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Topics Covered in this section:

  • Opioid measure reportingSafe Use of Opioids – Concurrent Prescribing

  • Social Drivers of Health (SDOH)

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Safe Use of Opioids – Concurrent Prescribing

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title7.1: Is the safe use of opioid measure voluntary for 2022?

Yes, for 2022 the Opioid measure is a voluntary eCQM, and may be submitted as one of the self-selected measures.

Hospitals can use the DDSP to start reporting this measure to better understand the measure construction and calculationFor Joint Commission reporting purposes applicable to CY2024, the “Safe Use of Opioids - Concurrent Prescribing” measure is a required measure for Large Acute Care Hospitals. It remains optional for Small and Critical Access Hospitals.

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title7.2: How many quarters is the Safe Use of Opioids eCQM reported?

As with all other eCQMs, if your organization selects the The Safe Use of Opioids measures as one of the eCQMs to report for CY2022, the Safe Use of Opioid eCQM is reported for three quartersmeasure is submitted the same as any other eCQM, based on the calendar year requirements.

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title7.3: What criteria does the Opioid eCQM look for?

CMS eCQM specifications can be found on the CMS eCQI Resource Center website. The direct link to the Safe Use of Opioids - Concurrent Use measure is: https://ecqi.healthit.gov/ecqm/eh/2021/cms506v3

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title7.4: Where can we find the specifications for the eCQM Safe Use of Opioids - Concurrent Prescribing?

CMS eCQM specifications can be found on the CMS eCQI Resource Center website. The direct link to the Safe Use of Opioids - Concurrent Use measure is below.
https://ecqi.healthit.gov/ecqm/eh/2021/cms506v3

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Social Drivers of Health (SDOH)

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title7.5: Are the SDOH measures voluntary?

For Joint Commission reporting purposes applicable to CY2024, Screening for Social Drivers of Health (SDOH-1) and Screen Positive Rate for Social Drivers of Health (SDOH-2)are optional measures. Organizations may choose to submit neither, one, or both

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title7.6: How many quarters are submitted for SDOH measures?

The SDOH measures are submitted once annually.

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title7.7: How are the SDOH measures submitted?

The SDOH measures are chart-abstracted measures:

  • The SDOH measures are submitted annually in alignment with the 4Q CAM submission deadline.

  • SDOH data entry will open on 1/1/2025 along with December data entry.

  • SDOH data entry will close on 3/31/2025 along with 4Q2024.

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title7.8: Where can we find the specifications for the SDOH measures?

The same measure specifications used for the CMS SDOH measures will be used for TJC collection. CMS chart-abstracted measure specifications can be found on the CMS Quality Net website. The direct link to the SDOH measures is below.

https://qualitynet.cms.gov/inpatient/iqr/measures#tab2

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title7.9: We do not participate in CMS programs - where do we access information?

The Social Drivers of Health (SDOH) 1 and 2 measures specifications are maintained by CMS, regardless of whether or not you participate in CMS programs.

If your organization chooses to submit the measures to The Joint Commission, please refer to and follow the CMS guidance in the measure information form and frequently asked questions.

Measure specifications are available on the CMS website (included below). Please check the site periodically to assure you are referring to the most up to date information: https://qualitynet.cms.gov/inpatient/iqr/measures#tab2

Social Drivers of Health (SDOH)

The Screening for Social Drivers of Health measure assesses a hospital’s rate of screening for five health-related social needs: food insecurity, housing instability, transportation needs, utility difficulties and interpersonal safety. 

The Screen Positive Rate for Social Drivers of Health measure assesses the rate of positive screens for the same five health-related social needs. 

Screening for Social Drivers of Health Measure and the Screen Positive Rate for Social Drivers of Health Measure is available via CMS Quality Net:

https://qualitynet.cms.gov/files/65b143951cda72001b119ca3?filename=ScrnSocDrvrs_Scrn_Pos_Specs.pdf

Frequently Asked Questions: Social Drivers of Health (SDOH) Measures s available via CMS Quality Net:

https://qualitynet.cms.gov/files/660c8435ba230f001c40f4f9?filename=SDOH_Measure_FAQs_Apr2024.pdf

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