.58

DY12 DPH San Mateo Medical Center 1.2.14.t Tobacco Assessment and Counseling 20577 0 21421 0 1 0.9606 0 0.9735 0 0.9579 674822.58

DY12 DPH San Mateo Medical Center 1.2.2 CG-CAHPS: Provider Rating 1896 0 2301 0 1 0.824 0 0.7874 0 0.7029 674822.58

DY12 DPH San Mateo Medical Center 1.2.3.c Colorectal Cancer Screening 5230 0 8781 0 1 0.5956 0 0.5683 0 0.5772 674822.58

DY12 DPH San Mateo Medical Center 1.2.4.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 1266 0 4855 0 1 0.2608 0 0.27 0 0.2968 674822.58

DY12 DPH San Mateo Medical Center 1.2.5.b Controlling Blood Pressure 4779 0 6580 0 1 0.7263 0 0.7067 0 0.7032 674822.58

DY12 DPH San Mateo Medical Center 1.2.6 Documented REAL and/or SO/GI disparity reduction plan: Documented disparity reduction plan? Yes Yes 0 Plan ? 0 1 0 0 NA 0 NA 674822.58

DY12 DPH San Mateo Medical Center 1.2.7.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 863 0 1002 0 1 0.8613 0 0.8386 0 0.8476 674822.58

DY12 DPH San Mateo Medical Center 1.2.8 Prevention Quality Overall Composite #90 168 0 39643 0 1 0.0042 0 0.0059 0 0 674822.58

DY12 DPH San Mateo Medical Center 1.2.9 Primary Care Redesign metrics stratified by REAL categories and SO/GI: Primary care redesign metrics stratified? Yes Yes 0 Stratified ? 0 1 0 0 NA 0 NA 674822.58

DY12 DPH San Mateo Medical Center 1.3.1 Closing the referral loop: receipt of specialist report (CMS50v3) 10255 0 10255 0 1 1 0 1 0 0 674822.58

DY12 DPH San Mateo Medical Center 1.3.2 DHCS All-Cause Readmissions 25 0 267 0 1 0.0936 0 0.0737 0 0.1318 674822.58

DY12 DPH San Mateo Medical Center 1.3.3 Influenza Immunization 8825 0 14457 0 1 0.6104 0 0.5709 0 0 674822.58

DY12 DPH San Mateo Medical Center 1.3.4 Post Procedure ED Visits 309 0 12203 0 1 0.0253 0 0.0338 0 0 674822.58

DY12 DPH San Mateo Medical Center 1.3.5 Request for Specialty Care Expertise Turnaround Time 1924 0 25569 0 1 0.0752 0 0.0012 0 0 674822.58

DY12 DPH San Mateo Medical Center 1.3.6 Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters 0 0 26537 0 1 0 0 0 0 0 674822.58

DY12 DPH San Mateo Medical Center 1.3.7 Tobacco Assessment and Counseling 6729 0 6978 0 1 0.9643 0 0.9838 0 0.9579 674822.58

DY12 DPH San Mateo Medical Center 1.6.1 BIRADS to Biopsy 106 0 237 0 1 0.4473 0 0.6549 0 0 674822.58

DY12 DPH San Mateo Medical Center 1.6.2 Breast Cancer Screening 4888 0 6647 0 1 0.7354 0 0.7922 0 0.7141 674822.58

DY12 DPH San Mateo Medical Center 1.6.3 Cervical Cancer Screening 8997 0 15794 0 1 0.5696 0 0.547 0 0.5654 674822.58

DY12 DPH San Mateo Medical Center 1.6.4.c Colorectal Cancer Screening 5230 0 8781 0 1 0.5956 0 0.5683 0 0.5772 674822.58

DY12 DPH San Mateo Medical Center 1.6.5 Receipt of appropriate follow-up for abnormal CRC screening 200 0 2372 0 1 0.0843 0 0.5028 0 0 674822.59

DY12 DPH San Mateo Medical Center 2.2.1 DHCS All-Cause Readmissions 27 0 312 0 1 0.0865 0 0.0668 0 0.1318 1256702.57

DY12 DPH San Mateo Medical Center 2.2.2 H-CAHPS: Care Transition Metrics (3) 5200 0 10000 0 1 0.52 0 0.5067 0 0.517 1256702.57

DY12 DPH San Mateo Medical Center 2.2.3 Medication Reconciliation 30 days 0 0 916 0 1 0 0 0 0 0 1256702.57

DY12 DPH San Mateo Medical Center 2.2.4 Reconciled Medication List Received by Discharged Patients 1039 0 1106 0 1 0.9394 0 0.9243 0 0 1256702.56

DY12 DPH San Mateo Medical Center 2.2.5 Timely Transmission of Transition Record 2393 0 2406 0 1 0.9946 0 0.9959 0 0 1256702.56

DY12 DPH San Mateo Medical Center 2.3.1 Care Coordinator Assignment None 1 351 0 1 None 1 0 0 0 1256702.57

DY12 DPH San Mateo Medical Center 2.3.2 Medication Reconciliation 30 days 0 0 96 0 1 0 0 0 0 0 1256702.57

DY12 DPH San Mateo Medical Center 2.3.3 Prevention Quality Overall Composite #90 19 0 351 0 1 0.0541 0 0.1191 0 0 1256702.56

DY12 DPH San Mateo Medical Center 2.3.4 Timely Transmission of Transition Record 209 0 210 0 1 0.9952 0 0.9966 0 0 1256702.56

DY12 DPH San Mateo Medical Center 2.4.1 Adolescent Well-Care Visit 20 0 None 4 0 None 4 None 1 0.5916 $-

DY12 DPH San Mateo Medical Center 2.4.2 Developmental Screening in the First Three Years of Life None 1 None 1 0 None 1 None 1 0 $-

DY12 DPH San Mateo Medical Center 2.4.3 Documentation of Current Medications in the Medical Record (0-18 yo) 100 0 124 0 1 0.8065 0 0.8723 0 0 1256702.56

DY12 DPH San Mateo Medical Center 2.4.4 Screening for Clinical Depression and follow-up None 1 None 4 0 None 1 None 1 0 $-

DY12 DPH San Mateo Medical Center 2.4.5 Tobacco Assessment and Counseling (13 yo and older) 17 0 None 4 0 None 4 None 1 0 $-

DY12 DPH San Mateo Medical Center 2.4.6 Well Child Visits - First 15 months of life 0 0 None 1 0 None 1 None 1 0.0427 $-

DY12 DPH San Mateo Medical Center 2.4.7 Well Child Visits - Third, Fourth, Fifth, and Sixth Years of life None 1 None 4 0 None 1 None 1 0.8375 $-

DY12 DPH San Mateo Medical Center 2.6.1 Alcohol and Drug Misuse (SBIRT) None 1 245 0 1 None 1 0.0267 0 0 1256702.56

DY12 DPH San Mateo Medical Center 2.6.2 Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen None 1 None 1 0 None 1 0.5 0 0 398466.67

DY12 DPH San Mateo Medical Center 2.6.3 Patients with chronic pain on long term opioid therapy checked in PDMPs None 1 None 1 0 None 1 None 1 0 $-

DY12 DPH San Mateo Medical Center 2.6.4 Screening for Clinical Depression and follow-up None 1 229 0 1 None 1 0 0 0 1256702.56

DY12 DPH San Mateo Medical Center 2.6.5 Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy 217 0 248 0 1 0.875 0 0.5943 0 0 1256702.56

DY12 DPH San Mateo Medical Center 3.2.1 Imaging for Routine Headaches (Choosing Wisely) 240 0 1606 0 1 0.1494 0 0.1348 0 0.17 1045975

DY12 DPH San Mateo Medical Center 3.2.2 Appropriate Emergency Department Utilization of CT for Pulmonary Embolism None 1 185 0 1 None 1 0.0779 0 0 1045975

DY12 DPH San Mateo Medical Center 3.2.3 Use of Imaging Studies for Low Back Pain 898 0 1002 0 1 0.8962 0 0.9044 0 0.8286 1045975

DY12 DPH San Mateo Medical Center 3.2.4 Use of Imaging Studies for Low Back Pain (anytime) Variation of HEDIS Use of Imaging Studies for Low Back Pain measures: Appropriate Score 280 0 1659 0 1 0.168776371 0 0 0 NA 522987.5

DY12 DPH San Mateo Medical Center 3.2.4 Use of Imaging Studies for Low Back Pain (anytime) Variation of HEDIS Use of Imaging Studies for Low Back Pain measures: Inappropriate Score 219 0 1379 0 1 0.158810732 0 0 0 NA 522987.5

DY12 DPH Santa Clara Valley Medical Center 1.1.1.a Alcohol and Drug Misuse (SBIRT) None 1 50698 0 1 None 1 0 0 0 2066955.18

DY12 DPH Santa Clara Valley Medical Center 1.1.2 Care Coordinator Assignment 1289 0 3134 0 1 0.4113 0 0.3722 0 0 2066955.17

DY12 DPH Santa Clara Valley Medical Center 1.1.3.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 3111 0 10913 0 1 0.2851 0 0.3599 0 0.3536 2066955.17

DY12 DPH Santa Clara Valley Medical Center 1.1.4 Depression Remission at 12 Months (CMS159v4) 60 0 1445 0 1 0.0415 0 0.0479 0 0 2066955.17

DY12 DPH Santa Clara Valley Medical Center 1.1.5.f Screening for Clinical Depression and follow-up 11189 0 33199 0 1 0.337 0 0.3282 0 0 2066955.17

DY12 DPH Santa Clara Valley Medical Center 1.1.6.t Tobacco Assessment and Counseling 28954 0 31075 0 1 0.9317 0 0.7611 0 0.7808 2066955.17

DY12 DPH Santa Clara Valley Medical Center 1.2.1.a Alcohol and Drug Misuse (SBIRT) None 1 50698 0 1 None 1 0 0 0 2066955.18

DY12 DPH Santa Clara Valley Medical Center 1.2.11 REAL data completeness 25794 0 61619 0 1 0.4186 0 0 0 NA 2066955.17

DY12 DPH Santa Clara Valley Medical Center 1.2.12.f Screening for Clinical Depression and follow-up 11189 0 33199 0 1 0.337 0 0.3282 0 0 2066955.17

DY12 DPH Santa Clara Valley Medical Center 1.2.13 SO/GI data completeness 0 0 61619 0 1 0 0 0 0 0 2066955.17

DY12 DPH Santa Clara Valley Medical Center 1.2.14.t Tobacco Assessment and Counseling 28954 0 31075 0 1 0.9317 0 0.7611 0 0.7808 2066955.17

DY12 DPH Santa Clara Valley Medical Center 1.2.2 CG-CAHPS: Provider Rating 4448 0 6014 0 1 0.7396 0 0.7359 0 0.7029 2066955.18

DY12 DPH Santa Clara Valley Medical Center 1.2.3.c Colorectal Cancer Screening 14977 0 21187 0 1 0.7069 0 0.744 0 0.6571 2066955.18

DY12 DPH Santa Clara Valley Medical Center 1.2.4.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 3111 0 10913 0 1 0.2851 0 0.3599 0 0.3536 2066955.17

DY12 DPH Santa Clara Valley Medical Center 1.2.5.b Controlling Blood Pressure 8135 0 12149 0 1 0.6696 0 0.6312 0 0.6384 2066955.17

DY12 DPH Santa Clara Valley Medical Center 1.2.6 Documented REAL and/or SO/GI disparity reduction plan: Documented disparity reduction plan? Yes Yes 0 Plan ? 0 1 0 0 NA 0 NA 2066955.17

DY12 DPH Santa Clara Valley Medical Center 1.2.7.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 2290 0 2563 0 1 0.8935 0 0.7559 0 0.7732 2066955.17

DY12 DPH Santa Clara Valley Medical Center 1.2.8 Prevention Quality Overall Composite #90 607 0 64624 0 1 0.0094 0 0.0088 0 0 2066955.17

DY12 DPH Santa Clara Valley Medical Center 1.2.9 Primary Care Redesign metrics stratified by REAL categories and SO/GI: Primary care redesign metrics stratified? Yes Yes 0 Stratified ? 0 1 0 0 NA 0 NA 2066955.17

DY12 DPH Santa Clara Valley Medical Center 1.3.1 Closing the referral loop: receipt of specialist report (CMS50v3) 6166 0 32058 0 1 0.1923 0 0.2068 0 0 2066955.18

DY12 DPH Santa Clara Valley Medical Center 1.3.2 DHCS All-Cause Readmissions 287 0 2031 0 1 0.1413 0 0.149 0 0.1473 2066955.18

DY12 DPH Santa Clara Valley Medical Center 1.3.3 Influenza Immunization 18983 0 27645 0 1 0.6867 0 0.5952 0 0 2066955.17

DY12 DPH Santa Clara Valley Medical Center 1.3.4 Post Procedure ED Visits 226 0 22879 0 1 0.0099 0 0.0155 0 0 2066955.17

DY12 DPH Santa Clara Valley Medical Center 1.3.5 Request for Specialty Care Expertise Turnaround Time 24237 0 83964 0 1 0.2887 0 0.0205 0 0 2066955.17

DY12 DPH Santa Clara Valley Medical Center 1.3.6 Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters 2445 0 83964 0 1 0.0291 0 0.003 0 0 2066955.17

DY12 DPH Santa Clara Valley Medical Center 1.3.7 Tobacco Assessment and Counseling 21118 0 22429 0 1 0.9415 0 0.8014 0 0.8171 2066955.17

DY12 DPH Santa Clara Valley Medical Center 1.4.1 Abnormal Results Follow-Up: Abnormal Potassium Follow-up 15955 0 17619 0 1 0.905556502 0 0.9006 0 NA 688985.06

DY12 DPH Santa Clara Valley Medical Center 1.4.1 Abnormal Results Follow-Up: Abnormal INR Follow-up 9255 0 9773 0 1 0.946996828 0 0.9488 0 NA 688985.06

DY12 DPH Santa Clara Valley Medical Center 1.4.1 Abnormal Results Follow-Up: Abnormal BIRADS Follow-up 2586 0 6837 0 1 0.378236068 0 0.5038 0 NA 688985.06

DY12 DPH Santa Clara Valley Medical Center 1.4.2 Annual Monitoring for Patients on Persistent Medications 16976 0 18833 0 1 0.9014 0 0.8693 0 0.874 2066955.17

DY12 DPH Santa Clara Valley Medical Center 1.4.3 INR Monitoring for Individuals on Warfarin 664 0 851 0 1 0.7803 0 0.7884 0 0 2066955.17

DY12 DPH Santa Clara Valley Medical Center 2.1.1 Baby Friendly Hospital designation: Discovery Phase Complete Yes Yes 0 Discovery Phase? 0 1 0 0 NA 0 NA 639378.13

DY12 DPH Santa Clara Valley Medical Center 2.1.1 Baby Friendly Hospital designation: Informational Webinar Participation Yes Yes 0 Webinar complete? 0 1 0 0 NA 0 NA 639378.13

DY12 DPH Santa Clara Valley Medical Center 2.1.1 Baby Friendly Hospital designation: BFUSA Designation No No 0 BFUSA Cert? 0 0 0 0 NA 0 NA 639378.13

DY12 DPH Santa Clara Valley Medical Center 2.1.2 Exclusive Breast Milk Feeding (PC-05) 1157 0 2083 0 1 0.5554 0 0.5035 0 0.533 1918134.4

DY12 DPH Santa Clara Valley Medical Center 2.1.3 OB Hemorrhage: Massive Transfusion None 1 2399 0 1 None 1 None 1 0 1918134.4

DY12 DPH Santa Clara Valley Medical Center 2.1.4 OB Hemorrhage: Total Products Transfused 45 0 2399 0 1 0.0188 0 0.0334 0 0 1918134.4

DY12 DPH Santa Clara Valley Medical Center 2.1.5 PC-02 Cesarean Section 194 0 734 0 0 0.2643 0 0.2011 0 0.1995 1918134.4

DY12 DPH Santa Clara Valley Medical Center 2.1.6 Prenatal and Postpartum Care: Prenatal Care 410 0 484 0 1 0.847107438 0 0.8574 0 0.8634 959067.2

DY12 DPH Santa Clara Valley Medical Center 2.1.6 Prenatal and Postpartum Care: Postpartum Care 330 0 484 0 1 0.681818182 0 0.6396 0 0.6481 959067.2

DY12 DPH Santa Clara Valley Medical Center 2.1.7 Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage 12 0 226 0 1 0.0531 0 0.0905 0 0 1918134.4

DY12 DPH Santa Clara Valley Medical Center 2.1.8 Unexpected Newborn Complications (UNC) 64 0 1767 0 1 0.0362 0 0.0346 0 0 1918134.4

DY12 DPH Santa Clara Valley Medical Center 2.1.9 OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed)
[Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) 9 0 16 0 1 0 0 NA 0 NA 1918134.4

DY12 DPH Santa Clara Valley Medical Center 2.2.1 DHCS All-Cause Readmissions 301 0 2217 0 1 0.1358 0 0.1404 0 0.1395 1918134.4

DY12 DPH Santa Clara Valley Medical Center 2.2.2 H-CAHPS: Care Transition Metrics (3) 3948 0 10000 0 0 0.3948 0 0.4201 0 0.48 1918134.4

DY12 DPH Santa Clara Valley Medical Center 2.2.3 Medication Reconciliation 30 days 2535 0 4373 0 1 0.5797 0 0.577 0 0 1918134.4

DY12 DPH Santa Clara Valley Medical Center 2.2.4 Reconciled Medication List Received by Discharged Patients 7743 0 8079 0 1 0.9584 0 0.96 0 0 1918134.4

DY12 DPH Santa Clara Valley Medical Center 2.2.5 Timely Transmission of Transition Record 1339 0 6088 0 1 0.2199 0 0.2644 0 0 1918134.4

DY12 DPH Santa Clara Valley Medical Center 2.3.1 Care Coordinator Assignment 616 0 951 0 1 0.6477 0 0.6145 0 0 1918134.4

DY12 DPH Santa Clara Valley Medical Center 2.3.2 Medication Reconciliation 30 days 157 0 267 0 1 0.588 0 0.608 0 0 1918134.4

DY12 DPH Santa Clara Valley Medical Center 2.3.3 Prevention Quality Overall Composite #90 53 0 948 0 1 0.0559 0 0.049 0 0 1918134.4

DY12 DPH Santa Clara Valley Medical Center 2.3.4 Timely Transmission of Transition Record 71 0 321 0 1 0.2212 0 0.2784 0 0 1918134.4

DY12 DPH Santa Clara Valley Medical Center 2.4.1 Adolescent Well-Care Visit 77 0 91 0 1 0.8462 0 0.9036 0 0.6658 1918134.4

DY12 DPH Santa Clara Valley Medical Center 2.4.2 Developmental Screening in the First Three Years of Life 0 0 118 0 1 0 0 0 0 0 1918134.4

DY12 DPH Santa Clara Valley Medical Center 2.4.3 Documentation of Current Medications in the Medical Record (0-18 yo) 1330 0 1577 0 1 0.8434 0 0.8122 0 0 1918134.4

DY12 DPH Santa Clara Valley Medical Center 2.4.4 Screening for Clinical Depression and follow-up None 1 69 0 1 None 1 0 0 0 1918134.4

DY12 DPH Santa Clara Valley Medical Center 2.4.5 Tobacco Assessment and Counseling (13 yo and older) 40 0 50 0 1 0.8 0 0.5429 0 0 1918134.4

DY12 DPH Santa Clara Valley Medical Center 2.4.6 Well Child Visits - First 15 months of life 28 0 49 0 1 0.5714 0 0.5116 0 0.0427 1918134.4

DY12 DPH Santa Clara Valley Medical Center 2.4.7 Well Child Visits - Third, Fourth, Fifth, and Sixth Years of life 98 0 112 0 1 0.875 0 0.8932 0 0.8375 1918134.4

DY12 DPH Santa Clara Valley Medical Center 3.3.1 Adherence to Medications: Rate 1 135 0 143 0 1 0.944055944 0 0 0 NA 3996113.33

DY12 DPH Santa Clara Valley Medical Center 3.3.3 High-Cost Pharmaceuticals Ordering Protocols: Rate 1 46 0 165 0 1 0.278787879 0 0 0 NA 3996113.34

DY12 DPH Santa Clara Valley Medical Center 3.3.4 Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 1 261 0 651 0 1 0.400921659 0 0 0 NA 3996113.33

DY12 DMPH Seneca Healthcare District, Chester 2.2.1 DHCS All-Cause Readmissions 11 0 137 0 1 0.0803 0 0 0 0 180000

DY12 DMPH Seneca Healthcare District, Chester 2.2.2 H-CAHPS: Care Transition Metrics (3) 2400 0 9300 0 1 0.2581 0 0 0 0 180000

DY12 DMPH Seneca Healthcare District, Chester 2.2.3 Medication Reconciliation 30 days 67 0 101 0 1 0.6634 0 0 0 0 180000

DY12 DMPH Seneca Healthcare District, Chester 2.2.4 Reconciled Medication List Received by Discharged Patients 28 0 142 0 1 0.1972 0 0 0 0 180000

DY12 DMPH Seneca Healthcare District, Chester 2.2.5 Timely Transmission of Transition Record 101 0 142 0 1 0.7113 0 0 0 0 180000

DY12 DMPH Seneca Healthcare District, Chester None Convene a workgroup to develop a Care Coordination Program None None None None 1 None None None None None 120000

DY12 DMPH Seneca Healthcare District, Chester None Develop curricula/training modules for staff, train staff and providers and assess the effectiveness of the training. None None None None 1 None None None None None 120000

DY12 DMPH Seneca Healthcare District, Chester None Expand the Care Coordination Program None None None None 1 None None None None None 120000

DY12 DMPH Seneca Healthcare District, Chester None Obtain approval of the Care Coordination Program from the Medical Staff. None None None None 1 None None None None None 120000

DY12 DMPH Seneca Healthcare District, Chester None Trial the Care Coordination Program. None None None None 1 None None None None None 120000

DY12 DMPH Sierra View District Hospital, Porterville 1.7.1 BMI Screening and Follow-up 11 0 111 0 1 0.0991 0 0 0 0 433846.16

DY12 DMPH Sierra View District Hospital, Porterville 1.7.2 Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Numerator - Criteria Met (If your system has more than one hospital, please enter the sum of all criteria met)
Denominator - Required Criteria (If your system has more than one hospital, multiply the number of hospitals by 2) 2 0 8 0 1 0 0 NA 0 NA 433846.15

DY12 DMPH Sierra View District Hospital, Porterville 1.7.3 Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition 0 0 0 0 1 0 0 0 0 0.5198 144615.38

DY12 DMPH Sierra View District Hospital, Porterville 1.7.3 Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity 0 0 0 0 1 0 0 0 0 0.4416 144615.38

DY12 DMPH Sierra View District Hospital, Porterville 1.7.3 Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI 0 0 0 0 1 0 0 0 0 0.5127 144615.38

DY12 DMPH Sierra View District Hospital, Porterville 2.2.1 DHCS All-Cause Readmissions 236 0 1455 0 1 0.1622 0 0 0 0 $-

DY12 DMPH Sierra View District Hospital, Porterville 2.2.2 H-CAHPS: Care Transition Metrics (3) 4250 0 10000 0 1 0.425 0 0 0 0 $-

DY12 DMPH Sierra View District Hospital, Porterville 2.2.3 Medication Reconciliation 30 days 0 0 0 0 1 0 0 0 0 0 $-

DY12 DMPH Sierra View District Hospital, Porterville 2.2.4 Reconciled Medication List Received by Discharged Patients 0 0 4093 0 1 0 0 0 0 0 $-

DY12 DMPH Sierra View District Hospital, Porterville 2.2.5 Timely Transmission of Transition Record 0 0 3516 0 1 0 0 0 0 0 $-

DY12 DMPH Sierra View District Hospital, Porterville 2.3.1 Care Coordinator Assignment 0 0 451 0 1 0 0 0 0 0 433846.16

DY12 DMPH Sierra View District Hospital, Porterville 2.3.2 Medication Reconciliation 30 days 0 0 0 0 1 0 0 0 0 0 433846.15

DY12 DMPH Sierra View District Hospital, Porterville 2.3.3 Prevention Quality Overall Composite #90 87 0 451 0 1 0.1929 0 0 0 0 433846.15

DY12 DMPH Sierra View District Hospital, Porterville 2.3.4 Timely Transmission of Transition Record 0 0 357 0 1 0 0 0 0 0 433846.15

DY12 DMPH Sierra View District Hospital, Porterville 2.7.1 Advance Care Plan None 1 34 0 1 None 1 0 0 0 433846.16

DY12 DMPH Sierra View District Hospital, Porterville 2.7.2 Ambulatory Palliative Care Team Established: Ambulatory Palliative Care Team Established? No Yes 0 Team Established? 0 1 0 0 NA 0 NA 433846.16

DY12 DMPH Sierra View District Hospital, Porterville 2.7.3 MWM #8: Treatment Preferences (documentation) Inpatient 47 0 48 0 1 0.9792 0 0 0 0 433846.16

DY12 DMPH Sierra View District Hospital, Porterville 2.7.4 MWM #8: Treatment Preferences (documentation) Outpatient 0 0 0 0 1 0 0 0 0 0 433846.15

DY12 DMPH Sierra View District Hospital, Porterville 2.7.5 Palliative Care Service Offered at Time of Diagnosis of Advanced Illness 30 0 388 0 1 0.0773 0 0 0 0 433846.15

DY12 DMPH Sierra View District Hospital, Porterville 2.7.6 Proportion Admitted to Hospice for Less Than 3 Days 13 0 34 0 1 0.3824 0 0 0 0 433846.15

DY12 DMPH Sierra View District Hospital, Porterville None Analyze current performance feedback and improve initiatives None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Automated functionality process to identify patients eligible for palliative care None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Complete gap analysis of existing software on tracking and reporting readmission rates, timeliness of discharge summaries, and establish a methodology to investigate system-specific root causes/risk factors for readmission None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Complete workforce gap analysis to determine staff that needs to be hired, redeployed, and retrained to implement the new program None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Convene project team to develop a nutritional and physical counseling plan None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Convene project team to develop mechanisms to complete discharge and primary care analysis and develop support program for patients and families on transition upon discharge from hospital to outpatient provider None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Convene project team to develop plan for electronic functionality to support clinical decision None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Convene project team to develop process and electronic functionality to identify patients at high-risk for readmission and develop standardized workflows to ensure accuracy of medication list at time of discharge None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Convene project team to develop tools, protocols, and modules for advanced care planning None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Convene project team to select nationally recognized care transitions model and develop standardized process to transition patients from sub-acute to long term care facilities None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Convene work group to develop BMI Screening guidelines, workflow, and policies None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Convene work group to develop protocols for patients with advanced illness, establish process to ensure timely transmission of advanced care plan to receiving facilities and care partners, and evaluate staffs knowledge in palliative care competence and communication skills None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Convene work group to identify methodologies for improving receipt of services and transition of care opportunities in the community for patients None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Convene work group to review best practices for care plans None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Determine buildings compliance and licensing requirements None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Determine the minimum requirements needed for the creation of a data registry (population health stratification of high risk patients) None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Develop a comprehensive health assessment for patient care coordination None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Develop a multi-disciplinary care team for care coordination to which each patient is assigned and whose interventions are tiered according to patient level of risk None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Develop a process of documentation in the EHR of advanced illness preferences None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Develop a referral mechanism to community resources and a tiered follow-up process for patient social and health needs None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Develop a referral process to identify patients for care coordination None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Develop a workforce plan to hire, train and/or retrain care coordination team members None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Develop culturally and linguistically appropriate patient educational materials on chronic disease management None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Develop plan to address EMR gaps None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Develop primary care referral for patients None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Develop process to ensure medication reconciliation across the continuum of care None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Develop program budget None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Develop tracking mechanism for patient follow up None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Develop training and education materials on complex care management None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Educate patients, families and staff on self-care program and process None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Engage with community stakeholders to improve and document transition of care opportunities and available services None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Engage with community stakeholders to improve population health None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Establish a mechanism for timely communication and coordination with receiving practitioner None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Establish a process to analyze clinical data, utilization and other available data to enable identification of high-risk/rising risk patients for targeted complex care management interventions None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Establish performance improvement structure and process for rapid cycle improvement None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Establish PRIME governance and organizational framework None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Establish training for Improve completion of Physician Orders for Life-Sustaining Treatment (POLST) with eligible patients None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Explore automated functionality of process to identify patients None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Explore potential clinic sites and partnerships None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Identify/adopt a nationally recognized complex care management program methodology None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Implement plan to address gaps in EMR None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Research and expand community resources for targeted patients in the community None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Select and develop appropriate care path None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Select evidence-based guidelines and processes to guide chronic disease management None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Submit application to city/state/federal None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Test changes to the system and make any additional necessary modifications None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Train 50% of active primary care (Family and Internal Medicine) physicians and 70% of Registered Nurses on palliative care path, advance care planning processes and implement advanced care planning documentation, and protocols None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Train 90% of Care Management staff on identifying high risk patients for readmissions and the process to ensure medication list accuracy at discharge, the medication reconciliation process, and the processes for each None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Train Director of Pharmacy and nine Care Management team members on care teams, tools, referral and tiered follow-up process, and effective team functioning and complex care management skills None None None None 1 None None None None None 75200

DY12 DMPH Sierra View District Hospital, Porterville None Train three Dietitians and nine Care Management team members on BMI Screening guidelines, workflows and policies None None None None 1 None None None None None 75200

DY12 DMPH Sonoma Valley Hospital, Sonoma 2.2.1 DHCS All-Cause Readmissions 14 0 75 0 1 0.1867 0 0 0 0 180000

DY12 DMPH Sonoma Valley Hospital, Sonoma 2.2.2 H-CAHPS: Care Transition Metrics (3) 99 0 189 0 1 0.5238 0 0 0 0 180000

DY12 DMPH Sonoma Valley Hospital, Sonoma 2.2.3 Medication Reconciliation 30 days None 1 143 0 1 None 1 0 0 0 180000

DY12 DMPH Sonoma Valley Hospital, Sonoma 2.2.4 Reconciled Medication List Received by Discharged Patients 60 0 262 0 1 0.229 0 0 0 0 180000

DY12 DMPH Sonoma Valley Hospital, Sonoma 2.2.5 Timely Transmission of Transition Record None 1 229 0 1 None 1 0 0 0 180000

DY12 DMPH Sonoma Valley Hospital, Sonoma None Community Health Coach role is fully implemented. None None None None 1 None None None None None 75000

DY12 DMPH Sonoma Valley Hospital, Sonoma None Develop and implement standards for education, core competencies and evaluation of coach effectiveness. None None None None 1 None None None None None 75000

DY12 DMPH Sonoma Valley Hospital, Sonoma None Develop care coordination tools that assess risk, plan for risk reduction, documents goal setting and intervention, and allows for effective evaluation within a database and communication system None None None None 1 None None None None None 75000

DY12 DMPH Sonoma Valley Hospital, Sonoma None Hire and train an ED/Community Case Manager None None None None 1 None None None None None 75000

DY12 DMPH Sonoma Valley Hospital, Sonoma None Implement a structure for obtaining the best possible medication history to assess medication accuracy: Inpatient and ED None None None None 1 None None None None None 75000

DY12 DMPH Sonoma Valley Hospital, Sonoma None Medication Reconciliation process includes all metric elements and is provided to the patient and provider upon discharge. None None None None 1 None None None None None 75000

DY12 DMPH Sonoma Valley Hospital, Sonoma None Pilot the role to identify gaps in the process. None None None None 1 None None None None None 75000

DY12 DMPH Sonoma Valley Hospital, Sonoma None Standardize a process for 30 day medication reconciliation compliance with Primary Care providers and the Community Health Center. None None None None 1 None None None None None 75000

DY12 DMPH Sonoma West Medical Center, Sebastopol 2.2.1 DHCS All-Cause Readmissions 14 0 144 0 1 0.0972 0 0 0 0 180000

DY12 DMPH Sonoma West Medical Center, Sebastopol 2.2.2 H-CAHPS: Care Transition Metrics (3) 45 0 100 0 1 0.45 0 0 0 0 180000

DY12 DMPH Sonoma West Medical Center, Sebastopol 2.2.3 Medication Reconciliation 30 days 26 0 30 0 1 0.8667 0 0 0 0 180000

DY12 DMPH Sonoma West Medical Center, Sebastopol 2.2.4 Reconciled Medication List Received by Discharged Patients 112 0 144 0 1 0.7778 0 0 0 0 180000

DY12 DMPH Sonoma West Medical Center, Sebastopol 2.2.5 Timely Transmission of Transition Record 43 0 144 0 1 0.2986 0 0 0 0 180000

DY12 DMPH Sonoma West Medical Center, Sebastopol None Analyze data of high-utilizers to see which facilities most patients are being discharged to from SWMC by 9/30/16. None None None None 0 None None None None None 31578.95

DY12 DMPH Sonoma West Medical Center, Sebastopol None Become a member of the appropriate County committee related to care transition providers. None None None None 0 None None None None None 31578.95

DY12 DMPH Sonoma West Medical Center, Sebastopol None Contract with Physicians providing Hospital services, including oversight for Care Management and Utilization functions, signed by 8/31/16. None None None None 0 None None None None None 31578.95

DY12 DMPH Sonoma West Medical Center, Sebastopol None Create formal written program for all staff involved in care transitions developed by 3/31/17. None None None None 0 None None None None None 31578.94

DY12 DMPH Sonoma West Medical Center, Sebastopol None Creation of PRIME reports (dashboard) to meet standards for continuous reporting by 9/30/16. None None None None 0 None None None None None 31578.95

DY12 DMPH Sonoma West Medical Center, Sebastopol None Enter into an MOU or contract as appropriate with County Mental Health by 12/31/16 to address the trends of this patient population. None None None None 0 None None None None None 31578.94

DY12 DMPH Sonoma West Medical Center, Sebastopol None Enter into an MOU with the appropriate paramedic organizations, with defined roles, responsibilities, and expectations by 3/31/17. None None None None 0 None None None None None 31578.94

DY12 DMPH Sonoma West Medical Center, Sebastopol None Enter into contract/MOU with Homeless Services Center to discharge patients from SWMC as appropriate for respite care in their shelter by 6/30/17, contingent upon the implementation of the respite care model in their facility. None None None None 0 None None None None None 31578.94

DY12 DMPH Sonoma West Medical Center, Sebastopol None Extract and analyze data for applicable study cohort (as defined by the grant) by 9/30/16 in order to understand the trends related to high utilization. None None None None 0 None None None None None 31578.95

DY12 DMPH Sonoma West Medical Center, Sebastopol None Identify applicable Core Measures for SWMC by 8/31/16. None None None None 0 None None None None None 31578.95

DY12 DMPH Sonoma West Medical Center, Sebastopol None Identify list of interventions by paramedics that would be helpful in keeping the patient safe at home by 12/31/16, and within scope of practice. None None None None 0 None None None None None 31578.95

DY12 DMPH Sonoma West Medical Center, Sebastopol None Map applicable Core Measure data fields to reports for PRIME reporting by 8/31/16. None None None None 0 None None None None None 31578.95

DY12 DMPH Sonoma West Medical Center, Sebastopol None Meet with Homeless Services Center by 12/31/16 to explain the goal of the project and advocate for the need of respite care beds in their new facility. None None None None 0 None None None None None 31578.95

DY12 DMPH Sonoma West Medical Center, Sebastopol None Meet with representatives from County EMS and paramedic organizations like AMR by 7/31/16. None None None None 0 None None None None None 31578.95

DY12 DMPH Sonoma West Medical Center, Sebastopol None Meet with representatives from Sonoma County Mental Health by 9/30/16 to discuss issues related to care transitions for patients with mental health and substance abuse problems. None None None None 0 None None None None None 31578.95

DY12 DMPH Sonoma West Medical Center, Sebastopol None Meet with top facilities with relation to discharge volume to share with them the projects goal and data by 10/31/16 and invite them to join steering committee. None None None None 0 None None None None None 31578.95

DY12 DMPH Sonoma West Medical Center, Sebastopol None MOU signed between SWMC and WCHC by 8/31/16. None None None None 0 None None None None None 31578.95

DY12 DMPH Sonoma West Medical Center, Sebastopol None Refine MOU with WCHC by 12/31/16 with necessary language related to the roles and responsibilities for the care of the study cohort patients. None None None None 0 None None None None None 31578.95

DY12 DMPH Sonoma West Medical Center, Sebastopol None Train 27 nurses involved in care transitions (at SWMC or applicable partners such as WCHC) on the program by 6/30/17. None None None None 0 None None None None None 31578.94

DY12 DMPH Southern Inyo Hospital, Lone Pine 1.2.1.a Alcohol and Drug Misuse (SBIRT) 0 0 198 0 1 0 0 0 0 0 50000

DY12 DMPH Southern Inyo Hospital, Lone Pine 1.2.11 REAL data completeness 0 0 198 0 1 0 0 0 0 0 50000

DY12 DMPH Southern Inyo Hospital, Lone Pine 1.2.12.f Screening for Clinical Depression and follow-up 0 0 169 0 1 0 0 0 0 0 50000

DY12 DMPH Southern Inyo Hospital, Lone Pine 1.2.13 SO/GI data completeness 0 0 198 0 1 0 0 0 0 0 50000

DY12 DMPH Southern Inyo Hospital, Lone Pine 1.2.14.t Tobacco Assessment and Counseling 0 0 169 0 1 0 0 0 0 0 50000

DY12 DMPH Southern Inyo Hospital, Lone Pine 1.2.2 CG-CAHPS: Provider Rating 0 0 0 0 1 0 0 0 0 0 50000

DY12 DMPH Southern Inyo Hospital, Lone Pine 1.2.3.c Colorectal Cancer Screening None 1 95 0 1 None 1 0 0 0 50000

DY12 DMPH Southern Inyo Hospital, Lone Pine 1.2.4.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 0 0 None 1 1 None 1 0 0 0 50000

DY12 DMPH Southern Inyo Hospital, Lone Pine 1.2.5.b Controlling Blood Pressure 0 0 None 1 1 None 1 0 0 0 50000

DY12 DMPH Southern Inyo Hospital, Lone Pine 1.2.6 Documented REAL and/or SO/GI disparity reduction plan: Documented disparity reduction plan? Yes Yes 0 Plan ? 0 1 0 0 NA 0 NA 50000

DY12 DMPH Southern Inyo Hospital, Lone Pine 1.2.7.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 0 0 0 0 1 0 0 0 0 0 50000

DY12 DMPH Southern Inyo Hospital, Lone Pine 1.2.8 Prevention Quality Overall Composite #90 0 0 169 0 1 0 0 0 0 0 50000

DY12 DMPH Southern Inyo Hospital, Lone Pine 1.2.9 Primary Care Redesign metrics stratified by REAL categories and SO/GI: Primary care redesign metrics stratified? No No 0 Stratified ? 0 1 0 0 NA 0 NA 50000

DY12 DMPH Southern Inyo Hospital, Lone Pine 1.6.1 BIRADS to Biopsy None 1 None 1 1 None 1 0 0 0 50000

DY12 DMPH Southern Inyo Hospital, Lone Pine 1.6.2 Breast Cancer Screening 17 0 58 0 1 0.2931 0 0 0 0 50000

DY12 DMPH Southern Inyo Hospital, Lone Pine 1.6.3 Cervical Cancer Screening 0 0 73 0 1 0 0 0 0 0 50000

DY12 DMPH Southern Inyo Hospital, Lone Pine 1.6.4.c Colorectal Cancer Screening None 1 95 0 1 None 1 0 0 0 50000

DY12 DMPH Southern Inyo Hospital, Lone Pine 1.6.5 Receipt of appropriate follow-up for abnormal CRC screening None 1 None 1 1 None 1 0 0 0 50000

DY12 DMPH Southern Inyo Hospital, Lone Pine None Complete manual chart extraction to ID patient population by recommended screening age and gender None None None None 1 None None None None None 120000

DY12 DMPH Southern Inyo Hospital, Lone Pine None Implement i2iTracks Population Management Tool None None None None 0 None None None None None 120000

DY12 DMPH Southern Inyo Hospital, Lone Pine None Implement Open Vista EHR None None None None 1 None None None None None 120000

DY12 DMPH Southern Inyo Hospital, Lone Pine None Seek NCQA PMCH recognition None None None None 1 None None None None None 120000

DY12 DMPH Southern Inyo Hospital, Lone Pine None Work with local health plans to present initiatives and increase community awareness of improvement efforts- including PCMH. None None None None 1 None None None None None 120000

DY12 DMPH Tahoe Forest Hospital District, Truckee 1.5.1.b Controlling Blood Pressure 39 0 53 0 1 0.7358 0 0 0 0 113333.34

DY12 DMPH Tahoe Forest Hospital District, Truckee 1.5.2.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 12 0 None 4 1 None 4 0 0 0 113333.33

DY12 DMPH Tahoe Forest Hospital District, Truckee 1.5.3 PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 15 0 146 0 1 0.1027 0 0 0 0 113333.33

DY12 DMPH Tahoe Forest Hospital District, Truckee 1.5.4.t Tobacco Assessment and Counseling 1248 0 1320 0 1 0.9455 0 0 0 0 113333.33

DY12 DMPH Tahoe Forest Hospital District, Truckee 2.6.1 Alcohol and Drug Misuse (SBIRT) 13 0 515 0 1 0.0252 0 0 0 0 113333.34

DY12 DMPH Tahoe Forest Hospital District, Truckee 2.6.2 Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen None 1 159 0 1 None 1 0 0 0 113333.34

DY12 DMPH Tahoe Forest Hospital District, Truckee 2.6.3 Patients with chronic pain on long term opioid therapy checked in PDMPs None 1 87 0 1 None 1 0 0 0 113333.33

DY12 DMPH Tahoe Forest Hospital District, Truckee 2.6.4 Screening for Clinical Depression and follow-up None 1 151 0 1 None 1 0 0 0 113333.33

DY12 DMPH Tahoe Forest Hospital District, Truckee 2.6.5 Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy 71 0 93 0 1 0.7634 0 0 0 0 113333.33

DY12 DMPH Tahoe Forest Hospital District, Truckee None Adopt Million Heart Screening assessments and Algorithms None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Adopt National Quality Forum Guidelines for screening Mental and Behavioral Health and develop depression screening policy None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Assess and determine Tahoe Forest Health Systems current capacity and estimate future resources needed to operate and sustain a data registry in a Gap Analysis None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Assess system needs to operate and sustain tracking mechanism None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Build project metric tracking and reporting mechanism None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Chronic Pain Advisory Group consensus to adopt, develop and train staff on tools and process. Make changes where necessary and implement tools. None None None None 1 None None None None None 14166.66

DY12 DMPH Tahoe Forest Hospital District, Truckee None Conduct a Data Gap Analysis within the EHR (EPIC) system None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Create Query reports and systems to track eligible PRIME patients for each PRIME and metrics None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Develop a system to identify eligible patients with external providers None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Develop Chronic Pain Registry None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Develop chronic pain program model workflow process, educate providers and implement None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Develop Data points to be monitored to align with PRIME project 2.6 such as Depression screening (PHQ2 and PHQ 9, use of the functional assessment tool, Prescription Drug Monitoring verification, SBIRT, CRAFFT, AUDIT and DAST screening tools, Medication Agreement documentation, annual urine toxicology screening, None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Develop mid-year and year-end metric reports according to the PRIME measurement period None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Develop orientation and training plan to include: a. Chronic Disease Self-Management program b. SBIRT online modules (evidenced based program) c. Unique tool (CRAFFT) specific to adolescent (12 -17) screening risk for alcohol and drug misuse d. Review Health Care Guideline Assessment and Management of Chronic Pain e. Assured codes are built into the EHR for CRAFFT and SBIRT None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Develop patient follow-up process and train clinicians on tools and processes. Implement tools and processes into HER None None None None 1 None None None None None 14166.66

DY12 DMPH Tahoe Forest Hospital District, Truckee None Develop policies and procedures for Chronic Pain Management to include: Safe Prescribe Practices, SBIRT, CRAFFT None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Develop process flows for tools to assist Medical Providers for follow through with PRIME metrics None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Develop referral process for patients to be enrolled into the chronic pain management program None None None None 1 None None None None None 14166.66

DY12 DMPH Tahoe Forest Hospital District, Truckee None Develop Safe Prescribe Practices Policy for Urine Toxicology and use of Naloxone. None None None None 1 None None None None None 14166.66

DY12 DMPH Tahoe Forest Hospital District, Truckee None Develop Team to create and implement tracking mechanism None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Develop Workflow Processes for accurate reporting and train staff to utilize Tracking mechanism to develop reports None None None None 1 None None None None None 14166.66

DY12 DMPH Tahoe Forest Hospital District, Truckee None Educate Community and Community Partners such as Family Resource Centers on Million Hearts Initiative None None None None 1 None None None None None 14166.66

DY12 DMPH Tahoe Forest Hospital District, Truckee None Educate Medical Providers and clinic staff re: process flows for screening tool None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Educate Multispecialty Clinic(9) providers and (4) lead staff to include Health and MSC clinics on the care coordination process None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Educate providers and clinic staff on protocols, care processes and competencies related to Million Hearts None None None None 1 None None None None None 14166.66

DY12 DMPH Tahoe Forest Hospital District, Truckee None Establish final Referral Process and systems None None None None 1 None None None None None 14166.66

DY12 DMPH Tahoe Forest Hospital District, Truckee None Establish plan for care coordination referral process implementation None None None None 1 None None None None None 14166.66

DY12 DMPH Tahoe Forest Hospital District, Truckee None Expand smoking cessation resources and referrals for the TFHD Multispecialty Clinics and TFHD Health Clinic. None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Finalize EHR system changes for data tracking and reporting None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Identify and Implement evidenced based BP education materials for community outreach re: Blood Pressure Control and Prevention None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Identify and Incorporate new chronic pain questions into existing Press-Ganey Medical Practice Survey None None None None 1 None None None None None 14166.66

DY12 DMPH Tahoe Forest Hospital District, Truckee None Identify and modify evidenced based assessment tools None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Identify and modify new and existing protocols to utilize assessment tools and Management algorithm None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Implement data driven improvement cycle such as DMAIC (Define , Measure, Analyze, Improve, and Control) quality improvement methodology None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Implement Safe Prescribe Practices Policy within the TFHD Health Clinics and TFHD Emergency Department None None None None 1 None None None None None 14166.66

DY12 DMPH Tahoe Forest Hospital District, Truckee None Include additional Survey questions to address Chronic Pain in existing patient survey tool None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Incorporate Assessment & Pain Management Guidelines or algorithm tools into the EHR None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Orient and Train Million Heart Initiative Staff on program policy and interventions None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Orient new and existing staff: Include Care Coordinator, Health Promotora, Community Educator and Practice Manager None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Pilot Safe Prescribe Practices per developed policy in TFHD Health Clinic None None None None 1 None None None None None 14166.66

DY12 DMPH Tahoe Forest Hospital District, Truckee None Plan for Screening tool (PHQ-SBIRT-CRAFFT) implementation at all annual wellness visits and as needed None None None None 1 None None None None None 14166.66

DY12 DMPH Tahoe Forest Hospital District, Truckee None Research community programs and availability of resources and compile a multi-modal therapy referral list. Train Multi-Specialty Clinic Staff and Health Clinic Staff on how to access multi-model therapy referral list None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Review existing Protocols and/or Algorithms related to Million Hearts and revise as necessary None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Review results of the Press-Ganey patient survey s that include the additional questions pertaining to Chronic non-malignant pain management and modify chronic pain management program if necessary None None None None 1 None None None None None 14166.66

DY12 DMPH Tahoe Forest Hospital District, Truckee None Revise policy and procedure to include chronic non-malignant pain project performance improvement to assure the performance model is reflected into the PRIME project None None None None 1 None None None None None 14166.67

DY12 DMPH Tahoe Forest Hospital District, Truckee None Streamline referral process and referrals to nutritional, exercise and support programs for the Multispecialty and TFHD Health clinics None None None None 1 None None None None None 14166.66

DY12 DMPH Tahoe Forest Hospital District, Truckee None Test Implementation of Care Processes None None None None 1 None None None None None 14166.66

DY12 DMPH Tahoe Forest Hospital District, Truckee None Train PRIME coordinators on the use of reporting Query tool None None None None 1 None None None None None 14166.67

DY12 DMPH Tri-City Medical Center, Oceanside 1.4.1 Abnormal Results Follow-Up: Abnormal BIRADS Follow-up 100 0 173 0 1 0.578034682 0 0 0 NA 65302.32

DY12 DMPH Tri-City Medical Center, Oceanside 1.4.1 Abnormal Results Follow-Up: Abnormal INR Follow-up 0 0 0 0 1 0 0 0 0 NA 65302.32

DY12 DMPH Tri-City Medical Center, Oceanside 1.4.1 Abnormal Results Follow-Up: Abnormal Potassium Follow-up 0 0 0 0 1 0 0 0 0 NA 65302.32

DY12 DMPH Tri-City Medical Center, Oceanside 1.4.2 Annual Monitoring for Patients on Persistent Medications 0 0 0 0 1 0 0 0 0 0.8446 195906.97

DY12 DMPH Tri-City Medical Center, Oceanside 1.4.3 INR Monitoring for Individuals on Warfarin 0 0 0 0 1 0 0 0 0 0 195906.98

DY12 DMPH Tri-City Medical Center, Oceanside 1.5.1.b Controlling Blood Pressure 0 0 3334 0 1 0 0 0 0 0 195906.97

DY12 DMPH Tri-City Medical Center, Oceanside 1.5.2.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 59 0 59 0 1 1 0 0 0 0 195906.98

DY12 DMPH Tri-City Medical Center, Oceanside 1.5.3 PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 1557 0 6170 0 1 0.2524 0 0 0 0 195906.98

DY12 DMPH Tri-City Medical Center, Oceanside 1.5.4.t Tobacco Assessment and Counseling 0 0 None 1 1 None 1 0 0 0 195906.98

DY12 DMPH Tri-City Medical Center, Oceanside 1.7.1 BMI Screening and Follow-up 969 0 2298 0 1 0.4217 0 0 0 0 195906.97

DY12 DMPH Tri-City Medical Center, Oceanside 1.7.2 Partnership for a Healthier Americas Hospital Health Food Initiative external food service verification: Numerator - Criteria Met (If your system has more than one hospital, please enter the sum of all criteria met)
Denominator - Required Criteria (If your system has more than one hospital, multiply the number of hospitals by 2) 2 0 8 0 1 0 0 NA 0 NA 195906.98

DY12 DMPH Tri-City Medical Center, Oceanside 1.7.3 Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Nutrition 0 0 0 0 1 0 0 0 0 0.5198 65302.33

DY12 DMPH Tri-City Medical Center, Oceanside 1.7.3 Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Counseling for Physical Activity 0 0 0 0 1 0 0 0 0 0.4416 65302.33

DY12 DMPH Tri-City Medical Center, Oceanside 1.7.3 Weight Assessment & Counseling for Nutrition and Physical Activity for Children & Adolescents: Weight Assessment - BMI 0 0 0 0 1 0 0 0 0 0.5127 65302.33

DY12 DMPH Tri-City Medical Center, Oceanside 2.1.1 Baby Friendly Hospital designation: BFUSA Designation Yes Yes 0 BFUSA Cert? 0 1 0 0 NA 0 NA 195906.97

DY12 DMPH Tri-City Medical Center, Oceanside 2.1.2 Exclusive Breast Milk Feeding (PC-05) 163 0 280 0 1 0.5821 0 0 0 0 195906.97

DY12 DMPH Tri-City Medical Center, Oceanside 2.1.3 OB Hemorrhage: Massive Transfusion 0 0 1718 0 1 0 0 0 0 0 195906.97

DY12 DMPH Tri-City Medical Center, Oceanside 2.1.4 OB Hemorrhage: Total Products Transfused 46 0 1718 0 1 0.0268 0 0 0 0 195906.97

DY12 DMPH Tri-City Medical Center, Oceanside 2.1.5 PC-02 Cesarean Section 110 0 542 0 1 0.203 0 0 0 0 195906.98

DY12 DMPH Tri-City Medical Center, Oceanside 2.1.6 Prenatal and Postpartum Care: Postpartum Care 0 0 2072 0 1 0 0 0 0 0.5547 97953.49

DY12 DMPH Tri-City Medical Center, Oceanside 2.1.6 Prenatal and Postpartum Care: Prenatal Care 0 0 2072 0 1 0 0 0 0 0.7744 97953.49

DY12 DMPH Tri-City Medical Center, Oceanside 2.1.7 Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage 30 0 93 0 1 0.3226 0 0 0 0 195906.98

DY12 DMPH Tri-City Medical Center, Oceanside 2.1.8 Unexpected Newborn Complications (UNC) 108 0 1345 0 1 0.0803 0 0 0 0 195906.98

DY12 DMPH Tri-City Medical Center, Oceanside 2.1.9 OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed)
[Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) 16 0 16 0 1 0 0 0 0 NA 195906.98

DY12 DMPH Tri-City Medical Center, Oceanside 2.2.1 DHCS All-Cause Readmissions 190 0 3485 0 1 0.0545 0 0 0 0 195906.97

DY12 DMPH Tri-City Medical Center, Oceanside 2.2.2 H-CAHPS: Care Transition Metrics (3) 217 0 422 0 1 0.5142 0 0 0 0 195906.98

DY12 DMPH Tri-City Medical Center, Oceanside 2.2.3 Medication Reconciliation 30 days 0 0 0 0 1 0 0 0 0 0 195906.98

DY12 DMPH Tri-City Medical Center, Oceanside 2.2.4 Reconciled Medication List Received by Discharged Patients 14385 0 15638 0 1 0.9199 0 0 0 0 195906.98

DY12 DMPH Tri-City Medical Center, Oceanside 2.2.5 Timely Transmission of Transition Record 12580 0 13062 0 1 0.9631 0 0 0 0 195906.98

DY12 DMPH Tri-City Medical Center, Oceanside 2.3.1 Care Coordinator Assignment 32 0 1251 0 1 0.0256 0 0 0 0 195906.97

DY12 DMPH Tri-City Medical Center, Oceanside 2.3.2 Medication Reconciliation 30 days 0 0 0 0 1 0 0 0 0 0 195906.98

DY12 DMPH Tri-City Medical Center, Oceanside 2.3.3 Prevention Quality Overall Composite #90 165 0 1251 0 1 0.1319 0 0 0 0 195906.98

DY12 DMPH Tri-City Medical Center, Oceanside 2.3.4 Timely Transmission of Transition Record 480 0 1729 0 1 0.2776 0 0 0 0 195906.98

DY12 DMPH Tri-City Medical Center, Oceanside 2.7.1 Advance Care Plan 108 0 331 0 1 0.3263 0 0 0 0 195906.97

DY12 DMPH Tri-City Medical Center, Oceanside 2.7.2 Ambulatory Palliative Care Team Established: Ambulatory Palliative Care Team Established? Yes Yes 0 Team Established? 0 1 0 0 NA 0 NA 195906.97

DY12 DMPH Tri-City Medical Center, Oceanside 2.7.3 MWM #8: Treatment Preferences (documentation) Inpatient 27 0 35 0 1 0.7714 0 0 0 0 195906.98

DY12 DMPH Tri-City Medical Center, Oceanside 2.7.4 MWM #8: Treatment Preferences (documentation) Outpatient None 1 None 1 1 None 1 0 0 0 195906.98

DY12 DMPH Tri-City Medical Center, Oceanside 2.7.5 Palliative Care Service Offered at Time of Diagnosis of Advanced Illness 36 0 331 0 1 0.1088 0 0 0 0 195906.98

DY12 DMPH Tri-City Medical Center, Oceanside 2.7.6 Proportion Admitted to Hospice for Less Than 3 Days None 1 None 4 1 None 1 0 0 0 195906.98

DY12 DMPH Tri-City Medical Center, Oceanside 3.1.1 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis 19 0 34 0 1 0.5588 0 0 0 0 195906.97

DY12 DMPH Tri-City Medical Center, Oceanside 3.1.3 National Healthcare Safety Network (NHSN) Antimicrobial Use Measure 13752 0 23706 0 1 0.5801 0 0 0 0 195906.98

DY12 DMPH Tri-City Medical Center, Oceanside 3.1.4 Peri-operative Prophylactic Antibiotics Administered after Surgical Closure 1351 0 1959 0 1 0.6896 0 0 0 0 195906.98

DY12 DMPH Tri-City Medical Center, Oceanside 3.1.5 Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR No 8170 0 10000 0 1 0.817 0 0 0 0 195906.98

DY12 DMPH Tri-City Medical Center, Oceanside None Analyze available directed health information exchange (HIE) options and identify the best fit for TCHD None None None None 1 None None None None None 100285.72

DY12 DMPH Tri-City Medical Center, Oceanside None Assess current practices for high-risk ED discharges and modify as required None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Assess the effectiveness of Tri-City's current nutrition and weight control program None None None None 1 None None None None None 100285.72

DY12 DMPH Tri-City Medical Center, Oceanside None Conduct a gap analysis in TCHDs nutrition and food choices community education None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Conduct a preventive care needs assessment and gap analysis specific to heart screening patients in the Cardiovascular Health Institute None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Conduct a workforce assessment and gap analysis, redeploy staff as needed None None None None 1 None None None None None 100285.72

DY12 DMPH Tri-City Medical Center, Oceanside None Design a revised utilization review process None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Design, train and implement the work flow to link patients to PCPs at ED registration None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Determine which HIE functionality TCHD will procure None None None None 1 None None None None None 100285.72

DY12 DMPH Tri-City Medical Center, Oceanside None Develop a list of post-acute, community-based resources None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Develop a nutrition and weight control curriculum and conduct at least two trainings on the curriculum None None None None 1 None None None None None 100285.72

DY12 DMPH Tri-City Medical Center, Oceanside None Develop a process to reduce avoidable acute care utilization None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Develop and implement educational plan for community-based providers on preventive services None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Develop and implement and train identified staff on policies and procedures to address and improve gaps in communication between inpatient and outpatient teams None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Develop and implement patient educational material and staff training for new educational material None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Develop charter for ASC None None None None 1 None None None None None 100285.72

DY12 DMPH Tri-City Medical Center, Oceanside None Develop educational tool for nutrition and weight management and use tools at least four times None None None None 1 None None None None None 100285.72

DY12 DMPH Tri-City Medical Center, Oceanside None Develop new clinical pathway to report on and follow-up of abnormal test results None None None None 1 None None None None None 100285.72

DY12 DMPH Tri-City Medical Center, Oceanside None Develop patient referral process to Sweet Success program None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Develop process to track patient medication lists upon arrival to the ED and upon discharge, and 30 days post-discharge None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Develop program to improve patient self-management None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Develop provider education program for preventive care for cardiovascular health None None None None 1 None None None None None 100285.72

DY12 DMPH Tri-City Medical Center, Oceanside None Develop resource manual and conduct training for at least 50% of RDNs None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Develop supportive care education plan and identify targeted hospital-based and community care providers None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Develop tool to track client visits and progress toward sound diet and weight control None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Document current workflow surrounding abnormal test results to include serum potassium, INR tests and mammograms None None None None 1 None None None None None 100285.72

DY12 DMPH Tri-City Medical Center, Oceanside None Educate at least 75% of front line staff on new utilization review process None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Establish a policy that requires that all providers assess and document a Bishop score prior to the initiation of an elective induction. None None None None 1 None None None None None 100285.72

DY12 DMPH Tri-City Medical Center, Oceanside None Establish process to access and deliver non-medical support services for PRIME patients at high risk for readmission None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Hire or redeploy an IT PRIME leader None None None None 1 None None None None None 100285.72

DY12 DMPH Tri-City Medical Center, Oceanside None Identify a minimum of 4 stakeholder groups, including consumers and CBOs, and conduct a minimum of 1 stakeholder meeting with each group None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Identify and implement program modifications based on stakeholder feedback None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Identify and select clinical decision support module that supports secure texting functionality None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Identify at least 2 providers and 2 care coordinators, dedicated to this PRIME project for a train the trainer model for care coordination None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Identify available community resources for preventive care in cardiovascular health and develop database to store and manage this information None None None None 1 None None None None None 100285.72

DY12 DMPH Tri-City Medical Center, Oceanside None Identify patient inclusion criteria for supportive care, provide access to our EMR and share information with the Supportive network Database. None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Implement IT infrastructure to identify patient population with 4 or more chronic conditions using Cerner High Risk for Readmission Risk screen tool None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Implement disease-specific 3-tier care plan that includes physical, psycho- social and spiritual needs None None None None 1 None None None None None 100285.72

DY12 DMPH Tri-City Medical Center, Oceanside None Implement pilot study to assess effectiveness of interventions in reducing antimicrobial days of therapy None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Implement the CDPH, California Diabetes and Pregnancy Program (CDAPP) Sweet Success and provide staff training None None None None 1 None None None None None 100285.72

DY12 DMPH Tri-City Medical Center, Oceanside None Integrate post-acute decision making tool into EMR None None None None 1 None None None None None 100285.72

DY12 DMPH Tri-City Medical Center, Oceanside None Perform baseline data analysis None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Perform gap analysis of current antimicrobial stewardship process and develop a road map for implementing best practices to close identified gaps None None None None 1 None None None None None 100285.72

DY12 DMPH Tri-City Medical Center, Oceanside None Prepare a gap analysis of the current utilization review process for abnormal lab results for mammograms, serum creatinine, potassium and INR. None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Prepare gap analysis between current capture of abnormal test result reporting and PRIME requirements None None None None 1 None None None None None 100285.72

DY12 DMPH Tri-City Medical Center, Oceanside None Prepare gap analysis of the current clinical communication provided to post-acute care providers None None None None 1 None None None None None 100285.72

DY12 DMPH Tri-City Medical Center, Oceanside None Put into place a secure VPN tunnel for bi-direction data exchange between hospital and external clinics. None None None None 1 None None None None None 100285.72

DY12 DMPH Tri-City Medical Center, Oceanside None Review IT PRIME Requirement table, ID Cerner data elements and gaps. Identify data management staff; Assign a data manager to each data build task, complete and test builds, go live. None None None None 1 None None None None None 100285.72

DY12 DMPH Tri-City Medical Center, Oceanside None Standardize patient education materials to mirror sweet success program None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Successfully implement remote monitoring solution for targeted PRIME patient population None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Test post-acute decision making tool and ensure optimal system functionality None None None None 1 None None None None None 100285.72

DY12 DMPH Tri-City Medical Center, Oceanside None Train at least 60% of relevant staff and providers and complete training assessment on the clinical pathway for the follow up of abnormal laboratory results None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Train all pharmacists and inform medical staff of antimicrobial stewardship program None None None None 1 None None None None None 100285.71

DY12 DMPH Tri-City Medical Center, Oceanside None Train data manager on required PRIME performance metrics by attending meetings as least monthly. None None None None 1 None None None None None 100285.72

DY12 DMPH Tri-City Medical Center, Oceanside None Train users on post-acute decision making tool None None None None 1 None None None None None 100285.72

DY12 DMPH Tri-City Medical Center, Oceanside None Train users on remote monitoring system None None None None 1 None None None None None 100285.71

DY12 DMPH Trinity Hospital, Weaverville 1.4.1 Abnormal Results Follow-Up: Abnormal BIRADS Follow-up 24 0 64 0 1 0.375 0 0 0 NA 37500

DY12 DMPH Trinity Hospital, Weaverville 1.4.1 Abnormal Results Follow-Up: Abnormal INR Follow-up 98 0 116 0 1 0.844827586 0 0 0 NA 37500

DY12 DMPH Trinity Hospital, Weaverville 1.4.1 Abnormal Results Follow-Up: Abnormal Potassium Follow-up 230 0 275 0 1 0.836363636 0 0 0 NA 37500

DY12 DMPH Trinity Hospital, Weaverville 1.4.2 Annual Monitoring for Patients on Persistent Medications 159 0 205 0 1 0.7756 0 0 0 0 112500

DY12 DMPH Trinity Hospital, Weaverville 1.4.3 INR Monitoring for Individuals on Warfarin 94 0 116 0 1 0.8103 0 0 0 0 112500

DY12 DMPH Trinity Hospital, Weaverville 1.6.1 BIRADS to Biopsy 0 0 0 0 1 0 0 0 0 0 112500

DY12 DMPH Trinity Hospital, Weaverville 1.6.2 Breast Cancer Screening 43 0 288 0 1 0.1493 0 0 0 0.5159 112500

DY12 DMPH Trinity Hospital, Weaverville 1.6.3 Cervical Cancer Screening 158 0 406 0 1 0.3892 0 0 0 0.5433 112500

DY12 DMPH Trinity Hospital, Weaverville 1.6.4.c Colorectal Cancer Screening 118 0 490 0 1 0.2408 0 0 0 0.2669 112500

DY12 DMPH Trinity Hospital, Weaverville 1.6.5 Receipt of appropriate follow-up for abnormal CRC screening 0 0 0 0 1 0 0 0 0 NA 112500

DY12 DMPH Trinity Hospital, Weaverville None Convene workgroup to review and analyze current EHR reports to identify gaps and needs. None None None None 1 None None None None None 120000

DY12 DMPH Trinity Hospital, Weaverville None Establish data collection and reports review procedures None None None None 1 None None None None None 120000

DY12 DMPH Trinity Hospital, Weaverville None Establish protocol to ensure timely review of current assessments (of workflow to identify gaps, abnormal test results and follow up needed) and sign off by the MCHD PRIME team. None None None None 1 None None None None None 120000

DY12 DMPH Trinity Hospital, Weaverville None Patient engagement through patient surveys and provider feedback None None None None 1 None None None None None 120000

DY12 DMPH Trinity Hospital, Weaverville None Train new staff member/Patient Care Coordinator (Tracy Miller) with one-on-one training on how to run reports for diagnosis and orders with the current EMR system and how to use the QIP Clinical Measure Data Tracking System None None None None 1 None None None None None 120000

DY12 DMPH Tulare Regional Medical Center, Tulare 1.1.1.a Alcohol and Drug Misuse (SBIRT) 111 0 1964 0 0 0.0565 0 0 0 0 118451.62

DY12 DMPH Tulare Regional Medical Center, Tulare 1.1.2 Care Coordinator Assignment 0 0 33 0 0 0 0 0 0 0 118451.62

DY12 DMPH Tulare Regional Medical Center, Tulare 1.1.3.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 104 0 142 0 0 0.7324 0 0 0 0 118451.61

DY12 DMPH Tulare Regional Medical Center, Tulare 1.1.4 Depression Remission at 12 Months (CMS159v4) 0 0 None 4 0 None 4 0 0 0 118451.61

DY12 DMPH Tulare Regional Medical Center, Tulare 1.1.5.f Screening for Clinical Depression and follow-up 0 0 1861 0 0 0 0 0 0 0 118451.61

DY12 DMPH Tulare Regional Medical Center, Tulare 1.1.6.t Tobacco Assessment and Counseling 612 0 1861 0 0 0.3289 0 0 0 0 118451.61

DY12 DMPH Tulare Regional Medical Center, Tulare 1.2.1.a Alcohol and Drug Misuse (SBIRT) 111 0 1964 0 0 0.0565 0 0 0 0 118451.62

DY12 DMPH Tulare Regional Medical Center, Tulare 1.2.11 REAL data completeness 0 0 1964 0 0 0 0 0 0 0 118451.61

DY12 DMPH Tulare Regional Medical Center, Tulare 1.2.12.f Screening for Clinical Depression and follow-up 0 0 1861 0 0 0 0 0 0 0 118451.61

DY12 DMPH Tulare Regional Medical Center, Tulare 1.2.13 SO/GI data completeness 0 0 1964 0 0 0 0 0 0 0 118451.61

DY12 DMPH Tulare Regional Medical Center, Tulare 1.2.14.t Tobacco Assessment and Counseling 612 0 1861 0 0 0.3289 0 0 0 0 118451.61

DY12 DMPH Tulare Regional Medical Center, Tulare 1.2.2 CG-CAHPS: Provider Rating 56 0 100 0 0 0.56 0 0 0 0 118451.62

DY12 DMPH Tulare Regional Medical Center, Tulare 1.2.3.c Colorectal Cancer Screening 91 0 600 0 0 0.1517 0 0 0 0 118451.62

DY12 DMPH Tulare Regional Medical Center, Tulare 1.2.4.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 33 0 142 0 0 0.2324 0 0 0 0 118451.62

DY12 DMPH Tulare Regional Medical Center, Tulare 1.2.5.b Controlling Blood Pressure 240 0 425 0 0 0.5647 0 0 0 0 118451.61

DY12 DMPH Tulare Regional Medical Center, Tulare 1.2.6 Documented REAL and/or SO/GI disparity reduction plan: Documented disparity reduction plan? No 0 Plan ? 0 0 0 0 NA 0 NA 118451.61

DY12 DMPH Tulare Regional Medical Center, Tulare 1.2.7.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 12 0 None 4 0 None 4 0 0 0 118451.61

DY12 DMPH Tulare Regional Medical Center, Tulare 1.2.8 Prevention Quality Overall Composite #90 15 0 1861 0 0 0.0081 0 0 0 0 118451.61

DY12 DMPH Tulare Regional Medical Center, Tulare 1.2.9 Primary Care Redesign metrics stratified by REAL categories and SO/GI: Primary care redesign metrics stratified? No No 0 Stratified ? 0 0 0 0 NA 0 NA 118451.61

DY12 DMPH Tulare Regional Medical Center, Tulare 1.4.1 Abnormal Results Follow-Up: Abnormal BIRADS Follow-up 35 0 48 0 0 0.729166667 0 0 0 NA 39483.87

DY12 DMPH Tulare Regional Medical Center, Tulare 1.4.1 Abnormal Results Follow-Up: Abnormal INR Follow-up 0 0 None 1 0 None 1 0 0 NA 39483.87

DY12 DMPH Tulare Regional Medical Center, Tulare 1.4.1 Abnormal Results Follow-Up: Abnormal Potassium Follow-up 173 0 178 0 0 0.971910112 0 0 0 NA 39483.87

DY12 DMPH Tulare Regional Medical Center, Tulare 1.4.2 Annual Monitoring for Patients on Persistent Medications 54 0 87 0 0 0.6207 0 0 0 0 118451.61

DY12 DMPH Tulare Regional Medical Center, Tulare 1.4.3 INR Monitoring for Individuals on Warfarin 0 0 None 1 0 None 1 0 0 0 118451.61

DY12 DMPH Tulare Regional Medical Center, Tulare 1.5.1.b Controlling Blood Pressure 240 0 425 0 0 0.5647 0 0 0 0 118451.62

DY12 DMPH Tulare Regional Medical Center, Tulare 1.5.2.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 12 0 None 4 0 None 4 0 0 0 118451.61

DY12 DMPH Tulare Regional Medical Center, Tulare 1.5.3 PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 0 0 1861 0 0 0 0 0 0 0 118451.61

DY12 DMPH Tulare Regional Medical Center, Tulare 1.5.4.t Tobacco Assessment and Counseling 612 0 1861 0 0 0.3289 0 0 0 0 118451.61

DY12 DMPH Tulare Regional Medical Center, Tulare 1.6.1 BIRADS to Biopsy 0 0 0 0 0 0 0 0 0 0 118451.62

DY12 DMPH Tulare Regional Medical Center, Tulare 1.6.2 Breast Cancer Screening 87 0 326 0 0 0.2669 0 0 0 0 118451.61

DY12 DMPH Tulare Regional Medical Center, Tulare 1.6.3 Cervical Cancer Screening 61 0 600 0 0 0.1017 0 0 0 0 118451.61

DY12 DMPH Tulare Regional Medical Center, Tulare 1.6.4.c Colorectal Cancer Screening 23 0 600 0 0 0.0383 0 0 0 0 118451.61

DY12 DMPH Tulare Regional Medical Center, Tulare 1.6.5 Receipt of appropriate follow-up for abnormal CRC screening 0 0 0 0 0 0 0 0 0 0 118451.61

DY12 DMPH Tulare Regional Medical Center, Tulare None Implement SBIRT screenings as part of the primary care visit None None None None 1 None None None None None 816000

DY12 DMPH Tulare Regional Medical Center, Tulare None Purchase and implement Cerner and i2i technology platforms None None None None 1 None None None None None 816000

DY12 DMPH Tulare Regional Medical Center, Tulare None Revise workflow to identify disease management needs in the areas of breast health, colorectal screenings, diabetes management, cardiovascular disease and disease prevention. None None None None 1 None None None None None 816000

DY12 DPH UC Davis Medical Center 1.1.1.a Alcohol and Drug Misuse (SBIRT) 0 0 65071 0 0 0 0 0 0 0 973886.67

DY12 DPH UC Davis Medical Center 1.1.2 Care Coordinator Assignment 192 0 1346 0 1 0.1426 0 0.0921 0 0 973886.67

DY12 DPH UC Davis Medical Center 1.1.3.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 1376 0 6878 0 1 0.2001 0 0.2145 0 0.2968 973886.67

DY12 DPH UC Davis Medical Center 1.1.4 Depression Remission at 12 Months (CMS159v4) 16 0 986 0 1 0.0162 0 0.0139 0 0 973886.67

DY12 DPH UC Davis Medical Center 1.1.5.f Screening for Clinical Depression and follow-up 1963 0 49966 0 1 0.0393 0 0.018 0 0 973886.66

DY12 DPH UC Davis Medical Center 1.1.6.t Tobacco Assessment and Counseling 59178 0 61313 0 1 0.9652 0 0.8839 0 0.8913 973886.66

DY12 DPH UC Davis Medical Center 1.2.1.a Alcohol and Drug Misuse (SBIRT) 0 0 65071 0 0 0 0 0 0 0 973886.67

DY12 DPH UC Davis Medical Center 1.2.11 REAL data completeness 73224 0 74413 0 1 0.984 0 0.932 0 NA 973886.66

DY12 DPH UC Davis Medical Center 1.2.12.f Screening for Clinical Depression and follow-up 1963 0 49966 0 1 0.0393 0 0.018 0 0 973886.66

DY12 DPH UC Davis Medical Center 1.2.13 SO/GI data completeness 2421 0 62489 0 1 0.0387 0 0 0 0 973886.66

DY12 DPH UC Davis Medical Center 1.2.14.t Tobacco Assessment and Counseling 59178 0 61313 0 1 0.9652 0 0.8839 0 0.8913 973886.66

DY12 DPH UC Davis Medical Center 1.2.2 CG-CAHPS: Provider Rating 30536 0 35943 0 1 0.8496 0 0.8163 0 0.7029 973886.67

DY12 DPH UC Davis Medical Center 1.2.3.c Colorectal Cancer Screening 22155 0 30561 0 1 0.7249 0 0.6809 0 0.6571 973886.67

DY12 DPH UC Davis Medical Center 1.2.4.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 1376 0 6878 0 1 0.2001 0 0.2145 0 0.2968 973886.67

DY12 DPH UC Davis Medical Center 1.2.5.b Controlling Blood Pressure 19001 0 23766 0 1 0.7995 0 0.6919 0 0.693 973886.67

DY12 DPH UC Davis Medical Center 1.2.6 Documented REAL and/or SO/GI disparity reduction plan: Documented disparity reduction plan? Yes Yes 0 Plan ? 0 1 0 0 NA 0 NA 973886.67

DY12 DPH UC Davis Medical Center 1.2.7.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 4079 0 4211 0 1 0.9687 0 0.9172 0 0.9183 973886.67

DY12 DPH UC Davis Medical Center 1.2.8 Prevention Quality Overall Composite #90 436 0 62087 0 1 0.007 0 0.0077 0 0 973886.67

DY12 DPH UC Davis Medical Center 1.2.9 Primary Care Redesign metrics stratified by REAL categories and SO/GI: Primary care redesign metrics stratified? Yes Yes 0 Stratified ? 0 1 0 0 NA 0 NA 973886.67

DY12 DPH UC Davis Medical Center 1.3.1 Closing the referral loop: receipt of specialist report (CMS50v3) 63257 0 84502 0 1 0.7486 0 0.0784 0 0 973886.67

DY12 DPH UC Davis Medical Center 1.3.2 DHCS All-Cause Readmissions 782 0 6132 0 1 0.1275 0 0.1142 0 0.1318 973886.67

DY12 DPH UC Davis Medical Center 1.3.3 Influenza Immunization 14924 0 21172 0 1 0.7049 0 0.5158 0 0 973886.67

DY12 DPH UC Davis Medical Center 1.3.4 Post Procedure ED Visits 891 0 90417 0 1 0.0099 0 0.0089 0 0 973886.67

DY12 DPH UC Davis Medical Center 1.3.5 Request for Specialty Care Expertise Turnaround Time 85529 0 124350 0 1 0.6878 0 0.673 0 0 973886.67

DY12 DPH UC Davis Medical Center 1.3.6 Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters 1424 0 103405 0 1 0.0138 0 0.004 0 0 973886.66

DY12 DPH UC Davis Medical Center 1.3.7 Tobacco Assessment and Counseling 22967 0 23432 0 1 0.9802 0 0.9088 0 0.9137 973886.66

DY12 DPH UC Davis Medical Center 1.5.1.b Controlling Blood Pressure 19001 0 23766 0 1 0.7995 0 0.6919 0 0.693 973886.67

DY12 DPH UC Davis Medical Center 1.5.2.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 4079 0 4211 0 1 0.9687 0 0.9172 0 0.9183 973886.66

DY12 DPH UC Davis Medical Center 1.5.3 PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 31245 0 37186 0 1 0.8402 0 0.508 0 0 973886.67

DY12 DPH UC Davis Medical Center 1.5.4.t Tobacco Assessment and Counseling 59178 0 61313 0 1 0.9652 0 0.8839 0 0.8913 973886.66

DY12 DPH UC Davis Medical Center 2.1.1 Baby Friendly Hospital designation: Discovery Phase Complete Yes Yes 0 Discovery Phase? 0 1 0 0 NA 0 NA 338743.19

DY12 DPH UC Davis Medical Center 2.1.1 Baby Friendly Hospital designation: Informational Webinar Participation Yes Yes 0 Webinar complete? 0 1 0 0 NA 0 NA 338743.19

DY12 DPH UC Davis Medical Center 2.1.1 Baby Friendly Hospital designation: BFUSA Designation No No 0 BFUSA Cert? 0 0 0 0 NA 0 NA 338743.19

DY12 DPH UC Davis Medical Center 2.1.2 Exclusive Breast Milk Feeding (PC-05) 152 0 257 0 0 0.5914 0 0.6865 0 0.6977 1016229.57

DY12 DPH UC Davis Medical Center 2.1.3 OB Hemorrhage: Massive Transfusion None 1 1289 0 1 None 1 None 1 0 1016229.57

DY12 DPH UC Davis Medical Center 2.1.4 OB Hemorrhage: Total Products Transfused 110 0 1289 0 1 0.0853 0 0.0991 0 0 1016229.57

DY12 DPH UC Davis Medical Center 2.1.5 PC-02 Cesarean Section 116 0 467 0 0 0.2484 0 0.2495 0 0.2431 1016229.57

DY12 DPH UC Davis Medical Center 2.1.6 Prenatal and Postpartum Care: Prenatal Care 796 0 930 0 1 0.855913978 0 0.8561 0 0.8622 508114.78

DY12 DPH UC Davis Medical Center 2.1.6 Prenatal and Postpartum Care: Postpartum Care 445 0 930 0 1 0.478494624 0 0.5126 0 0.5547 508114.78

DY12 DPH UC Davis Medical Center 2.1.7 Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage None 1 95 0 1 None 1 None 1 0 1016229.56

DY12 DPH UC Davis Medical Center 2.1.8 Unexpected Newborn Complications (UNC) 44 0 878 0 1 0.0501 0 0.0579 0 0 1016229.56

DY12 DPH UC Davis Medical Center 2.1.9 OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed)
[Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) 11 0 16 0 1 0 0 NA 0 NA 1016229.56

DY12 DPH UC Davis Medical Center 2.2.1 DHCS All-Cause Readmissions 809 0 6539 0 1 0.1237 0 0.1118 0 0.1318 1016229.57

DY12 DPH UC Davis Medical Center 2.2.2 H-CAHPS: Care Transition Metrics (3) 2898 0 5213 0 0 0.5559 0 0.5687 0 0.5728 1016229.57

DY12 DPH UC Davis Medical Center 2.2.3 Medication Reconciliation 30 days 5087 0 5420 0 1 0.9386 0 0.7528 0 0 1016229.57

DY12 DPH UC Davis Medical Center 2.2.4 Reconciled Medication List Received by Discharged Patients 7499 0 7794 0 1 0.9622 0 0.959 0 0 1016229.56

DY12 DPH UC Davis Medical Center 2.2.5 Timely Transmission of Transition Record 6351 0 6713 0 1 0.9461 0 0.959 0 0 1016229.56

DY12 DPH UC Davis Medical Center 2.3.1 Care Coordinator Assignment 325 0 1064 0 1 0.3055 0 0.2196 0 0 1016229.57

DY12 DPH UC Davis Medical Center 2.3.2 Medication Reconciliation 30 days 1568 0 1629 0 1 0.9626 0 0.7694 0 0 1016229.57

DY12 DPH UC Davis Medical Center 2.3.3 Prevention Quality Overall Composite #90 237 0 1073 0 1 0.2209 0 0.2955 0 0 1016229.56

DY12 DPH UC Davis Medical Center 2.3.4 Timely Transmission of Transition Record 1912 0 2056 0 1 0.93 0 0.9547 0 0 1016229.56

DY12 DPH UC Davis Medical Center 2.6.1 Alcohol and Drug Misuse (SBIRT) 0 0 6431 0 1 0 0 0 0 0 1016229.57

DY12 DPH UC Davis Medical Center 2.6.2 Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen 629 0 2581 0 1 0.2437 0 0.1362 0 0 1016229.57

DY12 DPH UC Davis Medical Center 2.6.3 Patients with chronic pain on long term opioid therapy checked in PDMPs 65 0 357 0 1 0.1821 0 0.1905 0 0 1016229.56

DY12 DPH UC Davis Medical Center 2.6.4 Screening for Clinical Depression and follow-up 312 0 4377 0 1 0.0713 0 0.0281 0 0 1016229.56

DY12 DPH UC Davis Medical Center 2.6.5 Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy 5697 0 6459 0 1 0.882 0 0.8723 0 0 1016229.56

DY12 DPH UC Davis Medical Center 3.2.1 Imaging for Routine Headaches (Choosing Wisely) 374 0 2256 0 1 0.1658 0 0.1361 0 0.17 1460830

DY12 DPH UC Davis Medical Center 3.2.2 Appropriate Emergency Department Utilization of CT for Pulmonary Embolism 850 0 1011 0 1 0.8408 0 0.9676 0 0 1460830

DY12 DPH UC Davis Medical Center 3.2.3 Use of Imaging Studies for Low Back Pain 1495 0 1656 0 1 0.9028 0 0.8872 0 0.8286 1460830

DY12 DPH UC Davis Medical Center 3.2.4 Use of Imaging Studies for Low Back Pain (anytime) Variation of HEDIS Use of Imaging Studies for Low Back Pain measures: Appropriate Score 154 0 7050 0 1 0.021843972 0 0 0 NA 730415

DY12 DPH UC Davis Medical Center 3.2.4 Use of Imaging Studies for Low Back Pain (anytime) Variation of HEDIS Use of Imaging Studies for Low Back Pain measures: Inappropriate Score 1715 0 7050 0 1 0.243262411 0 0 0 NA 730415

DY12 DPH UC Irvine Medical Center 1.1.1.a Alcohol and Drug Misuse (SBIRT) 1846 0 15980 0 1 0.1155 0 0.0873 0 0 628044.83

DY12 DPH UC Irvine Medical Center 1.1.2 Care Coordinator Assignment 440 0 4263 0 1 0.1032 0 0.0979 0 0 628044.83

DY12 DPH UC Irvine Medical Center 1.1.3.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 737 0 2325 0 0 0.317 0 0.2756 0 0.2968 628044.83

DY12 DPH UC Irvine Medical Center 1.1.4 Depression Remission at 12 Months (CMS159v4) None 1 30 0 1 None 1 None 1 0 628044.83

DY12 DPH UC Irvine Medical Center 1.1.5.f Screening for Clinical Depression and follow-up 2817 0 15495 0 1 0.1818 0 0.13 0 0 628044.83

DY12 DPH UC Irvine Medical Center 1.1.6.t Tobacco Assessment and Counseling 13563 0 14030 0 1 0.9667 0 0.9462 0 0.9474 628044.82

DY12 DPH UC Irvine Medical Center 1.2.1.a Alcohol and Drug Misuse (SBIRT) 1846 0 15980 0 1 0.1155 0 0.0873 0 0 628044.83

DY12 DPH UC Irvine Medical Center 1.2.11 REAL data completeness 577 0 19268 0 0 0.0299 0 0 0 NA 628044.83

DY12 DPH UC Irvine Medical Center 1.2.12.f Screening for Clinical Depression and follow-up 2814 0 15493 0 1 0.1816 0 0.13 0 0 628044.82

DY12 DPH UC Irvine Medical Center 1.2.13 SO/GI data completeness 1020 0 14779 0 1 0.069 0 0 0 0 628044.82

DY12 DPH UC Irvine Medical Center 1.2.14.t Tobacco Assessment and Counseling 13568 0 14031 0 1 0.967 0 0.9462 0 0.9474 628044.82

DY12 DPH UC Irvine Medical Center 1.2.2 CG-CAHPS: Provider Rating 8321 0 10000 0 1 0.8321 0 0.8274 0 0.7029 628044.83

DY12 DPH UC Irvine Medical Center 1.2.3.c Colorectal Cancer Screening 3534 0 6231 0 1 0.5672 0 0.4931 0 0.5095 628044.83

DY12 DPH UC Irvine Medical Center 1.2.4.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 737 0 2325 0 0 0.317 0 0.2756 0 0.2968 628044.83

DY12 DPH UC Irvine Medical Center 1.2.5.b Controlling Blood Pressure 2907 0 4449 0 0 0.6534 0 0.686 0 0.6877 628044.83

DY12 DPH UC Irvine Medical Center 1.2.6 Documented REAL and/or SO/GI disparity reduction plan: Documented disparity reduction plan? Yes Yes 0 Plan ? 0 1 0 0 NA 0 NA 628044.83

DY12 DPH UC Irvine Medical Center 1.2.7.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 1157 0 1386 0 1 0.8348 0 0.6664 0 0.6926 628044.83

DY12 DPH UC Irvine Medical Center 1.2.8 Prevention Quality Overall Composite #90 971 0 15022 0 1 0.0646 0 0.0269 0 0 628044.83

DY12 DPH UC Irvine Medical Center 1.2.9 Primary Care Redesign metrics stratified by REAL categories and SO/GI: Primary care redesign metrics stratified? Yes Yes 0 Stratified ? 0 1 0 0 NA 0 NA 628044.83

DY12 DPH UC Irvine Medical Center 1.3.1 Closing the referral loop: receipt of specialist report (CMS50v3) 13481 0 14554 0 1 0.9263 0 0.8344 0 0 628044.83

DY12 DPH UC Irvine Medical Center 1.3.2 DHCS All-Cause Readmissions 292 0 1649 0 0 0.1771 0 0.1573 0 0.1548 628044.83

DY12 DPH UC Irvine Medical Center 1.3.3 Influenza Immunization 3493 0 8025 0 1 0.4353 0 0.4347 0 0 628044.83

DY12 DPH UC Irvine Medical Center 1.3.4 Post Procedure ED Visits 2071 0 31610 0 1 0.0655 0 0.0547 0 0 628044.83

DY12 DPH UC Irvine Medical Center 1.3.5 Request for Specialty Care Expertise Turnaround Time 6376 0 22764 0 1 0.2801 0 0.146 0 0 628044.83

DY12 DPH UC Irvine Medical Center 1.3.6 Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters 67 0 33838 0 1 0.002 0 0.0016 0 0 628044.82

DY12 DPH UC Irvine Medical Center 1.3.7 Tobacco Assessment and Counseling 7198 0 7415 0 1 0.9707 0 0.9743 0 0.9579 628044.82

DY12 DPH UC Irvine Medical Center 1.4.1 Abnormal Results Follow-Up: Abnormal Potassium Follow-up 3137 0 3307 0 1 0.948593892 0 0.956 0 NA 209348.28

DY12 DPH UC Irvine Medical Center 1.4.1 Abnormal Results Follow-Up: Abnormal INR Follow-up 425 0 662 0 1 0.641993958 0 0.8004 0 NA 209348.28

DY12 DPH UC Irvine Medical Center 1.4.1 Abnormal Results Follow-Up: Abnormal BIRADS Follow-up 1243 0 1878 0 1 0.661874334 0 0.7331 0 NA 209348.28

DY12 DPH UC Irvine Medical Center 1.4.2 Annual Monitoring for Patients on Persistent Medications 5397 0 6067 0 1 0.8896 0 0.8081 0 0.8446 628044.83

DY12 DPH UC Irvine Medical Center 1.4.3 INR Monitoring for Individuals on Warfarin 412 0 1235 0 1 0.3336 0 0.3712 0 0 628044.82

DY12 DPH UC Irvine Medical Center 2.1.1 Baby Friendly Hospital designation: Discovery Phase Complete Yes Yes 0 Discovery Phase? 0 1 0 0 NA 0 NA 211168.7

DY12 DPH UC Irvine Medical Center 2.1.1 Baby Friendly Hospital designation: Informational Webinar Participation Yes Yes 0 Webinar complete? 0 1 0 0 NA 0 NA 211168.7

DY12 DPH UC Irvine Medical Center 2.1.1 Baby Friendly Hospital designation: BFUSA Designation No No 0 BFUSA Cert? 0 0 0 0 NA 0 NA 211168.7

DY12 DPH UC Irvine Medical Center 2.1.2 Exclusive Breast Milk Feeding (PC-05) 129 0 209 0 0 0.6172 0 0.6522 0 0.6668 633506.09

DY12 DPH UC Irvine Medical Center 2.1.3 OB Hemorrhage: Massive Transfusion 11 0 1237 0 1 0.0089 0 None 1 0 633506.09

DY12 DPH UC Irvine Medical Center 2.1.4 OB Hemorrhage: Total Products Transfused 199 0 1237 0 1 0.1609 0 0.1343 0 0 633506.09

DY12 DPH UC Irvine Medical Center 2.1.5 PC-02 Cesarean Section 89 0 365 0 0.5 0.2438 0 0.2483 0 0.242 633506.09

DY12 DPH UC Irvine Medical Center 2.1.6 Prenatal and Postpartum Care: Prenatal Care 529 0 1294 0 1 0.408809892 0 0.4607 0 0.7744 316753.05

DY12 DPH UC Irvine Medical Center 2.1.6 Prenatal and Postpartum Care: Postpartum Care 732 0 1294 0 1 0.56568779 0 0.6564 0 0.6632 316753.05

DY12 DPH UC Irvine Medical Center 2.1.7 Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage 31 0 144 0 1 0.2153 0 0.2 0 0 633506.08

DY12 DPH UC Irvine Medical Center 2.1.8 Unexpected Newborn Complications (UNC) 11 0 671 0 1 0.0164 0 0.0396 0 0 633506.08

DY12 DPH UC Irvine Medical Center 2.1.9 OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed)
[Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) 15 0 16 0 1 0 0 NA 0 NA 633506.08

DY12 DPH UC Irvine Medical Center 2.2.1 DHCS All-Cause Readmissions 310 0 1884 0 0 0.1645 0 0.148 0 0.1464 633506.09

DY12 DPH UC Irvine Medical Center 2.2.2 H-CAHPS: Care Transition Metrics (3) 9426 0 10000 0 1 0.9426 0 0.9443 0 0.61 633506.09

DY12 DPH UC Irvine Medical Center 2.2.3 Medication Reconciliation 30 days 1631 0 1875 0 1 0.8699 0 0.8571 0 0 633506.09

DY12 DPH UC Irvine Medical Center 2.2.4 Reconciled Medication List Received by Discharged Patients 1936 0 3227 0 1 0.5999 0 0.6131 0 0 633506.08

DY12 DPH UC Irvine Medical Center 2.2.5 Timely Transmission of Transition Record 2727 0 2763 0 1 0.987 0 0.9495 0 0 633506.08

DY12 DPH UC Irvine Medical Center 2.3.1 Care Coordinator Assignment 447 0 14674 0 1 0.0305 0 0.1018 0 0 633506.09

DY12 DPH UC Irvine Medical Center 2.3.2 Medication Reconciliation 30 days 1328 0 1505 0 1 0.8824 0 0.873 0 0 633506.09

DY12 DPH UC Irvine Medical Center 2.3.3 Prevention Quality Overall Composite #90 842 0 11467 0 1 0.0734 0 0.0306 0 0 633506.09

DY12 DPH UC Irvine Medical Center 2.3.4 Timely Transmission of Transition Record 2123 0 2151 0 1 0.987 0 0.9472 0 0 633506.09

DY12 DPH UC Irvine Medical Center 2.6.1 Alcohol and Drug Misuse (SBIRT) None 1 89 0 1 None 1 None 1 0 633506.09

DY12 DPH UC Irvine Medical Center 2.6.2 Assessment and Management of Chronic Pain: Patients with chronic pain prescribed an opioid who have an opioid agreement form and an annual urine toxicology screen None 1 87 0 1 None 1 0 0 0 633506.09

DY12 DPH UC Irvine Medical Center 2.6.3 Patients with chronic pain on long term opioid therapy checked in PDMPs 13 0 87 0 1 0.1494 0 0 0 0 633506.09

DY12 DPH UC Irvine Medical Center 2.6.4 Screening for Clinical Depression and follow-up 12 0 88 0 1 0.1364 0 None 1 0 633506.08

DY12 DPH UC Irvine Medical Center 2.6.5 Treatment of Chronic Non-Malignant Pain with Multi-Modal Therapy 78 0 88 0 1 0.8864 0 0.9455 0 0 633506.08

DY12 DPH UC Irvine Medical Center 3.1.1 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis 60 0 146 0 1 0.411 0 0.9697 0 0.4038 819598.5

DY12 DPH UC Irvine Medical Center 3.1.2 Avoidance of Antibiotic Treatment with Low Colony Urinary Cultures 0 0 0 0 0 0 0 0.0963 0 NA 364266

DY12 DPH UC Irvine Medical Center 3.1.3 National Healthcare Safety Network (NHSN) Antimicrobial Use Measure 35237 0 140423 0 1 0.2509 0 0.2139 0 0 819598.5

DY12 DPH UC Irvine Medical Center 3.1.4 Peri-operative Prophylactic Antibiotics Administered after Surgical Closure 1758 0 5168 0 1 0.3402 0 0.2799 0 0 819598.5

DY12 DPH UC Irvine Medical Center 3.1.5 Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR No 8900 0 10000 0 1 0.89 0 0 0 0 819598.5

DY12 DPH UC Los Angeles Medical Center 1.1.1.a Alcohol and Drug Misuse (SBIRT) 1661 0 116356 0 1 0.0143 0 0.0432 0 0 450365.52

DY12 DPH UC Los Angeles Medical Center 1.1.2 Care Coordinator Assignment 1527 0 1564 0 1 0.9763 0 0.4206 0 0 450365.52

DY12 DPH UC Los Angeles Medical Center 1.1.3.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 360 0 2576 0 1 0.1398 0 0.1777 0 0.2968 450365.52

DY12 DPH UC Los Angeles Medical Center 1.1.4 Depression Remission at 12 Months (CMS159v4) 12 0 746 0 1 0.0161 0 None 1 0 450365.52

DY12 DPH UC Los Angeles Medical Center 1.1.5.f Screening for Clinical Depression and follow-up 16587 0 86649 0 1 0.1914 0 0.156 0 0 450365.51

DY12 DPH UC Los Angeles Medical Center 1.1.6.t Tobacco Assessment and Counseling 106731 0 110683 0 1 0.9643 0 0.9543 0 0.9547 450365.51

DY12 DPH UC Los Angeles Medical Center 1.2.1.a Alcohol and Drug Misuse (SBIRT) 1661 0 116356 0 1 0.0143 0 0.0432 0 0 450365.52

DY12 DPH UC Los Angeles Medical Center 1.2.11 REAL data completeness 0 0 131049 0 0 0 0 0.9143 0 NA 450365.51

DY12 DPH UC Los Angeles Medical Center 1.2.12.f Screening for Clinical Depression and follow-up 16587 0 86649 0 1 0.1914 0 0.1559 0 0 450365.51

DY12 DPH UC Los Angeles Medical Center 1.2.13 SO/GI data completeness 0 0 131049 0 1 0 0 0 0 0 450365.51

DY12 DPH UC Los Angeles Medical Center 1.2.14.t Tobacco Assessment and Counseling 106731 0 110683 0 1 0.9643 0 0.9543 0 0.9547 450365.51

DY12 DPH UC Los Angeles Medical Center 1.2.2 CG-CAHPS: Provider Rating 369 0 478 0 1 0.772 0 0.7727 0 0.7029 450365.52

DY12 DPH UC Los Angeles Medical Center 1.2.3.c Colorectal Cancer Screening 26965 0 47443 0 1 0.5684 0 0.5096 0 0.5244 450365.52

DY12 DPH UC Los Angeles Medical Center 1.2.4.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 360 0 2576 0 1 0.1398 0 0.1777 0 0.2968 450365.52

DY12 DPH UC Los Angeles Medical Center 1.2.5.b Controlling Blood Pressure 18262 0 25578 0 1 0.714 0 0.6829 0 0.6849 450365.52

DY12 DPH UC Los Angeles Medical Center 1.2.6 Documented REAL and/or SO/GI disparity reduction plan: Documented disparity reduction plan? Yes Yes 0 Plan ? 0 1 0 0 NA 0 NA 450365.52

DY12 DPH UC Los Angeles Medical Center 1.2.7.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 5541 0 7034 0 0 0.7877 0 0.7909 0 0.8047 450365.52

DY12 DPH UC Los Angeles Medical Center 1.2.8 Prevention Quality Overall Composite #90 670 0 112092 0 1 0.006 0 0.0068 0 0 450365.52

DY12 DPH UC Los Angeles Medical Center 1.2.9 Primary Care Redesign metrics stratified by REAL categories and SO/GI: Primary care redesign metrics stratified? Yes Yes 0 Stratified ? 0 1 0 0 NA 0 NA 450365.52

DY12 DPH UC Los Angeles Medical Center 1.3.1 Closing the referral loop: receipt of specialist report (CMS50v3) 38796 0 39303 0 1 0.9871 0 0.9847 0 0 450365.52

DY12 DPH UC Los Angeles Medical Center 1.3.2 DHCS All-Cause Readmissions 805 0 4549 0 0 0.177 0 0.174 0 0.1698 450365.52

DY12 DPH UC Los Angeles Medical Center 1.3.3 Influenza Immunization 55589 0 124541 0 1 0.4464 0 0.4987 0 0 450365.52

DY12 DPH UC Los Angeles Medical Center 1.3.4 Post Procedure ED Visits 275 0 19569 0 1 0.0141 0 0.0111 0 0 450365.52

DY12 DPH UC Los Angeles Medical Center 1.3.5 Request for Specialty Care Expertise Turnaround Time 7038 0 60781 0 1 0.1158 0 0.1268 0 0 450365.52

DY12 DPH UC Los Angeles Medical Center 1.3.6 Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters 1048 0 19733 0 1 0.0531 0 0.0118 0 0 450365.51

DY12 DPH UC Los Angeles Medical Center 1.3.7 Tobacco Assessment and Counseling 64197 0 66084 0 1 0.9714 0 0.9672 0 0.9579 450365.51

DY12 DPH UC Los Angeles Medical Center 1.4.1 Abnormal Results Follow-Up: Abnormal Potassium Follow-up 64523 0 70199 0 1 0.919144147 0 0.9226 0 NA 150121.84

DY12 DPH UC Los Angeles Medical Center 1.4.1 Abnormal Results Follow-Up: Abnormal INR Follow-up 20308 0 21618 0 1 0.93940235 0 0.9164 0 NA 150121.84

DY12 DPH UC Los Angeles Medical Center 1.4.1 Abnormal Results Follow-Up: Abnormal BIRADS Follow-up 9511 0 12705 0 1 0.748602912 0 0.7778 0 NA 150121.84

DY12 DPH UC Los Angeles Medical Center 1.4.2 Annual Monitoring for Patients on Persistent Medications 33239 0 37181 0 1 0.894 0 0.8859 0 0.8889 450365.52

DY12 DPH UC Los Angeles Medical Center 1.4.3 INR Monitoring for Individuals on Warfarin 1100 0 1824 0 1 0.6031 0 0.5104 0 0 450365.52

DY12 DPH UC Los Angeles Medical Center 2.1.1 Baby Friendly Hospital designation: Discovery Phase Complete Yes Yes 0 Discovery Phase? 0 1 0 0 NA 0 NA 145117.78

DY12 DPH UC Los Angeles Medical Center 2.1.1 Baby Friendly Hospital designation: Informational Webinar Participation Yes Yes 0 Webinar complete? 0 1 0 0 NA 0 NA 145117.78

DY12 DPH UC Los Angeles Medical Center 2.1.1 Baby Friendly Hospital designation: BFUSA Designation No No 0 BFUSA Cert? 0 0 0 0 NA 0 NA 145117.78

DY12 DPH UC Los Angeles Medical Center 2.1.2 Exclusive Breast Milk Feeding (PC-05) 261 0 357 0 0 0.7311 0 0.76 0 0.7638 435353.34

DY12 DPH UC Los Angeles Medical Center 2.1.3 OB Hemorrhage: Massive Transfusion None 1 433 0 1 None 1 None 1 0 435353.34

DY12 DPH UC Los Angeles Medical Center 2.1.4 OB Hemorrhage: Total Products Transfused 36 0 433 0 1 0.0831 0 0.0587 0 0 435353.33

DY12 DPH UC Los Angeles Medical Center 2.1.5 PC-02 Cesarean Section 54 0 216 0 0 0.25 0 0.2482 0 0.2419 435353.33

DY12 DPH UC Los Angeles Medical Center 2.1.6 Prenatal and Postpartum Care: Prenatal Care 2278 0 2329 0 1 0.97810219 0 0.6791 0 0.7744 217676.67

DY12 DPH UC Los Angeles Medical Center 2.1.6 Prenatal and Postpartum Care: Postpartum Care 1798 0 2329 0 1 0.772005152 0 0.8033 0 0.7243 217676.67

DY12 DPH UC Los Angeles Medical Center 2.1.7 Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage None 1 31 0 1 None 1 0.2052 0 0 435353.33

DY12 DPH UC Los Angeles Medical Center 2.1.8 Unexpected Newborn Complications (UNC) 16 0 339 0 1 0.0472 0 0.0337 0 0 435353.33

DY12 DPH UC Los Angeles Medical Center 2.1.9 OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed)
[Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) 32 0 32 0 1 0 0 NA 0 NA 435353.33

DY12 DPH UC Los Angeles Medical Center 2.2.1 DHCS All-Cause Readmissions 969 0 5559 0 0.5 0.1743 0 0.1768 0 0.1723 435353.34

DY12 DPH UC Los Angeles Medical Center 2.2.2 H-CAHPS: Care Transition Metrics (3) 5793 0 10000 0 0 0.5793 0 0.6044 0 0.605 435353.34

DY12 DPH UC Los Angeles Medical Center 2.2.3 Medication Reconciliation 30 days 773 0 799 0 1 0.9675 0 1 0 0 435353.33

DY12 DPH UC Los Angeles Medical Center 2.2.4 Reconciled Medication List Received by Discharged Patients 10336 0 10540 0 1 0.9806 0 0.9388 0 0 435353.33

DY12 DPH UC Los Angeles Medical Center 2.2.5 Timely Transmission of Transition Record 9084 0 9441 0 1 0.9622 0 0.966 0 0 435353.33

DY12 DPH UC Los Angeles Medical Center 2.3.1 Care Coordinator Assignment 8107 0 8193 0 1 0.9895 0 0.4733 0 0 435353.34

DY12 DPH UC Los Angeles Medical Center 2.3.2 Medication Reconciliation 30 days 451 0 455 0 1 0.9912 0 1 0 0 435353.33

DY12 DPH UC Los Angeles Medical Center 2.3.3 Prevention Quality Overall Composite #90 521 0 15904 0 1 0.0328 0 0.039 0 0 435353.33

DY12 DPH UC Los Angeles Medical Center 2.3.4 Timely Transmission of Transition Record 4285 0 4398 0 1 0.9743 0 0.971 0 0 435353.33

DY12 DPH UC Los Angeles Medical Center 2.7.1 Advance Care Plan 7797 0 33670 0 1 0.2316 0 0.401 0 0 435353.34

DY12 DPH UC Los Angeles Medical Center 2.7.2 Ambulatory Palliative Care Team Established: Ambulatory Palliative Care Team Established? Yes Yes 0 Team Established? 0 1 0 0 NA 0 NA 435353.34

DY12 DPH UC Los Angeles Medical Center 2.7.3 MWM #8: Treatment Preferences (documentation) Inpatient 198 0 242 0 1 0.8182 0 0.5612 0 0 435353.33

DY12 DPH UC Los Angeles Medical Center 2.7.4 MWM #8: Treatment Preferences (documentation) Outpatient 27 0 32 0 1 0.8438 0 None 4 0 435353.33

DY12 DPH UC Los Angeles Medical Center 2.7.5 Palliative Care Service Offered at Time of Diagnosis of Advanced Illness 30 0 698 0 1 0.043 0 0 0 0 435353.33

DY12 DPH UC Los Angeles Medical Center 2.7.6 Proportion Admitted to Hospice for Less Than 3 Days None 1 43 0 1 None 1 0.3681 0 0 435353.33

DY12 DPH UC Los Angeles Medical Center 3.3.1 Adherence to Medications: Rate 1 122 0 228 0 1 0.535087719 0 0.4795 0 NA 870706.67

DY12 DPH UC Los Angeles Medical Center 3.3.3 High-Cost Pharmaceuticals Ordering Protocols: Rate 1 0 0 98 0 1 0 0 0 0 NA 870706.66

DY12 DPH UC Los Angeles Medical Center 3.3.4 Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 1 1296 0 1458 0 1 0.888888889 0 0 0 NA 870706.67

DY12 DPH UC San Diego Medical Center 1.1.1.a Alcohol and Drug Misuse (SBIRT) None 1 36292 0 1 None 1 0 0 0 584056.67

DY12 DPH UC San Diego Medical Center 1.1.2 Care Coordinator Assignment 46 0 490 0 1 0.0939 0 0.0191 0 0 584056.67

DY12 DPH UC San Diego Medical Center 1.1.3.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 485 0 3314 0 1 0.1463 0 0.1445 0 0.2968 584056.67

DY12 DPH UC San Diego Medical Center 1.1.4 Depression Remission at 12 Months (CMS159v4) 13 0 771 0 1 0.0169 0 0.2147 0 0 584056.67

DY12 DPH UC San Diego Medical Center 1.1.5.f Screening for Clinical Depression and follow-up 9061 0 25340 0 1 0.3576 0 0.3966 0 0 584056.66

DY12 DPH UC San Diego Medical Center 1.1.6.t Tobacco Assessment and Counseling 34415 0 35473 0 1 0.9702 0 0.9543 0 0.9547 584056.66

DY12 DPH UC San Diego Medical Center 1.2.1.a Alcohol and Drug Misuse (SBIRT) None 1 36292 0 1 None 1 0 0 0 584056.67

DY12 DPH UC San Diego Medical Center 1.2.11 REAL data completeness 9672 0 35696 0 1 0.271 0 0.0566 0 NA 584056.66

DY12 DPH UC San Diego Medical Center 1.2.12.f Screening for Clinical Depression and follow-up 9061 0 25340 0 1 0.3576 0 0.3966 0 0 584056.66

DY12 DPH UC San Diego Medical Center 1.2.13 SO/GI data completeness 53 0 34907 0 1 0.0015 0 0 0 0 584056.66

DY12 DPH UC San Diego Medical Center 1.2.14.t Tobacco Assessment and Counseling 34415 0 35473 0 1 0.9702 0 0.9543 0 0.9547 584056.66

DY12 DPH UC San Diego Medical Center 1.2.2 CG-CAHPS: Provider Rating 7309 0 8365 0 1 0.8738 0 0.8686 0 0.7029 584056.67

DY12 DPH UC San Diego Medical Center 1.2.3.c Colorectal Cancer Screening 13941 0 17769 0 1 0.7846 0 0.7847 0 0.6571 584056.67

DY12 DPH UC San Diego Medical Center 1.2.4.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 485 0 3314 0 1 0.1463 0 0.1445 0 0.2968 584056.67

DY12 DPH UC San Diego Medical Center 1.2.5.b Controlling Blood Pressure 6837 0 9197 0 1 0.7434 0 0.7258 0 0.7032 584056.67

DY12 DPH UC San Diego Medical Center 1.2.6 Documented REAL and/or SO/GI disparity reduction plan: Documented disparity reduction plan? Yes Yes 0 Plan ? 0 1 0 0 NA 0 NA 584056.67

DY12 DPH UC San Diego Medical Center 1.2.7.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 3011 0 3641 0 0 0.827 0 0.8419 0 0.8506 584056.67

DY12 DPH UC San Diego Medical Center 1.2.8 Prevention Quality Overall Composite #90 921 0 38482 0 1 0.0239 0 0.0355 0 0 584056.67

DY12 DPH UC San Diego Medical Center 1.2.9 Primary Care Redesign metrics stratified by REAL categories and SO/GI: Primary care redesign metrics stratified? Yes Yes 0 Stratified ? 0 1 0 0 NA 0 NA 584056.67

DY12 DPH UC San Diego Medical Center 1.3.1 Closing the referral loop: receipt of specialist report (CMS50v3) 34270 0 47414 0 1 0.7228 0 0.753 0 0 584056.67

DY12 DPH UC San Diego Medical Center 1.3.2 DHCS All-Cause Readmissions 294 0 1815 0 0 0.162 0 0.1484 0 0.1467 584056.67

DY12 DPH UC San Diego Medical Center 1.3.3 Influenza Immunization 11546 0 16601 0 1 0.6955 0 0.7101 0 0 584056.67

DY12 DPH UC San Diego Medical Center 1.3.4 Post Procedure ED Visits 2172 0 121784 0 1 0.0178 0 0.0295 0 0 584056.67

DY12 DPH UC San Diego Medical Center 1.3.5 Request for Specialty Care Expertise Turnaround Time 954 0 168035 0 1 0.0057 0 0.0064 0 0 584056.67

DY12 DPH UC San Diego Medical Center 1.3.6 Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters 2013 0 168035 0 1 0.012 0 0.0021 0 0 584056.66

DY12 DPH UC San Diego Medical Center 1.3.7 Tobacco Assessment and Counseling 22763 0 23323 0 1 0.976 0 0.962 0 0.9579 584056.66

DY12 DPH UC San Diego Medical Center 1.5.1.b Controlling Blood Pressure 6837 0 9197 0 1 0.7434 0 0.7258 0 0.7032 584056.67

DY12 DPH UC San Diego Medical Center 1.5.2.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 3011 0 3641 0 0 0.827 0 0.8419 0 0.8506 584056.67

DY12 DPH UC San Diego Medical Center 1.5.3 PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 8884 0 18682 0 1 0.4755 0 0.5031 0 0 584056.66

DY12 DPH UC San Diego Medical Center 1.5.4.t Tobacco Assessment and Counseling 34415 0 35473 0 1 0.9702 0 0.9543 0 0.9547 584056.66

DY12 DPH UC San Diego Medical Center 2.1.1 Baby Friendly Hospital designation: BFUSA Designation Yes Yes 0 BFUSA Cert? 0 1 0 0 NA 0 NA 584056.67

DY12 DPH UC San Diego Medical Center 2.1.2 Exclusive Breast Milk Feeding (PC-05) 1146 0 1786 0 0 0.6417 0 0.6786 0 0.6905 584056.67

DY12 DPH UC San Diego Medical Center 2.1.3 OB Hemorrhage: Massive Transfusion None 1 2454 0 1 None 1 None 1 0 584056.67

DY12 DPH UC San Diego Medical Center 2.1.4 OB Hemorrhage: Total Products Transfused 54 0 2454 0 1 0.022 0 0.0844 0 0 584056.67

DY12 DPH UC San Diego Medical Center 2.1.5 PC-02 Cesarean Section 221 0 931 0 1 0.2374 0 0.251 0 0.2444 584056.67

DY12 DPH UC San Diego Medical Center 2.1.6 Prenatal and Postpartum Care: Prenatal Care 1676 0 1693 0 1 0.989958653 0 0.4803 0 0.7744 292028.34

DY12 DPH UC San Diego Medical Center 2.1.6 Prenatal and Postpartum Care: Postpartum Care 1250 0 1693 0 1 0.738334318 0 0.7017 0 0.704 292028.34

DY12 DPH UC San Diego Medical Center 2.1.7 Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage 67 0 296 0 1 0.2264 0 0.1917 0 0 584056.66

DY12 DPH UC San Diego Medical Center 2.1.8 Unexpected Newborn Complications (UNC) 115 0 1294 0 1 0.0889 0 0.093 0 0 584056.66

DY12 DPH UC San Diego Medical Center 2.1.9 OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed)
[Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) 16 0 16 0 1 0 0 NA 0 NA 584056.66

DY12 DPH UC San Diego Medical Center 2.2.1 DHCS All-Cause Readmissions 307 0 1924 0 0 0.1596 0 0.1453 0 0.144 584056.67

DY12 DPH UC San Diego Medical Center 2.2.2 H-CAHPS: Care Transition Metrics (3) 6053 0 10000 0 1 0.6053 0 0.6034 0 0.6041 584056.67

DY12 DPH UC San Diego Medical Center 2.2.3 Medication Reconciliation 30 days 1934 0 3185 0 1 0.6072 0 0.6182 0 0 584056.67

DY12 DPH UC San Diego Medical Center 2.2.4 Reconciled Medication List Received by Discharged Patients 2936 0 2964 0 1 0.9906 0 0.982 0 0 584056.66

DY12 DPH UC San Diego Medical Center 2.2.5 Timely Transmission of Transition Record 2795 0 3424 0 1 0.8163 0 0.7189 0 0 584056.66

DY12 DPH UC San Diego Medical Center 2.3.1 Care Coordinator Assignment 60 0 493 0 1 0.1217 0 None 1 0 584056.67

DY12 DPH UC San Diego Medical Center 2.3.2 Medication Reconciliation 30 days 113 0 163 0 1 0.6933 0 0.7159 0 0 584056.67

DY12 DPH UC San Diego Medical Center 2.3.3 Prevention Quality Overall Composite #90 53 0 393 0 1 0.1349 0 0.337 0 0 584056.67

DY12 DPH UC San Diego Medical Center 2.3.4 Timely Transmission of Transition Record 184 0 228 0 1 0.807 0 0.6519 0 0 584056.66

DY12 DPH UC San Diego Medical Center 2.7.1 Advance Care Plan 5576 0 13559 0 1 0.4112 0 0.4622 0 0 584056.67

DY12 DPH UC San Diego Medical Center 2.7.2 Ambulatory Palliative Care Team Established: Ambulatory Palliative Care Team Established? Yes Yes 0 Team Established? 0 1 0 0 NA 0 NA 584056.67

DY12 DPH UC San Diego Medical Center 2.7.3 MWM #8: Treatment Preferences (documentation) Inpatient 98 0 132 0 1 0.7424 0 None 1 0 584056.67

DY12 DPH UC San Diego Medical Center 2.7.4 MWM #8: Treatment Preferences (documentation) Outpatient 23 0 33 0 1 0.697 0 None 1 0 584056.67

DY12 DPH UC San Diego Medical Center 2.7.5 Palliative Care Service Offered at Time of Diagnosis of Advanced Illness 21 0 178 0 1 0.118 0 0 0 0 584056.66

DY12 DPH UC San Diego Medical Center 2.7.6 Proportion Admitted to Hospice for Less Than 3 Days 14 0 113 0 1 0.1239 0 0 0 0 584056.66

DY12 DPH UC San Diego Medical Center 3.1.1 Avoidance of Antibiotic Treatment in Adults with Acute Bronchitis 123 0 197 0 1 0.6244 0 0.5802 0 0.4038 469331.25

DY12 DPH UC San Diego Medical Center 3.1.2 Avoidance of Antibiotic Treatment with Low Colony Urinary Cultures 0 0 0 0 0 0 0 0.1092 0 NA 219021.25

DY12 DPH UC San Diego Medical Center 3.1.3 National Healthcare Safety Network (NHSN) Antimicrobial Use Measure 70027 0 208031 0 1 0.3366 0 0.1774 0 0 469331.25

DY12 DPH UC San Diego Medical Center 3.1.4 Peri-operative Prophylactic Antibiotics Administered after Surgical Closure 3230 0 5253 0 1 0.6149 0 0.126 0 0 469331.25

DY12 DPH UC San Diego Medical Center 3.1.5 Reduction in Hospital Acquired Clostridium Difficile Infections: Please report data as SIR No 9592 0 10000 0 1 0.9592 0 0 0 0 469331.25

DY12 DPH UC San Diego Medical Center 3.3.1 Adherence to Medications: Rate 1 160 0 226 0 1 0.707964602 0 None 1 NA 469331.25

DY12 DPH UC San Diego Medical Center 3.3.3 High-Cost Pharmaceuticals Ordering Protocols: Rate 1 0 0 62 0 1 0 0 0 0 NA 469331.25

DY12 DPH UC San Diego Medical Center 3.3.4 Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 1 980 0 1206 0 1 0.812603648 0 0 0 NA 469331.25

DY12 DPH UC San Francisco Medical Center 1.1.1.a Alcohol and Drug Misuse (SBIRT) 326 0 33749 0 1 0.0097 0 0 0 0 713232.26

DY12 DPH UC San Francisco Medical Center 1.1.2 Care Coordinator Assignment 417 0 449 0 1 0.9287 0 0.0475 0 0 713232.26

DY12 DPH UC San Francisco Medical Center 1.1.3.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 449 0 2374 0 1 0.1891 0 0.1728 0 0.2968 713232.26

DY12 DPH UC San Francisco Medical Center 1.1.4 Depression Remission at 12 Months (CMS159v4) None 1 78 0 1 None 1 None 1 0 713232.26

DY12 DPH UC San Francisco Medical Center 1.1.5.f Screening for Clinical Depression and follow-up 160 0 24607 0 1 0.0065 0 0.1135 0 0 713232.26

DY12 DPH UC San Francisco Medical Center 1.1.6.t Tobacco Assessment and Counseling 29594 0 31112 0 1 0.9512 0 0.875 0 0.8833 713232.25

DY12 DPH UC San Francisco Medical Center 1.2.1.a Alcohol and Drug Misuse (SBIRT) 326 0 33749 0 1 0.0097 0 0 0 0 713232.26

DY12 DPH UC San Francisco Medical Center 1.2.11 REAL data completeness 35254 0 41134 0 1 0.8571 0 0 0 NA 713232.26

DY12 DPH UC San Francisco Medical Center 1.2.12.f Screening for Clinical Depression and follow-up 160 0 24607 0 1 0.0065 0 0.1135 0 0 713232.25

DY12 DPH UC San Francisco Medical Center 1.2.13 SO/GI data completeness 14 0 31636 0 1 0.0004 0 0 0 0 713232.25

DY12 DPH UC San Francisco Medical Center 1.2.14.t Tobacco Assessment and Counseling 29594 0 31112 0 1 0.9512 0 0.875 0 0.8833 713232.25

DY12 DPH UC San Francisco Medical Center 1.2.2 CG-CAHPS: Provider Rating 8343 0 9984 0 1 0.8356 0 0.8029 0 0.7029 713232.26

DY12 DPH UC San Francisco Medical Center 1.2.3.c Colorectal Cancer Screening 9990 0 13114 0 1 0.7618 0 0.7607 0 0.6571 713232.26

DY12 DPH UC San Francisco Medical Center 1.2.4.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 449 0 2374 0 1 0.1891 0 0.1728 0 0.2968 713232.26

DY12 DPH UC San Francisco Medical Center 1.2.5.b Controlling Blood Pressure 4877 0 6640 0 1 0.7345 0 0.7259 0 0.7032 713232.26

DY12 DPH UC San Francisco Medical Center 1.2.6 Documented REAL and/or SO/GI disparity reduction plan: Documented disparity reduction plan? Yes Yes 0 Plan ? 0 1 0 0 NA 0 NA 713232.26

DY12 DPH UC San Francisco Medical Center 1.2.7.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 1934 0 2272 0 1 0.8512 0 0.8326 0 0.8422 713232.26

DY12 DPH UC San Francisco Medical Center 1.2.8 Prevention Quality Overall Composite #90 288 0 33714 0 1 0.0085 0 0.0172 0 0 713232.26

DY12 DPH UC San Francisco Medical Center 1.2.9 Primary Care Redesign metrics stratified by REAL categories and SO/GI: Primary care redesign metrics stratified? Yes Yes 0 Stratified ? 0 1 0 0 NA 0 NA 713232.26

DY12 DPH UC San Francisco Medical Center 1.3.1 Closing the referral loop: receipt of specialist report (CMS50v3) 48085 0 59452 0 1 0.8088 0 0.8596 0 0 713232.26

DY12 DPH UC San Francisco Medical Center 1.3.2 DHCS All-Cause Readmissions 239 0 1815 0 1 0.1317 0 0.1586 0 0.1559 713232.26

DY12 DPH UC San Francisco Medical Center 1.3.3 Influenza Immunization 9831 0 15429 0 1 0.6372 0 0.6412 0 0 713232.26

DY12 DPH UC San Francisco Medical Center 1.3.4 Post Procedure ED Visits 442 0 65809 0 1 0.0067 0 0.0137 0 0 713232.26

DY12 DPH UC San Francisco Medical Center 1.3.5 Request for Specialty Care Expertise Turnaround Time 171362 0 223322 0 1 0.7673 0 0.8997 0 0 713232.26

DY12 DPH UC San Francisco Medical Center 1.3.6 Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters 2916 0 223322 0 1 0.0131 0 0.0322 0 0 713232.26

DY12 DPH UC San Francisco Medical Center 1.3.7 Tobacco Assessment and Counseling 13586 0 13929 0 1 0.9754 0 0.8968 0 0.9029 713232.25

DY12 DPH UC San Francisco Medical Center 1.6.1 BIRADS to Biopsy 135 0 224 0 1 0.6027 0 0.4087 0 0 713232.26

DY12 DPH UC San Francisco Medical Center 1.6.2 Breast Cancer Screening 6087 0 7502 0 1 0.8114 0 0.8061 0 0.7141 713232.26

DY12 DPH UC San Francisco Medical Center 1.6.3 Cervical Cancer Screening 10507 0 13918 0 1 0.7549 0 0.7298 0 0.7299 713232.26

DY12 DPH UC San Francisco Medical Center 1.6.4.c Colorectal Cancer Screening 9990 0 13114 0 1 0.7618 0 0.7607 0 0.6571 713232.26

DY12 DPH UC San Francisco Medical Center 1.6.5 Receipt of appropriate follow-up for abnormal CRC screening 13 0 36 0 1 0.3611 0 0.4894 0 0 713232.25

DY12 DPH UC San Francisco Medical Center 2.1.1 Baby Friendly Hospital designation: Discovery Phase Complete Yes Yes 0 Discovery Phase? 0 1 0 0 NA 0 NA 245668.89

DY12 DPH UC San Francisco Medical Center 2.1.1 Baby Friendly Hospital designation: Informational Webinar Participation Yes Yes 0 Webinar complete? 0 1 0 0 NA 0 NA 245668.89

DY12 DPH UC San Francisco Medical Center 2.1.1 Baby Friendly Hospital designation: BFUSA Designation No No 0 BFUSA Cert? 0 0 0 0 NA 0 NA 245668.89

DY12 DPH UC San Francisco Medical Center 2.1.2 Exclusive Breast Milk Feeding (PC-05) 1464 0 1852 0 0 0.7905 0 0.8361 0 0.798 737006.67

DY12 DPH UC San Francisco Medical Center 2.1.3 OB Hemorrhage: Massive Transfusion 18 0 2411 0 1 0.0075 0 None 1 0 737006.67

DY12 DPH UC San Francisco Medical Center 2.1.4 OB Hemorrhage: Total Products Transfused 381 0 2411 0 1 0.158 0 0.0886 0 0 737006.67

DY12 DPH UC San Francisco Medical Center 2.1.5 PC-02 Cesarean Section 237 0 1235 0 1 0.1919 0 0.2059 0 0.2038 737006.67

DY12 DPH UC San Francisco Medical Center 2.1.6 Prenatal and Postpartum Care: Prenatal Care 2308 0 2326 0 1 0.992261393 0 0.79 0 0.8027 368503.34

DY12 DPH UC San Francisco Medical Center 2.1.6 Prenatal and Postpartum Care: Postpartum Care 1840 0 2326 0 1 0.79105761 0 0.7801 0 0.7243 368503.34

DY12 DPH UC San Francisco Medical Center 2.1.7 Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage 84 0 319 0 1 0.2633 0 0.1809 0 0 737006.66

DY12 DPH UC San Francisco Medical Center 2.1.8 Unexpected Newborn Complications (UNC) 85 0 1755 0 1 0.0484 0 0.0737 0 0 737006.66

DY12 DPH UC San Francisco Medical Center 2.1.9 OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed)
[Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) 12 0 16 0 1 0 0 NA 0 NA 737006.66

DY12 DPH UC San Francisco Medical Center 2.2.1 DHCS All-Cause Readmissions 253 0 1940 0 1 0.1304 0 0.1494 0 0.1476 737006.67

DY12 DPH UC San Francisco Medical Center 2.2.2 H-CAHPS: Care Transition Metrics (3) 6156 0 10000 0 1 0.6156 0 0.62 0 0.61 737006.67

DY12 DPH UC San Francisco Medical Center 2.2.3 Medication Reconciliation 30 days 1295 0 1447 0 1 0.895 0 0.7806 0 0 737006.67

DY12 DPH UC San Francisco Medical Center 2.2.4 Reconciled Medication List Received by Discharged Patients 3544 0 3605 0 1 0.9831 0 0 0 0 737006.66

DY12 DPH UC San Francisco Medical Center 2.2.5 Timely Transmission of Transition Record 4266 0 4549 0 1 0.9378 0 0.9796 0 0 737006.66

DY12 DPH UC San Francisco Medical Center 2.3.1 Care Coordinator Assignment 84 0 90 0 1 0.9333 0 0.1395 0 0 737006.67

DY12 DPH UC San Francisco Medical Center 2.3.2 Medication Reconciliation 30 days 120 0 133 0 1 0.9023 0 0.7485 0 0 737006.67

DY12 DPH UC San Francisco Medical Center 2.3.3 Prevention Quality Overall Composite #90 52 0 90 0 1 0.5778 0 0.7326 0 0 737006.67

DY12 DPH UC San Francisco Medical Center 2.3.4 Timely Transmission of Transition Record 284 0 301 0 1 0.9435 0 0.9908 0 0 737006.66

DY12 DPH UC San Francisco Medical Center 2.7.1 Advance Care Plan 8163 0 9288 0 1 0.8789 0 0.3402 0 0 737006.67

DY12 DPH UC San Francisco Medical Center 2.7.2 Ambulatory Palliative Care Team Established: Ambulatory Palliative Care Team Established? Yes Yes 0 Team Established? 0 1 0 0 NA 0 NA 737006.67

DY12 DPH UC San Francisco Medical Center 2.7.3 MWM #8: Treatment Preferences (documentation) Inpatient 87 0 102 0 1 0.8529 0 0.6563 0 0 737006.67

DY12 DPH UC San Francisco Medical Center 2.7.4 MWM #8: Treatment Preferences (documentation) Outpatient 106 0 129 0 1 0.8217 0 0.8194 0 0 737006.67

DY12 DPH UC San Francisco Medical Center 2.7.5 Palliative Care Service Offered at Time of Diagnosis of Advanced Illness 26 0 136 0 1 0.1912 0 0.1462 0 0 737006.66

DY12 DPH UC San Francisco Medical Center 2.7.6 Proportion Admitted to Hospice for Less Than 3 Days None 1 98 0 1 None 1 None 1 0 737006.66

DY12 DPH UC San Francisco Medical Center 3.3.1 Adherence to Medications: Rate 1 58 0 67 0 1 0.865671642 0 0.5333 0 NA 1842516.67

DY12 DPH UC San Francisco Medical Center 3.3.3 High-Cost Pharmaceuticals Ordering Protocols: Rate 1 None 1 None 1 0 None 1 0 0 NA 737006.66

DY12 DPH UC San Francisco Medical Center 3.3.4 Documentation of Medication Reconciliation in the Medical Record for Patients Taking High Cost Pharmaceuticals: Rate 1 50 0 81 0 1 0.617283951 0 0 0 NA 1842516.67

DY12 DPH Ventura County Medical Center 1.1.1.a Alcohol and Drug Misuse (SBIRT) 76 0 45280 0 1 0.0017 0 0.0004 0 0 1572340

DY12 DPH Ventura County Medical Center 1.1.2 Care Coordinator Assignment 437 0 890 0 1 0.491 0 0.2199 0 0 1572340

DY12 DPH Ventura County Medical Center 1.1.3.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 1188 0 6144 0 1 0.1934 0 0.2135 0 0.2968 1572340

DY12 DPH Ventura County Medical Center 1.1.4 Depression Remission at 12 Months (CMS159v4) None 1 115 0 1 None 1 None 1 0 1572340

DY12 DPH Ventura County Medical Center 1.1.5.f Screening for Clinical Depression and follow-up 13025 0 36874 0 1 0.3532 0 0.033 0 0 1572340

DY12 DPH Ventura County Medical Center 1.1.6.t Tobacco Assessment and Counseling 33439 0 35810 0 1 0.9338 0 0.5747 0 0.7237 1572340

DY12 DPH Ventura County Medical Center 1.2.1.a Alcohol and Drug Misuse (SBIRT) 76 0 45280 0 1 0.0017 0 0.0004 0 0 1572340

DY12 DPH Ventura County Medical Center 1.2.11 REAL data completeness 59647 0 63126 0 1 0.9449 0 0 0 NA 1572340

DY12 DPH Ventura County Medical Center 1.2.12.f Screening for Clinical Depression and follow-up 13025 0 36874 0 1 0.3532 0 0.033 0 0 1572340

DY12 DPH Ventura County Medical Center 1.2.13 SO/GI data completeness 10328 0 38476 0 1 0.2684 0 0 0 0 1572340

DY12 DPH Ventura County Medical Center 1.2.14.t Tobacco Assessment and Counseling 33439 0 35810 0 1 0.9338 0 0.5747 0 0.7237 1572340

DY12 DPH Ventura County Medical Center 1.2.2 CG-CAHPS: Provider Rating 38394 0 47694 0 1 0.805 0 0.7825 0 0.7029 1572340

DY12 DPH Ventura County Medical Center 1.2.3.c Colorectal Cancer Screening 6809 0 15498 0 1 0.4393 0 0.3145 0 0.3488 1572340

DY12 DPH Ventura County Medical Center 1.2.4.d Comprehensive Diabetes Care: HbA1c Poor Control (>9.0%) 1188 0 6144 0 1 0.1934 0 0.2135 0 0.2968 1572340

DY12 DPH Ventura County Medical Center 1.2.5.b Controlling Blood Pressure 8716 0 13362 0 1 0.6523 0 0.6365 0 0.6432 1572340

DY12 DPH Ventura County Medical Center 1.2.6 Documented REAL and/or SO/GI disparity reduction plan: Documented disparity reduction plan? Yes Yes 0 Plan ? 0 1 0 0 NA 0 NA 1572340

DY12 DPH Ventura County Medical Center 1.2.7.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 741 0 862 0 1 0.8596 0 0.5749 0 0.6808 1572340

DY12 DPH Ventura County Medical Center 1.2.8 Prevention Quality Overall Composite #90 13025 0 54374 0 1 0.2395 0 0.0034 0 0 1572340

DY12 DPH Ventura County Medical Center 1.2.9 Primary Care Redesign metrics stratified by REAL categories and SO/GI: Primary care redesign metrics stratified? Yes Yes 0 Stratified ? 0 1 0 0 NA 0 NA 1572340

DY12 DPH Ventura County Medical Center 1.3.1 Closing the referral loop: receipt of specialist report (CMS50v3) 3223 0 18998 0 1 0.1696 0 1 0 0 1572340

DY12 DPH Ventura County Medical Center 1.3.2 DHCS All-Cause Readmissions 141 0 1569 0 1 0.0899 0 0.14 0 0.1392 1572340

DY12 DPH Ventura County Medical Center 1.3.3 Influenza Immunization 5645 0 12124 0 1 0.4656 0 0.3772 0 0 1572340

DY12 DPH Ventura County Medical Center 1.3.4 Post Procedure ED Visits 347 0 29285 0 1 0.0118 0 0.0221 0 0 1572340

DY12 DPH Ventura County Medical Center 1.3.5 Request for Specialty Care Expertise Turnaround Time 14593 0 25204 0 1 0.579 0 0.3388 0 0 1572340

DY12 DPH Ventura County Medical Center 1.3.6 Specialty Care Touches: Specialty Expertise Requests Managed Via Non-Face to Face Specialty Encounters 17 0 15548 0 1 0.0011 0 0 0 0 1572340

DY12 DPH Ventura County Medical Center 1.3.7 Tobacco Assessment and Counseling 9926 0 10355 0 1 0.9586 0 0.5868 0 0.7237 1572340

DY12 DPH Ventura County Medical Center 1.5.1.b Controlling Blood Pressure 8716 0 13362 0 1 0.6523 0 0.6365 0 0.6432 1572340

DY12 DPH Ventura County Medical Center 1.5.2.i Ischemic Vascular Disease (IVD): Use of Aspirin or Another Antithrombotic 741 0 862 0 1 0.8596 0 0.5749 0 0.6808 1572340

DY12 DPH Ventura County Medical Center 1.5.3 PQRS # 317 Preventative Care and Screening: Screening for High Blood Pressure and Follow-Up Documented 11738 0 24858 0 1 0.4722 0 0.1634 0 0 1572340

DY12 DPH Ventura County Medical Center 1.5.4.t Tobacco Assessment and Counseling 33439 0 35810 0 1 0.9338 0 0.5747 0 0.7237 1572340

DY12 DPH Ventura County Medical Center 2.1.1 Baby Friendly Hospital designation: BFUSA Designation Yes Yes 0 BFUSA Cert? 0 1 0 0 NA 0 NA 1509446.4

DY12 DPH Ventura County Medical Center 2.1.2 Exclusive Breast Milk Feeding (PC-05) 1131 0 1368 0 1 0.8268 0 0.8809 0 0.798 1509446.4

DY12 DPH Ventura County Medical Center 2.1.3 OB Hemorrhage: Massive Transfusion None 1 1548 0 1 None 1 None 1 0 1509446.4

DY12 DPH Ventura County Medical Center 2.1.4 OB Hemorrhage: Total Products Transfused 46 0 1548 0 1 0.0297 0 0.0416 0 0 1509446.4

DY12 DPH Ventura County Medical Center 2.1.5 PC-02 Cesarean Section 106 0 432 0 0 0.2454 0 0.2112 0 0.2086 1509446.4

DY12 DPH Ventura County Medical Center 2.1.6 Prenatal and Postpartum Care: Prenatal Care 1140 0 1445 0 1 0.788927336 0 0.7198 0 0.7744 754723.2

DY12 DPH Ventura County Medical Center 2.1.6 Prenatal and Postpartum Care: Postpartum Care 1074 0 1445 0 1 0.743252595 0 0.7198 0 0.7203 754723.2

DY12 DPH Ventura County Medical Center 2.1.7 Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage 30 0 142 0 1 0.2113 0 0.2197 0 0 1509446.4

DY12 DPH Ventura County Medical Center 2.1.8 Unexpected Newborn Complications (UNC) 68 0 1278 0 1 0.0532 0 0.0467 0 0 1509446.4

DY12 DPH Ventura County Medical Center 2.1.9 OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed)
[Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) 22 0 32 0 1 0 0 NA 0 NA 1509446.4

DY12 DPH Ventura County Medical Center 2.2.1 DHCS All-Cause Readmissions 165 0 1804 0 1 0.0915 0 0.1138 0 0.1318 1509446.4

DY12 DPH Ventura County Medical Center 2.2.2 H-CAHPS: Care Transition Metrics (3) 5004 0 10000 0 0 0.5004 0 0.5171 0 0.5264 1509446.4

DY12 DPH Ventura County Medical Center 2.2.3 Medication Reconciliation 30 days 1579 0 2077 0 1 0.7602 0 0.6507 0 0 1509446.4

DY12 DPH Ventura County Medical Center 2.2.4 Reconciled Medication List Received by Discharged Patients 991 0 4797 0 1 0.2066 0 0.1434 0 0 1509446.4

DY12 DPH Ventura County Medical Center 2.2.5 Timely Transmission of Transition Record 103 0 3321 0 1 0.031 0 0.0576 0 0 1509446.4

DY12 DPH Ventura County Medical Center 2.3.1 Care Coordinator Assignment 418 0 693 0 1 0.6032 0 0.3071 0 0 1509446.4

DY12 DPH Ventura County Medical Center 2.3.2 Medication Reconciliation 30 days 103 0 141 0 1 0.7305 0 0.6732 0 0 1509446.4

DY12 DPH Ventura County Medical Center 2.3.3 Prevention Quality Overall Composite #90 76 0 693 0 1 0.1097 0 0.0647 0 0 1509446.4

DY12 DPH Ventura County Medical Center 2.3.4 Timely Transmission of Transition Record 156 0 311 0 1 0.5016 0 0.5479 0 0 1509446.4

DY12 DPH Ventura County Medical Center 2.4.1 Adolescent Well-Care Visit 52 0 65 0 1 0.8 0 0.6447 0 0.6468 1509446.4

DY12 DPH Ventura County Medical Center 2.4.2 Developmental Screening in the First Three Years of Life 32 0 83 0 1 0.3855 0 0.5094 0 0 1509446.4

DY12 DPH Ventura County Medical Center 2.4.3 Documentation of Current Medications in the Medical Record (0-18 yo) 626 0 881 0 1 0.7106 0 0.6838 0 0 1509446.4

DY12 DPH Ventura County Medical Center 2.4.4 Screening for Clinical Depression and follow-up 15 0 51 0 1 0.2941 0 0.22 0 0 1509446.4

DY12 DPH Ventura County Medical Center 2.4.5 Tobacco Assessment and Counseling (13 yo and older) 38 0 40 0 1 0.95 0 0.5581 0 0 1509446.4

DY12 DPH Ventura County Medical Center 2.4.6 Well Child Visits - First 15 months of life 16 0 34 0 1 0.4706 0 0.3256 0 0.0427 1509446.4

DY12 DPH Ventura County Medical Center 2.4.7 Well Child Visits - Third, Fourth, Fifth, and Sixth Years of life 55 0 62 0 1 0.8871 0 0.8235 0 0.8249 1509446.4

DY12 DPH Ventura County Medical Center 3.4.1 ePBM-01 Pre-op Anemia Screening, Selected Elective Surgical Patients 100 0 302 0 1 0.3311 0 0.4054 0 0 1886808

DY12 DPH Ventura County Medical Center 3.4.2 ePBM-02 Pre-op Hemoglobin Level, Selected Elective Surgical Patients 30 0 33 0 1 0.9091 0 None 1 0 1886808

DY12 DPH Ventura County Medical Center 3.4.3 ePBM-03 Pre-op Type and Crossmatch, Type and Screen, Selected elective Surgical Patients 266 0 302 0 1 0.8808 0 0.8455 0 0 1886808

DY12 DPH Ventura County Medical Center 3.4.4 ePBM-04 Initial Transfusion Threshold 289 0 291 0 1 0.9931 0 None 4 0 1886808

DY12 DPH Ventura County Medical Center 3.4.5 ePBM-05 Outcome of Patient Blood Management, Selected Elective Surgical Patients 11 0 100 0 1 0.11 0 0 0 0 1886808

DY12 DMPH Washington Hospital Healthcare System, Fremont 2.1.1 Baby Friendly Hospital designation: BFUSA Designation Yes Yes 0 BFUSA Cert? 0 1 0 0 NA 0 NA 305600

DY12 DMPH Washington Hospital Healthcare System, Fremont 2.1.2 Exclusive Breast Milk Feeding (PC-05) 64 0 88 0 1 0.7273 0 0 0 0 305600

DY12 DMPH Washington Hospital Healthcare System, Fremont 2.1.3 OB Hemorrhage: Massive Transfusion 0 0 113 0 1 0 0 0 0 0 305600

DY12 DMPH Washington Hospital Healthcare System, Fremont 2.1.4 OB Hemorrhage: Total Products Transfused None 1 113 0 1 None 1 0 0 0 305600

DY12 DMPH Washington Hospital Healthcare System, Fremont 2.1.5 PC-02 Cesarean Section None 1 36 0 1 None 1 0 0 0 305600

DY12 DMPH Washington Hospital Healthcare System, Fremont 2.1.6 Prenatal and Postpartum Care: Postpartum Care 482 0 585 0 1 0.823931624 0 0 0 0.5547 152800

DY12 DMPH Washington Hospital Healthcare System, Fremont 2.1.6 Prenatal and Postpartum Care: Prenatal Care 529 0 585 0 1 0.904273504 0 0 0 0.7744 152800

DY12 DMPH Washington Hospital Healthcare System, Fremont 2.1.7 Severe Maternal Morbidity (SMM) per 100 women with obstetric hemorrhage None 1 None 1 1 None 1 0 0 0 305600

DY12 DMPH Washington Hospital Healthcare System, Fremont 2.1.8 Unexpected Newborn Complications (UNC) None 1 81 0 1 None 1 0 0 0 305600

DY12 DMPH Washington Hospital Healthcare System, Fremont 2.1.9 OB Hemorrhage Safety Bundle: [Numerator] Structure Elements Completed (If your system has more than one hospital, please enter the sum of all elements completed)
[Denominator] Structure Elements Required (if your system has more than one hospital, multiply the number of hospitals by 16) 9 0 16 0 1 0 0 NA 0 NA 305600

DY12 DMPH Washington Hospital Healthcare System, Fremont 2.7.1 Advance Care Plan 127 0 242 0 1 0.5248 0 0 0 0 305600

DY12 DMPH Washington Hospital Healthcare System, Fremont 2.7.2 Ambulatory Palliative Care Team Established: Ambulatory Palliative Care Team Established? Yes Yes 0 Team Established? 0 1 0 0 NA 0 NA 305600

DY12 DMPH Washington Hospital Healthcare System, Fremont 2.7.3 MWM #8: Treatment Preferences (documentation) Inpatient 29 0 31 0 1 0.9355 0 0 0 0 305600

DY12 DMPH Washington Hospital Healthcare System, Fremont 2.7.4 MWM #8: Treatment Preferences (documentation) Outpatient 0 0 0 0 1 0 0 0 0 0 305600

DY12 DMPH Washington Hospital Healthcare System, Fremont 2.7.5 Palliative Care Service Offered at Time of Diagnosis of Advanced Illness 124 0 1486 0 1 0.0834 0 0 0 0 305600

DY12 DMPH Washington Hospital Healthcare System, Fremont 2.7.6 Proportion Admitted to Hospice for Less Than 3 Days None 1 39 0 1 None 1 0 0 0 305600

DY12 DMPH Washington Hospital Healthcare System, Fremont None Complete credentialing of the Medical Director and Nurse Practitioner for the Inpatient Palliative Care program None None None None 1 None None None None None 483866.67

DY12 DMPH Washington Hospital Healthcare System, Fremont None Complete development of Ambulatory Palliative Care Plan None None None None 1 None None None None None 483866.67

DY12 DMPH Washington Hospital Healthcare System, Fremont None Complete Development of Policies and Procedures for Prenatal Diagnostic Clinic None None None None 1 None None None None None 483866.67

DY12 DMPH Washington Hospital Healthcare System, Fremont None Complete Development of Prenatal Diagnostic Clinic space and staffing plan None None None None 1 None None None None None 483866.67

DY12 DMPH Washington Hospital Healthcare System, Fremont None Complete Physician and Staff training sessions on clinical decision support tool which guides ordering of imaging studies. None None None None 0 None None None None None $-

DY12 DMPH Washington Hospital Healthcare System, Fremont None Complete recruitment of one Physician for Prenatal Diagnostic Clinic None None None None 1 None None None None None 483866.66

DY12 DMPH Washington Hospital Healthcare System, Fremont None Conduct 3 Process Improvement Workshops for Imaging Services None None None None 0 None None None None None $-

DY12 DMPH Washington Hospital Healthcare System, Fremont None Establish Ambulatory Palliative Care Team None None None None 1 None None None None None 483866.66

DY12 DMPH Washington Hospital Healthcare System, Fremont None Establish Value Stream Map for Imaging Department None None None None 1 None None None None None 152800

DY12 DMPH Washington Hospital Healthcare System, Fremont None Implement Clinical Decision Support Tool to guide ordering of imaging studies. None None None None 0 None None None None None $-