IT-3.15: Risk Adjusted Behavioral Health /Substance Abuse30-day Readmission Rate

Measure Title / IT-3.15 Risk Adjusted Behavioral Health /Substance Abuse (BH/SA) 30-day Readmission Rate
Description / Risk adjusted rate of hospital admissions for Behavioral Health /Substance Abuse (BH/SA)that had at least one readmission for any reason within 30 days of discharge for patients 18 years of age and older.
A readmission is a subsequent hospital admission in the same hospital within 30 days following an original admission. The discharge date for the index admission must occur within the time period defined as one month prior to the beginning of the measurement period and ending one month prior to the end of the measurement year to allow for the 30-day follow-up period for readmissions within the measurement year.
NQF Number / Not applicable
Measure Steward / Not applicable
Link to measure citation / Category 3 Risk-adjusting Resources:
Measure type / Standalone (SA)
Performance and Achievement Type / Pay for Performance (P4P) – Improvement Over Self (IOS)
DY4 / DY5
Achievement Level Calculation / Baseline - 5% *(performance gap)
=
Baseline - 5% *(0% – Baseline rate) / Baseline -10% *(performance gap)
=
Baseline -10% *(0% – Baseline rate)
Baseline is equal to the ratio of Observed divided by Expected rate of readmissions.
Baseline = Observed rate / Expected rate
DSRIP-specific modifications to Measure Steward’s specification / None
DenominatorDescription / Expected (risk-adjusted) rate of readmissions for BH/SA during the measurement year.
The Expected rate reflects the anticipated (or expected) number of readmissions based on the case-mix of Index Admissions. The Expected rate is equal to the sum of the Index Admissions weighted by the normative coefficients for likelihood of readmission within 30 days, divided by the total number of Index Admissions.
Case-mix factors may include APR-DRG and Severity of Illness classifications, patient age, co-morbid mental health conditions, etc.
Denominator Inclusions / The Expected rate of readmissions should be calculated using a validated, tested, and approved methodology. Providers may use the following methodologies:
  • Vendor Supported software
  • Internal or Provider developed risk adjustment algorithms (e.g. multivariable logistic regression)
  • Texas External Review Organization (EQRO) Category 4 data
  • Indirect Standardization (i.e. "home grown" approach)
More information on calculation of the Expected rateof readmissions can be found in the Key Information for reporting OD-2 and OD-3 Risk Adjusted rates for Category 3documentation
Denominator Exclusions / Global exclusionary criteria:
  • Patients that left against medical advice (LAMA)
  • Patients with discharge status "deceased" during Index Admission
  • Depending on the risk-adjusting methodology to be used, additional exclusionary criteria may be applicable (to be defined by the performing provider or vendor methodology).

Denominator Size / Providers must report a minimum of 30 cases (defined as an Index Admission) per measure during a 12-month measurement period (15 cases for a 6-month measurement period)
  • For a measurement period (either 6 or 12 months) where the denominator size is less than or equal to 75, providers must report on all cases. No sampling is allowed.
  • For a measurement period (either 6 or 12 months) where the denominator size is less than or equal to 380 but greater than 75, providers must report on all cases (preferred, particularly for providers using an electronic health record) or a random sample of not less than 76 cases.
  • For a measurement period (either 6 or 12-months) where the denominator size is greater than 380, providers must report on all cases (preferred, particularly for providers using an electronic health record) or a random sample of cases that is not less than 20% of all cases; however, providers may cap the total sample size at 300 cases.

Numerator Description / Observed (Actual) rate of readmissions within 30 days following an Index Admission for BH/SA during the measurement year
The Observed (Actual) rate is calculated by dividing the number of readmissions within 30 days of an Index Admission by the total number of at-risk BH/SA admissions during the measurement period.
Numerator Inclusions / The number of observed readmissions and Index Admissions are specific to the methodology being applied. Various software allow for delineation of readmissions based on planned vs unplanned, clinically related, and whether the readmission was considered preventable.
More information on calculation of the Observed (Actual) rateof readmissions can be found in the Key Information for reporting OD-2 and OD-3 Risk Adjusted rates for Category 3documentation
Numerator Exclusions / Global exclusionary criteria:
  • Patients that left against medical advice (LAMA)
  • Patients with discharge status "deceased" during Index Admission
Depending on the risk-adjusting methodology to be used, additional exclusionary criteria may be applicable (to be defined by the performing provider or vendor methodology).
Setting / Inpatient
Data Source / Administrative Claims, Electronic Health Records
Allowable Denominator Sub-sets / All denominator subsets are permissible for this outcome

09/24/14