Primary Care Quality Measures For Medicaid Home Health Beneficiaries Page 3
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4Primary Care Quality Measures for Medicaid Home Health Beneficiaries
Patient Name _______________________
Date of Review_________________
Medicaid ID Number _________________
Date of Birth ______________
MD Name _____________________
Diagnosis Codes ICD9s 250.00 – 250.93 or V58.67
________________________________________________________________________
Measure 1
Hemoglobin A1C - most recent value in last 12 months
Date obtained___________ Result____________________
A1C not performed_______
________________________________________________________________________
Measure 2
HDL – Cholesterol - most recent value in last 12 months
Date obtained___________ Result____________________
LDL – Cholesterol - most recent value in last 12 months
Date obtained___________ Result____________________
Triglycerides - most recent values in last 12 months
Date obtained___________ Result____________________
Lipids not obtained_______
________________________________________________________________________
Measure 3
Blood Pressure - most recent value in last 12 months
Date measured__________ Result____________________
Systolic BP range_________________________________
Diastolic BP range________________________________
BP not performed_______
Health Care Utilization
Frequency of MD visits ___________________________________________________
Date of last MD visit _____________________________________________________
Emergent care this cert period - Yes____ No_____ Date of service_________________
Chief complaint __________________________________________________________
Recent hospital admission for DM - Yes______ No_____ Date of service____________
Eye exam, date of last examination __________________________________________
Foot exam, date of last examination __________________________________________
Last flu vaccine __________________ Last pneumococcal vaccine _________________
Height _____________ Weight ___________ Desired Weight______________________
Change in treatment regimen - Yes________ No ___________
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