MIPS Center Impact Evaluation v3 Survey

MIPS Center Impact Evaluation v3

Page 1 of 1

1.	Center Name & CCN#:*

2.	Is this your baseline report?*
	Yes No

3.	If this is not your baseline report, what quarter/year are you reporting for?

4.	Name of person submitting the form:*

5.	Email address of person submitting the form:*

6.	Date signed MIPS Participation Agreement:*
	mm/dd/yyyy

7.	Have the program champion(s) at your center changed?*
	Yes No

8.	If your program champion(s) have changed, please enter the new champion(s) name(s) & email(s) below:

9.	M&M certification completion date:*
	mm/dd/yyyy

Enter the following data:

		Rate/Response		Comments
Anti-Psychotic Drug Rate (%, Quality Measure)
LS Depressive Symptoms (%, Quality Measure)
LS Antianxiety/Sedative Hypnotics (%, Quality Measure)
LS Rehospitalization Rate (%, Trend Tracker)
LS Pain (% Quality Measure)
Total Employee Turnover Rate (%, Facility Record)
Number of residents with active M&M care plan (# 1-15, facility Record)
Overall State Rating (1-5 scale, NH Compare)
Quality Measure Star Rating (1-5 scale, NH Compare)

11.	Upon completion of certiﬁcation and implementation of program, outline plan for program sustainability and/or changes to enhance program: