2021 Quality Performance Results:

Quality performance results are based on MIPS CQMs

ACO Quality Measure Number

Measure Name

Rate

ACO Mean

001

 Diabetes: Hemoglobin A1c (HbA1c) Poor

27.36

40.68

134

 Preventative Care and Screening: Screening for Depression and Follow-up

86.48

51.53

236

 Controlling High Blood Pressure

79.19

69.61

321

 CAHPS for MIPS3

N/A

N/A

479

 Hospital-Wide, 30-Day, All-Cause Unplanned Readmission (HWR) Rate for

0.1685

0.1685

MCC1

 All-Cause Unplanned Admissions for Patients with Multiple Chronic Conditions

39.41

33.99

CAHPS-1

 Getting Timely Care, Appointments, and

79.06

84.67

CAHPS-2

 How Well Providers Communicate

92.24

93.56

CAHPS-3

 Patient’s Rating of Provider

90.47

92.19

CAHPS-4

 Access to Specialists

71.76

78.80

CAHPS-5

 Health Promotion and Education

60.74

61.61

CAHPS-6

 Shared Decision Making

54.38

60.89

CAHPS-7

 Health Status and Functional Status

51.76

71.78

CAHPS-8

 Care Coordination

79.67

85.66

CAHPS-9

 Courteous and Helpful Office Staff

87.44

91.88

CAHPS-11

 Stewardship of Patient Resources

29.25

24.71

For Previous Years’ Financial and Quality Performance Results, please visit data.cms.gov.