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MIPS Center Impact Evaluation v3
 
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1.
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2.
Is this your baseline report?*
 
 
 
 
3.

 
 
 
 
4.
*
 
 
 
 
5.
*
 
 
 
 
6.
*
  mm/dd/yyyy
 
 
 
7.
Have the program champion(s) at your center changed?*
 
 
 
 
8.

 
 
 
 
9.
*
  mm/dd/yyyy
 
 
 
10.
Enter the following data:
 
     
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.

 
 
 
 
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