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Standardized Performance
Measures for Advanced
Certification in Heart Failure
Karen Kolbusz, RN, BSN, MBA
Associate Project Director
Division of Healthcare Quality Evaluation
The Joint Commission
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Objectives
Discuss the six inpatient ACHF measures
and related data elements
Review associated measure algorithms
Provide opportunity for questions
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Performance Measure
Requirements for ACHF
Effective January 1, 2014, data collection for
6 inpatient ACHF measures (mandatory)
Continue data collection for HF core
measures HF-2 Evaluation of LVS Function
and HF-3 ACEI/ARB for LVSD (mandatory)
Data collection for 7 outpatient ACHFOP
measures is strongly encouraged for
healthcare organizations with access to
outpatient data but not required
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ACHF Measure Specifications http://www.jointcommission.org/adv_certification_heart_failure_standardized_
performance_measures/
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Initial ACHF Patient Population
Discharges with ICD-9-CM Principal
Diagnosis Code for HF as defined in
Appendix A, Table 2.1
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Excluded Populations – ALL
ACHF Measures
Patients who had a LVAD or heart
transplantation procedure during the
hospital stay
Age < 18 years
Inpatient Discharges > 120 days
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ACHF-01 Beta-Blocker Therapy for
LVSD Prescribed at Discharge
Denominator: Heart failure patients with
current or prior documentation of left
ventricular ejection fraction (LVSD) < 40%
Numerator: Patients who are prescribed
bisoprolol, carvedilol, or sustained-release
metoprolol succinate for LVSD at hospital
discharge
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ACHF-01 Excluded Populations
Patients with Comfort Measures Only
documented
Patients enrolled in a Clinical Trial
Patients discharged to another hospital
Patients who left against medical
advice
Patients who expired
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ACHF-01 Excluded Populations
Patients discharged to home for
hospice care
Patients discharged to a healthcare
facility for hospice care
Patients with a documented Reason for
No Bisoprolol, Carvedilol, or Sustained-
Release Metoprolol Succinate
Prescribed for LVSD at Discharge
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ACHF-01 Data Elements
Denominator:
Admission Date
Birthdate
Clinical Trial
Comfort Measures Only
Discharge Disposition
ICD-9-CM Other Procedure Codes
ICD-9-CM Principal Diagnosis Code
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ACHF-01 Data Elements
Denominator:
ICD-9-CM Principal Procedure Code
ICD-9-CM Principal Procedure Date
LVSD < 40%
Reason for No Bisoprolol, Carvedilol, or
Sustained-Release Metoprolol Prescribed
for LVSD at Discharge
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ACHF-01 Data Elements
Numerator:
Bisoprolol, Carvedilol, or Sustained-Release
Metoprolol Prescribed for LVSD at Discharge
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Only Acceptable Beta-Blockers
Inclusion
– Bisoprolol
– Bisoprolol/fumarate
– Bisoprolol/HCTZ
– Carvedilol
– Carvedilol
phosphate
– Coreg
– Coreg CR
– Metoprolol succinate
– Toprol-XL
– Zebeta
– Ziac
Exclusion
– All other beta-
blocker medications
other than those
listed as inclusions
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LVSD < 40%
Use the lowest ejection fraction (EF)
– Calculated or estimated EF is acceptable
Use the worst narrative description of
severity (Inclusion List A)
– Moderate/severe inclusion term counts
– Mild/moderate excluded
Use narrative description without
severity specified (Inclusion List B)
– Abnormal, compromised, decreased
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Reason for No Bisoprolol,
Carvedilol, or Sustained-Release
Metoprolol
Beta-blocker allergy
Second or third-degree heart block on
ECG on arrival or during
Other reasons documented by the
physician/APN/PA or pharmacist
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ACHF-01 Algorithm Highlights
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ACHF-02 Post-Discharge
Appointment for HF Patients
Denominator: All heart failure patients
discharged from a hospital inpatient setting
to home or home care
Numerator: Patients for whom a follow-up
appointment for an office or home health
visit for management of heart failure was
scheduled within 7 days post-discharge
and documented including location, date,
and time.
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ACHF-02 Excluded Populations
Patients with Comfort Measures Only
documented
Patients enrolled in a Clinical Trial
Patients discharged to locations other
than home, home care, or law
enforcement
Patients with a documented Reason for
No Post-Discharge Appointment Within
7 Days
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ACHF-02 Data Elements
Denominator:
Admission Date
Birthdate
Clinical Trial
Comfort Measures Only
Discharge Disposition
ICD-9-CM Other Procedure Codes
ICD-9-CM Principal Diagnosis Code
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ACHF-02 Data Elements
Denominator:
ICD-9-CM Principal Procedure Code
ICD-9-CM Principal Procedure Date
Reason for No Post-Discharge Appointment
Within 7 Days
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ACHF-02 Data Elements
Numerator:
Post-Discharge Appointment Scheduled Within
7 Days
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Post-Discharge Appointment
Scheduled Within 7 Days Follow-up appointment with a
physician/APN/PA in a physician office
or ambulatory care clinic that occurs
within 7 days of discharge
Home health visit with a RN/APN that
occurs within 7 days of discharge
– telemedicine/teleconference to assess the
patient in the home setting
Appointment must include location,
date, and time
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Reason for No Post-Discharge
Appointment Within 7 Days Reasons must be documented by
MD/APN/PA in the context of 7 days
Acceptable reasons include:
– Patient refusal of follow-up or refusal of an
appointment scheduled within 7 days
– Out-of-town visitor who will follow-up with
PCP in another state, region, or country
– Follow-up not scheduled because patient
is cognitively impaired and has no
caregiver available to receive details of the
scheduled appointment
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ACHF-02 Algorithm Highlights
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ACHF-03 Care Transition Record
Transmitted
Denominator: All heart failure patients
discharged from a hospital inpatient setting
to home or home care
Numerator: Care transition record
transmitted to a next level of care provider
within 7 days of discharge containing ALL
of the following:
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ACHF-03 Care Transition Record
Transmitted
Numerator:
– Reason for hospitalization
– Procedures performed during this
hospitalization
– Treatment(s)/Service(s) provided during this
hospitalization
– Discharge medications, including dosage and
indication for use
– Follow-up treatment(s) and service(s) needed
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ACHF-03 Excluded Populations
Patients with Comfort Measures Only
documented
Patients enrolled in a Clinical Trial
Patients discharged to locations other
than home, home care, or law
enforcement
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ACHF-03 Data Elements
Denominator:
Admission Date
Birthdate
Clinical Trial
Comfort Measures Only
Discharge Disposition
ICD-9-CM Other Procedure Codes
ICD-9-CM Principal Diagnosis Code
ICD-9-CM Principal Procedure Code
ICD-9-CM Principal Procedure Date
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ACHF-03 Data Elements
Numerator:
Care Transition Record Transmitted
Care Transition Record-Discharge Medications
Care Transition Record-Follow-Up Treatment(s)
and Service(s) Needed
Care Transition Record-Procedures Performed
During Hospitalization
Care Transition Record-Reason for
Hospitalization
Care Transition Record-Treatment(s)/Service(s)
Provided
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Care Transition Record
Transmitted Allowable Values:
1. The medical record contains a care transition
record that was transmitted to the next level of
care provider no later than the seventh post-
discharge day
2. The medical record contains a care transition
record but was not transmitted to the next level
of care provider by the seventh post discharge
day
3. The medical record does not contain a care
transition record, or unable to determine from
medical record documentation
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Care Transition Record
Transmitted A care transition record may consist of
one document or several documents
The first post-discharge day is defined
as the day after discharge
The next level of care provider is the
clinician, hospital or clinic responsible
for managing the patient’s heart failure
after hospital discharge
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Care Transition Record
Transmitted Methods for transmitting:
– EMR access
– Fax
– USPS
– In-hospital mailbox
– Medical transport personnel
Giving a copy of the care transition
record to the patient DOES NOT
comprise transmission
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Care Transition Record-
Discharge Medications All medications prescribed for the
patient at discharge
– Includes PRN medications
– NOT limited to only those medications
prescribed for heart failure
Medication name, dosage, and
indication for use
Select “YES” if no medications were
prescribed at discharge
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Follow-Up Treatment(s) and
Service(s) Needed Treatments/services after discharge:
– Laboratory tests and results
– Imaging services (MRI, PET/CT, US)
– Rehabilitation services (PT, OT, SLT)
– Respiratory treatments (O2, CPAP)
– Nutrition services
– Hospice or home care
– Mental health / counseling services
– Durable medical equipment (DME) /
medical transport (Medi-car)
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Procedures Performed During
Hospitalization List of any diagnostic procedure(s),
therapeutic procedure(s), or surgery(s)
performed during the hospital stay
– Procedures described by name, ICD-9-CM
Principal or Other Procedure Codes are
acceptable
Select “YES” if no procedures were
performed during the hospitalization
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Reason for Hospitalization
Patient’s primary diagnosis
Patient’s other or secondary diagnoses
Documentation of the patient’s “chief
complaint” on the care transition record
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Treatment(s)/Service(s)
Provided Treatments and services provided
during the hospital stay
– Includes documentation of tests performed
during the hospital stay with results
pending that will require follow-up after
discharge
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ACHF-03 Algorithm Highlights
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ACHF-03 Algorithm Highlights
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ACHF-04 Discussion of Advance
Directives/Advance Care Planning
Denominator: All heart failure patients
Numerator: Patients who have
documentation in the medical record of a
one-time discussion of advance
directives/advance care planning with a
healthcare provider
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ACHF-04 Excluded Populations
Patients with Comfort Measures Only
documented
Patients discharged to another hospital
Patients discharged to home for
hospice care
Patients discharged to a health care
facility for hospice care
Patients who expire
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ACHF-04 Data Elements
Denominator:
Admission Date
Birthdate
Comfort Measures Only
Discharge Disposition
ICD-9-CM Other Procedure Codes
ICD-9-CM Principal Diagnosis Code
ICD-9-CM Principal Procedure Code
ICD-9-CM Principal Procedure Date
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ACHF-04 Data Elements
Numerator:
Discussion of Advance Directives/Advance
Care Planning
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Discussion of Advance
Directives/Advance Care
Planning
A one-time discussion with the
patient/caregiver documented
anywhere in the medical record
– Discussion may be with a
physician/APN/PA, social worker, pastoral
care, or nurse
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Discussion of Advance
Directives/Advance Care
Planning
Select “YES” for discussion:
– Do Not Resuscitate (DNR) orders or an
executed advance directive is present in
the medical record
– Patient/family/caregiver refusal of
discussion
– Patient’s cultural beliefs are in conflict with
discussion, e.g., Navajo Indian
– Patient did not wish/unable to name a
surrogate decision maker
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ACHF-04 Algorithm Highlights
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ACHF-05 Advance Directive
Executed
Denominator: All heart failure patients
Numerator: Patients who have
documentation in the medical record that
an advance directive was executed
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ACHF-05 Excluded Populations
Patients with Comfort Measures Only
documented
Patients discharged to another hospital
Patients discharged to home for
hospice care
Patients discharged to a health care
facility for hospice care
Patients who expire
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ACHF-05 Data Elements
Denominator:
Admission Date
Birthdate
Comfort Measures Only
Discharge Disposition
ICD-9-CM Other Procedure Codes
ICD-9-CM Principal Diagnosis Code
ICD-9-CM Principal Procedure Code
ICD-9-CM Principal Procedure Date
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ACHF-05 Data Elements
Numerator:
Advance Directive Executed
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Advance Directive Executed
Advance directive, health care proxy,
living will, MOLST/POLST, power of
attorney in the patient’s medical record
– Legal document
Do Not Resuscitate (DNR) orders do
not count as an executed advance
directive
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ACHF-05 Algorithm Highlights
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ACHF-06 Post-Discharge
Evaluation for HF Patients
Denominator: All heart failure patients
discharged from a hospital inpatient setting
to home or home care AND patients
leaving against medical advice (AMA)
Numerator: Patients who have a
documented re-evaluation conducted via
phone call or home visit within 72 hours
after discharge
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ACHF-06 Excluded Populations
Patients with Comfort Measures Only
documented
Patients enrolled in a Clinical Trial
Patients discharged to locations other
than home, home care, or law
enforcement
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ACHF-06 Data Elements
Denominator:
Admission Date
Birthdate
Clinical Trial
Comfort Measures Only
Discharge Disposition
ICD-9-CM Other Procedure Codes
ICD-9-CM Principal Diagnosis Code
ICD-9-CM Principal Procedure Code
ICD-9-CM Principal Procedure Date
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ACHF-06 Data Elements
Numerator:
Post-Discharge Evaluation Conducted Within
72 Hours
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Post-Discharge Evaluation
Conducted Within 72 Hours A post-discharge evaluation with
patient/caregiver conducted within 72
hours (day after discharge = Day 1):
– telephone
– electronically (e-mail)
– home health evaluation
– office visit
After 3 unsuccessful attempts, select
“YES”.
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ACHF-06 Algorithm Highlights
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Direct questions to
http://manual.jointcommission.org
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Thank you
