All Regions
Regional President: Abhijit Chatterjee

HPIP/SHIP Measures At-Risk

Hospital Name Consultant Name President Name Measure Point At Risk Baseline Rate Target Rate Q1 Actual Rate Q2 Actual Rate Q3 Actual Rate Q4 Actual Rate Final Actual Rate
Auburn Community Hospital Denise Hull
All Cause Rate of readmission after discharge from hospital (hospital-wide) 15 10.72 14.6 43.83 43.83 43.83 - -
Postnatal Care 15 35.06 43.83 14.6 14.6 14.6 - -
Discharge information - Star Rating 30 84.08 84.51 69.43 69.43 69.43 - -
Nurse communication - Star Rating 30 66.2 69.43 84.51 84.51 84.51 - -
Communication about medicines - Star Rating 10 43.69 48.45 48.45 48.45 48.45 - -
Reviewed By
Crouse Hospital Shelly LoPresti
Severe Sepsis 6-Hour Bundle 30 74.17 80.85 56.2 56.2 56.2 - -
Overall hospital rating - Star Rating 10 58.57 61.58 80.85 80.85 80.85 - -
Postoperative acute kidney injury requiring dialysis rate 30 0.53 0.92 0.92 0.92 0.92 - -
Notification of Inpatient Admission 15 74.05 56.2 61.58 61.58 61.58 - -
Medication Reconciliation Conducted 15 70.66 74.29 74.29 74.29 74.29 - -
Reviewed By
Guthrie Cortland Medical Center Shannon Campbell, Laurie Foster
Postnatal Care 30 13.12 16.4 16.4 16.4 16.4 - -
Severe Sepsis 6-Hour Bundle 30 92.13 94.26 0.22 0.22 0.22 - -
In-hospital fall with hip fracture rate 30 0.29 0.22 94.26 94.26 94.26 - -
All Cause Rate of readmission after discharge from hospital (hospital-wide) 10 10.79 14.6 14.6 14.6 14.6 - -
Reviewed By
Oswego Hospital Denise Hull
Follow-Up After Hospitalization for Mental Illness Total / 7 Day* 15 37.01 43.97 43.97 43.97 43.97 - -
ED Left Without Being Seen 30 8.23 6.17 14.6 14.6 14.6 - -
Doctor communication - Star Rating 10 81 79 6.17 6.17 6.17 - -
Quietness - Star Rating 30 61.5 61.66 61.66 61.66 61.66 - -
All Cause Rate of readmission after discharge from hospital (hospital-wide) 15 10.87 14.6 79 79 79 - -
Reviewed By
Upstate University Hospital Denise Hull
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy 30 3.72 5.4 14.6 14.6 14.6 - -
Communication about medicines - Star Rating 10 60.18 60.33 3.2 3.2 3.2 - -
All Cause Rate of readmission after discharge from hospital (hospital-wide) 30 11.37 14.6 5.4 5.4 5.4 - -
Hospital-Level Risk-Standardized Complication Rate Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) 30 1.03 3.2 60.33 60.33 60.33 - -
Reviewed By Payor Admin Tina Faccini 2024-11-13 14:59:34
St. Joseph's Health Hospital Shelly LoPresti
Follow-Up After Emergency Department Visit for Mental Illness / 7 Day* 7.5 31.25 39.06 14 14 14 - -
Heart failure (HF) 30-day readmission rate 7.5 23.38 22.42 22.42 22.42 22.42 - -
ED Left Without Being Seen 30 3 2.25 39.06 39.06 39.06 - -
Follow-Up After Emergency Department Visit for Alcohol and Other Drug Dependence/ 7 Day* 10 29.41 18.26 2.25 2.25 2.25 - -
Nurse communication - Star Rating 30 77.33 77.73 77.73 77.73 77.73 - -
Acute myocardial infarction (AMI) 30-day readmission rate 15 8.6 14 18.26 18.26 18.26 - -
Reviewed By
Clifton Springs Hospital & Clinic Jennifer de Jong
Heart failure (HF) 30-day readmission rate 10 21.82 21.37 56.2 56.2 56.2 - -
Doctor communication - Star Rating 30 82.91 79 46.72 46.72 46.72 - -
Perioperative pulmonary embolism or deep vein thrombosis rate 30 6.25 4.88 79 79 79 - -
Notification of Inpatient Admission 15 99.91 56.2 21.37 21.37 21.37 - -
Receipt of Discharge Information 15 95.45 46.72 4.88 4.88 4.88 - -
Reviewed By
Highland Hospital Teresa Stokelin
ED Left Without Being Seen 30 8.6 6.45 56.2 56.2 56.2 - -
Doctor communication - Star Rating 10 78.71 79 46.72 46.72 46.72 - -
Discharge information - Star Rating 30 86.28 86 86 86 86 - -
Notification of Inpatient Admission 15 95.28 56.2 79 79 79 - -
Receipt of Discharge Information 15 98.62 46.72 6.45 6.45 6.45 - -
Reviewed By
Jones Memorial Hospital Teresa Stokelin
Postnatal Care 100 76.72 81.45 81.45 81.45 81.45 - -
Reviewed By
Newark-Wayne Community Hospital Jennifer de Jong
Nurse communication - Star Rating 30 72.37 74.04 56.2 56.2 56.2 - -
Doctor communication - Star Rating 30 75.09 76.06 46.72 46.72 46.72 - -
Discharge information - Star Rating 10 83.15 83.79 76.06 76.06 76.06 - -
Notification of Inpatient Admission 15 84.04 56.2 74.04 74.04 74.04 - -
Receipt of Discharge Information 15 95.46 46.72 83.79 83.79 83.79 - -
Reviewed By
Noyes Memorial Hospital Teresa Stokelin
Nurse communication - Star Rating 10 72.85 74.35 56.2 56.2 56.2 - -
Communication about medicines - Star Rating 50 68.87 61 46.72 46.72 46.72 - -
Severe Sepsis 3-Hour Bundle 10 78.2 81.42 81.42 81.42 81.42 - -
Notification of Inpatient Admission 15 95.69 56.2 61 61 61 - -
Receipt of Discharge Information 15 97.34 46.72 74.35 74.35 74.35 - -
Reviewed By
Rochester General Hospital Jennifer de Jong
Notification of Inpatient Admission 15 99.9 56.2 56.2 56.2 56.2 - -
In-hospital fall with hip fracture rate 20 0.19 0.14 46.72 46.72 46.72 - -
Receipt of Discharge Information 15 99.05 46.72 0.14 0.14 0.14 - -
Hospital-Level Risk-Standardized Complication Rate Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) 20 3.58 3.47 3.47 3.47 3.47 - -
Perioperative pulmonary embolism or deep vein thrombosis rate 20 4.08 3.87 3.87 3.87 3.87 - -
Recommend hospital - Star Rating 10 57.91 60.74 60.74 60.74 60.74 - -
Reviewed By
Soldiers & Sailors Hospital
Strong Memorial Hospital Teresa Stokelin
Blues Distinction Measures 10 21 15.75 56.2 56.2 56.2 - -
Recommend hospital - Star Rating 50 87.09 69 46.72 46.72 46.72 - -
Postoperative acute kidney injury requiring dialysis rate 10 3.05 2.29 69 69 69 - -
Notification of Inpatient Admission 15 92.63 56.2 2.29 2.29 2.29 - -
Receipt of Discharge Information 15 98.24 46.72 15.75 15.75 15.75 - -
Reviewed By
F.F. Thompson Hospital Teresa Stokelin
Communication about medicines - Star Rating 30 53 55.04 56.2 56.2 56.2 - -
Recommend hospital - Star Rating 30 68 68.17 46.72 46.72 46.72 - -
Care Transitions - Star Rating 10 44 45.81 68.17 68.17 68.17 - -
Notification of Inpatient Admission 15 84.35 56.2 55.04 55.04 55.04 - -
Receipt of Discharge Information 15 98.22 46.72 45.81 45.81 45.81 - -
Reviewed By
United Memorial Medical Center Jennifer de Jong
Heart failure (HF) 30-day readmission rate 10 25.57 23.79 56.2 56.2 56.2 - -
Nurse communication - Star Rating 30 75.71 76.49 46.72 46.72 46.72 - -
Recommend hospital - Star Rating 30 55.69 59.13 76.49 76.49 76.49 - -
Notification of Inpatient Admission 15 99.91 56.2 59.13 59.13 59.13 - -
Receipt of Discharge Information 15 92.14 46.72 23.79 23.79 23.79 - -
Reviewed By
Unity Hospital Jennifer de Jong
Notification of Inpatient Admission 15 99.81 56.2 56.2 56.2 56.2 - -
Receipt of Discharge Information 15 99.35 46.72 46.72 46.72 46.72 - -
In-hospital fall with hip fracture rate 20 0.49 0.37 0.37 0.37 0.37 - -
Hospital-Level Risk-Standardized Complication Rate Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) 20 3.69 3.55 3.55 3.55 3.55 - -
Perioperative pulmonary embolism or deep vein thrombosis rate 20 4.11 3.89 3.89 3.89 3.89 - -
Recommend hospital - Star Rating 10 59.49 61.94 61.94 61.94 61.94 - -
Reviewed By
Adirondack Health Denise Hull
Severe Sepsis 6-Hour Bundle 30 57.69 69.28 14.6 14.6 14.6 - -
Quietness - Star Rating 10 62.3 62 33 33 33 - -
Follow-Up After Emergency Department Visit for People With Multiple High-Risk Chronic Conditions / 7 Day* 15 26.42 33 80.95 80.95 80.95 - -
All Cause Rate of readmission after discharge from hospital (hospital-wide) 15 6.31 14.6 69.28 69.28 69.28 - -
Severe Sepsis 3-Hour Bundle 30 77.55 80.95 62 62 62 - -
Reviewed By
Alice Hyde Medical Center Laurie Foster
All Cause Rate of readmission after discharge from hospital (hospital-wide) 100 10.46 14.6 14.6 14.6 14.6 - -
Reviewed By
A.O. Fox Hospital Shannon Campbell
All Cause Rate of readmission after discharge from hospital (hospital-wide) 50 11.48 14.6 14.6 14.6 14.6 - -
Receipt of Discharge Information 25 78.85 46.72 46.72 46.72 46.72 - -
Medication Reconciliation Conducted 25 100 84.67 84.67 84.67 84.67 - -
Reviewed By
Canton-Potsdam Hospital Jennifer de Jong
Notification of Inpatient Admission 50 99.52 56.2 56.2 56.2 56.2 - -
Receipt of Discharge Information 50 95.51 46.72 46.72 46.72 46.72 - -
Reviewed By
Champlain Valley Physicians Hospital Laurie Foster
Postnatal Care 10 54.41 65.54 14.6 14.6 14.6 - -
Septic Shock 3-Hour Bundle 30 59.09 69.46 65.54 65.54 65.54 - -
Doctor communication - Star Rating 10 71.95 73.8 69.46 69.46 69.46 - -
Care Transitions - Star Rating 30 43.97 45.78 45.78 45.78 45.78 - -
All Cause Rate of readmission after discharge from hospital (hospital-wide) 20 10.54 14.6 73.8 73.8 73.8 - -
Reviewed By
Claxton-Hepburn Medical Center
Community Memorial Hospital Denise Hull
ED Left Without Being Seen 30 1.42 1.07 56.2 56.2 56.2 - -
Overall hospital rating - Star Rating 30 68.96 69.31 46.72 46.72 46.72 - -
Notification of Inpatient Admission 20 79.69 56.2 1.07 1.07 1.07 - -
Receipt of Discharge Information 20 85.88 46.72 69.31 69.31 69.31 - -
Reviewed By
Gouverneur Hospital Jennifer de Jong
Notification of Inpatient Admission 50 100 56.2 56.2 56.2 56.2 - -
Receipt of Discharge Information 50 78.15 46.72 46.72 46.72 46.72 - -
Reviewed By
Lewis County General Hospital Denise Hull
All Cause Rate of readmission after discharge from hospital (hospital-wide) 100 9.66 14.6 14.6 14.6 14.6 - -
Reviewed By
Little Falls Hospital
Bassett Medical Center Shannon Campbell
Rate of emergency department (ED) visits for patients receiving outpatient chemotherapy 30 1.15 5.4 56.22 56.22 56.22 - -
Postnatal Care 15 85.9 88.33 14.6 14.6 14.6 - -
Staff responsiveness - Star Rating 10 53.21 56.22 88.33 88.33 88.33 - -
All Cause Rate of readmission after discharge from hospital (hospital-wide) 15 10.88 14.6 5.4 5.4 5.4 - -
Severe Sepsis 3-Hour Bundle 30 81.68 83.99 83.99 83.99 83.99 - -
Reviewed By
Massena Hospital Jennifer de Jong
Notification of Inpatient Admission 50 100 56.2 56.2 56.2 56.2 - -
Receipt of Discharge Information 50 72.7 46.72 46.72 46.72 46.72 - -
Reviewed By
MVHS, Inc. (Wynn Hospital) Laurie Foster
ED Left Without Being Seen 30 4.49 3.37 3.37 3.37 3.37 3.37 -
Nurse communication - Star Rating 10 72.34 74.01 0.14 0.14 0.14 0.14 -
In-hospital fall with hip fracture rate 30 0.18 0.14 74.01 - - - -
Receipt of Discharge Information 15 51.87 46.72 84.67 84.67 84.67 84.67 -
Medication Reconciliation Conducted 15 96.18 84.67 46.72 46.72 46.72 46.72 -
Reviewed By
Nathan Littauer Hospital
Oneida Health Laurie Foster
ED Left Without Being Seen 30 2.27 1.7 95.38 95.38 95.38 - -
Postnatal Care 30 96.77 95.38 1.7 1.7 1.7 - -
Septic Shock 3-Hour Bundle 30 79.22 83.09 83.09 83.09 83.09 - -
Care Transitions - Star Rating 10 54.08 51 51 51 51 - -
Reviewed By
Rome Health Shannon Campbell
Nurse communication - Star Rating 10 76.51 77.1 14.6 14.6 14.6 - -
Quietness - Star Rating 30 52.38 54.8 79.79 79.79 79.79 - -
All Cause Rate of readmission after discharge from hospital (hospital-wide) 30 5.59 14.6 54.8 54.8 54.8 - -
Severe Sepsis 3-Hour Bundle 30 75.89 79.79 77.1 77.1 77.1 - -
Reviewed By
Samaritan Hospital Laurie Foster
Postnatal Care 15 81.93 85.3 85.3 85.3 85.3 - -
Overall hospital rating - Star Rating 30 60.31 62.79 14.6 14.6 14.6 - -
All Cause Rate of readmission after discharge from hospital (hospital-wide) 15 9.6 14.6 79.97 79.97 79.97 - -
Severe Sepsis 3-Hour Bundle 30 76.06 79.97 62.79 62.79 62.79 - -
Obstructive Pulmonary Disease (COPD) Hospitalization 30-day readmission rate 10 11.96 19.3 19.3 19.3 19.3 - -
Reviewed By
University of Vermont Medical Center (UVMMC)
Faxton St. Luke's Healthcare
St. Mary's Hospital (Amsterdam)
St. Elizabeth Medical Center
Brooks Memorial Hospital
Erie County Medical Center Denise Hull
Follow-Up After High-Intensity Care for Substance Use Disorder Total / 7 Day 30 94.93 57.46 57.46 57.46 57.46 - -
Nurse communication - Star Rating 10 70.34 72.51 86 86 86 - -
Doctor communication - Star Rating 30 70.27 72.44 72.51 72.51 72.51 - -
Discharge information - Star Rating 30 86 86 72.44 72.44 72.44 - -
Reviewed By
Kaleida Health Denise Hull
Severe Sepsis 6-Hour Bundle 30 86.71 90.05 46.39 46.39 46.39 - -
Septic Shock 6-Hour Bundle 30 90.57 92.9 92.9 92.9 92.9 - -
Staff responsiveness - Star Rating 10 54.1 56.88 90.05 90.05 90.05 - -
Follow-Up After Emergency Department Visit for People With Multiple High-Risk Chronic Conditions / 7 Day* 30 38.63 46.39 56.88 56.88 56.88 - -
Reviewed By
Lockport Memorial
Niagara Falls Memorial Medical Center Denise Hull
All Cause Rate of readmission after discharge from hospital (hospital-wide) 100 8.87 14.6 14.6 14.6 14.6 - -
Reviewed By
Orleans Community Health – Medina Memorial Hospital Denise Hull
All Cause Rate of readmission after discharge from hospital (hospital-wide) 100 9.06 14.6 14.6 14.6 14.6 - -
Reviewed By
Roswell
UPMC Chautauqua Denise Hull
Heart failure (HF) 30-day readmission rate 15 15.65 20.2 74.39 74.39 74.39 - -
ED Left Without Being Seen 30 2.77 2.08 20.2 20.2 20.2 - -
Postnatal Care 15 66.17 74.39 2.08 2.08 2.08 - -
Nurse communication - Star Rating 10 77 77.59 86 86 86 - -
Discharge information - Star Rating 30 89.99 86 77.59 77.59 77.59 - -
Reviewed By
Arnot Ogden Medical Center Teresa Stokelin
Severe Sepsis 6-Hour Bundle 30 80.22 85.38 83.91 83.91 83.91 - -
Nurse communication - Star Rating 10 79.32 79 85.38 85.38 85.38 - -
Severe Sepsis 3-Hour Bundle 30 81.4 83.91 79 79 79 - -
Receipt of Discharge Information 15 59.01 46.72 46.72 46.72 46.72 - -
Medication Reconciliation Conducted 15 89.7 84.67 84.67 84.67 84.67 - -
Reviewed By
Guthrie Corning Hospital Shannon Campbell, Laurie Foster
Severe Sepsis 6-Hour Bundle 30 85.83 89.58 27.5 27.5 27.5 - -
In-hospital fall with hip fracture rate 30 0.52 0.39 0.39 0.39 0.39 - -
Follow-Up After Emergency Department Visit for People With Multiple High-Risk Chronic Conditions / 7 Day* 30 22 27.5 89.58 89.58 89.58 - -
All Cause Rate of readmission after discharge from hospital (hospital-wide) 10 6.64 14.6 14.6 14.6 14.6 - -
Reviewed By
Guthrie Lourdes Hospital Shannon Campbell, Laurie Foster
Heart failure (HF) 30-day readmission rate 15 21.53 21.14 21.14 21.14 21.14 - -
Rate of inpatient admissions for patients receiving outpatient chemotherapy 30 27.08 20.31 45.11 45.11 45.11 - -
Postnatal Care 15 36.09 45.11 4.56 4.56 - - -
Care Transitions - Star Rating 10 47.32 48.29 20.31 20.31 20.31 - -
Hospital-Level Risk-Standardized Complication Rate Following Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA) 30 5.83 4.56 48.29 48.29 48.29 - -
Reviewed By
Schuyler Hospital Teresa Stokelin
ED Left Without Being Seen 30 0.74 0.56 48.86 48.86 48.86 48.86 -
Notification of Inpatient Admission 35 46.36 48.86 46.72 46.72 46.72 46.72 -
Receipt of Discharge Information 35 53.86 46.72 0.56 0.56 0.56 0.56 -
Reviewed By
St. James Hospital Teresa Stokelin
Receipt of Discharge Information 50 95.25 46.72 56.2 56.2 56.2 56.2 56.2
Notification of Inpatient Admission 50 92.16 56.2 46.72 46.72 46.72 46.72 46.72
Reviewed By
UHS Chenango Memorial Hospital
United Health Services Hospitals Shannon Campbell
Hospital 30-Day, All-Cause, Risk-Standardization Readmission Rate (RSRR) Following Pneumonia Hospitalization 7.5 13.1 16.9 56.2 56.2 56.2 - -
Nurse communication - Star Rating 20 74.73 75.88 36.78 36.78 36.78 - -
Communication about medicines - Star Rating 10 51.66 54.05 19.3 19.3 19.3 - -
Obstructive Pulmonary Disease (COPD) Hospitalization 30-day readmission rate 7.5 13.01 19.3 16.9 16.9 16.9 - -
Notification of Inpatient Admission 7.5 57.31 56.2 75.88 75.88 75.88 - -
Receipt of Discharge Information 7.5 32.94 36.78 54.05 54.05 54.05 - -
Postnatal Care 20 66.55 74.57 74.57 74.57 74.57 - -
Pressure ulcer rate 20 3.13 2.35 2.35 2.35 2.35 - -
Reviewed By