Denominator: Place of Service: Emergency Medicine, Observation, Inpatient Hospitalization, Critical Care, and SNF. • Patients aged 18 or older AND who have one of the of the following conditions (Primary Criteria) • Advanced Cancer
• Stroke
• Chronic obstructive pulmonary disease (COPD)
• Neurodegenerative Disease
• Congestive Heart Failure (CHF) – with LVEF < or = to 40%
• Kidney Failure (ESRD) AND Secondary criteria (has ANY ONE criteria listed below): • Pair with all: Two or more ED visits or hospitalizations within 12 months with the same primary diagnosis
• Pair with all: Chronic home oxygen use, or Ventilator
• Pair all for non ambulatory care (e.g. Not in ER): Admission from long-term care facility
• Pair with Cancer: Stage 4, or Metastatic cancer
• Pair with all: Difficult to control physical symptoms (intractable or uncontrollable pain, vomiting, dehydration, lethargy, weakness, failure to thrive, depression, anxiety, suicidal thoughts, loss of appetite
• Pair with all: Complex care requirements
-Home infusion (pain medication (PCA pump), hydration, Total parenteral nutrition, milrinone)
-Tube feedings via PEG
-Requirement for mechanical ventilation
-Bedbound and requiring 24 hr medical care
• Pair with all: SDOH (refer to list) Denominator Exceptions: - Patient or medical decision maker refusal
- Palliative care not available, or system issue preventing palliative care consult
Denominator Exclusions: - Patient on hospice, or discharged to hospice
- Eloped or left AMA
- Expired
|