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SOONERCARE PCMH REDESIGN
Quality Measure Review
THE PACIFIC HEALTH POLICY GROUP
December 19, 2016
Agenda: Quality Measure Review


CPC+ Measures and Oklahoma Selections
Inventory of Measures for Consideration to Address
 Adult Preventive
 Child, Adolescent and Adult Chronic Health Conditions
 OHIP Flagship Issues




Tobacco
Obesity
Child Health (Maternal, Preventive)
Behavioral Health
Utilization, Efficiency and Coordination
 Patient Experience
Appendix: Behavioral Health




Integrated Physical Health and Behavioral Health Model Components
Pediatric Screening Tools
PCMH Redesign, Quality Measure Review
2
CPC+ Quality Measure Overview
CPC+ contains 271 measures across 6 domains.
States & practices are asked to select measures from this list to participate.
Oklahoma has selected 16 measures across the 6 domains.
CPC+ Domains & Measure Counts
Oklahoma Selection
Person and Caregiver-Centered
Experience and Outcomes
Person and Caregiver-Centered
Experience and Outcomes
Patient Safety
Patient Safety
Efficiency and Cost Reduction
Efficiency and Cost Reduction
Effective Clinical Care
Effective Clinical Care
Community/Population Health
Community/Population Health
Communication and Care
Coordination
Communication and Care Coordination
0
20
40
60
80
100
120
140
0
1
2
3
4
5
6
OK Selected Measures by
Population Type
CPC+ measures selected in OK are appropriately
geared toward adults and therefore only partially align
with Oklahoma Health Improvement Plan priorities.
PCMH Redesign, Dec 2016
Child &
Adult, 4
Adult
(65+), 3
Adult, 9
3
7
CPC+ Selected Measure Set: Oklahoma
Domain
Measure(s)
Primary Measure Steward
Communication & Care
Coordination
• Closing the Referral Loop: Receipt of
Specialist Report
Community & Population Health
•
•
•
•
•
Pneumococcal Vaccine/Older Adults
•
Influenza Immunization
•
Screening for Clinical Depression/F/U Plan
Tobacco Use: Screening & Cessation Intervention •
NCQA
Phys. Consortium for PI
CMS
Phys. Consortium for PI
Effective Clinical Care
•
•
•
•
•
•
Breast Cancer Screening
Cervical Cancer Screening
Colorectal Cancer Screening
Controlling High Blood Pressure
Diabetes: Eye Exam
Diabetes: Hemoglobin A1c (>9%)
NCQA
NCQA
NCQA
NCQA
NCQA
NCQA
Efficiency & Cost Reduction
Patient Safety
Person & Caregiver Centered
Experience & Outcomes
PCMH Redesign, Dec 2016
• Use of Imaging Studies for Low Back Pain
• CMS
•
•
•
•
•
•
• NCQA
• Documentation of Current Meds in
Medical Record
• Falls: Screening for Future Fall Risk
• Use of High-Risk Meds in the Elderly
• CMS
• CAHPS for PQRS Clinical/Group Survey
• AHRQ
• NCQA
• NCQA
4
Methodology for Measure Inventory
CPC+
As Baseline
Incremental
HEDIS
Incremental
Medicaid/CHIP
Incremental CMS
PCMH/ACO
Select National
Quality Forum
(Target Areas)
• Cumulative inventory of quality measures (300+) combining these
sources
• Further filtered measure set to account for the covered population and
Oklahoma Health Improvement Plan target areas (100+)
• Categorized by type of measure in the following pages for consideration
• A is used beside a measure if Oklahoma has selected it for CPC+ (the
attached presentation accounts for 13 of the 16; three that do not apply
to the PCMH population were excluded: pneumococcal vaccine;
screening for risk of falls; and high-risk medications in the elderly)
PCMH Redesign, Quality Measure Review
5
Adult Preventive Screening
Measure
Brief Description
Breast Cancer Screening
Percentage of women 50-74 years of age who had a mammogram to screen for National Committee for
breast cancer.
Quality Assurance
Cervical Cancer Screening
Percentage of women 21-64 years of age who were screened for cervical
cancer using either of the following criteria: * Women age 21-64 who had
cervical cytology performed every 3 years * Women age 30-64 who had
cervical cytology/human papillomavirus (HPV) co-testing performed every 5
years.
National Committee for
Quality Assurance
Colorectal Cancer
Screening
Percentage of adults 50-75 years of age who had appropriate screening for
colorectal cancer.
National Committee for
Quality Assurance
Adult Access to
Preventive/Ambulatory
Health Services
Percentage of members 20 years and older who had an ambulatory or
preventive care visit.
AHRQ
PCMH Redesign, Quality Measure Review
Primary Steward
6
Chronic Health Issues - Child, Adolescent & Adult
Measure
Brief Description
Diabetes: Comprehensive
Care
HbA1c testing (most recent date and result from 2015) − HbA1c < 8.0 % =
National Committee for
control − HbA1c > 9.0 % = poor control 2. Retinal eye exam (most recent date Quality Assurance
and result from 2014 or 2015) 3. Medical attention for nephropathy (one of the
following during 2015): − Nephropathy screening or monitoring test −
ACE/ARB therapy − Evidence of nephropathy (ESRD, CKD, kidney transplant)
4. Blood pressure (most recent date and result from 2015) − BP of < 140/90 =
control
Diabetes: Medical
Attention for Nephropathy
Percentage of patients 18-75 years of age with diabetes who had a
nephropathy screening test or evidence of nephropathy during the
measurement period.
National Committee for
Quality Assurance
Diabetes: Hemoglobin A1c
(HbA1c) Poor Control
(>9%)
Percentage of patients 18-75 years of age with diabetes who had hemoglobin
A1c > 9.0% during the measurement period
National Committee for
Quality Assurance
Diabetes: Foot Exam
Percentage of patients 18-75 years of age with diabetes (type 1 and type 2)
who received a foot exam (visual inspection and sensory exam with mono
filament and a pulse exam) during the measurement year
National Committee for
Quality Assurance
Diabetes: Eye Exam
Percentage of patients 18-75 years of age with diabetes who had a retinal or
dilated eye exam by an eye care professional during the measurement period
or a negative retinal exam (no evidence of retinopathy) in the 12 months prior
to the measurement period
National Committee for
Quality Assurance
Diabetes Care for People
with Serious Mental Illness
Hemoglobin (HbA1c) Poor
Control (>9.0%)
Percentage of patients 18-75 years of age with a serious mental illness and
diabetes (type 1 or type 2) whose most recent HbA1c level during the
measurement year is >9.0%.
National Committee for
Quality Assurance (New to
CMCS in 2017)
PCMH Redesign, Quality Measure Review
Primary Steward
7
Chronic Health Issues - Child, Adolescent & Adult (cont’d)
Measure
Brief Description
Primary Steward
Controlling High Blood
Pressure
Percentage of patients 18-85 years of age who had a diagnosis of hypertension and
whose blood pressure was adequately controlled (<140/90mmHg) during the
measurement period
National Committee for
Quality Assurance
Preventive Care and
Screening: Screening for
High Blood Pressure and
Follow-Up Documented
Percentage of patients aged 18 years and older seen during the reporting period who
were screened for high blood pressure AND a recommended follow-up plan is
documented based on the current blood pressure (BP) reading as indicated
Centers for Medicare &
Medicaid Services
Hypertension:
Improvement in Blood
Pressure
Percentage of patients aged 18-85 years of age with a diagnosis of hypertension whose
blood pressure improved during the measurement period.
Centers for Medicare &
Medicaid Services
Optimal Asthma Control
Composite measure of the percentage of pediatric and adult patients whose asthma is
well-controlled as demonstrated by one of three age appropriate patient reported
outcome tools and not at risk for exacerbation
Minnesota Community
Measurement
Medication Management
for People with Asthma
The percentage of patients 5-64 years of age during the measurement year who were
identified as having persistent asthma and were dispensed appropriate medications
that they remained on for at least 75% of their treatment period.
National Committee for
Quality Assurance
Asthma Medication Ratio
Percentage of members ages 5 to 64 who were identified as having persistent asthma
in 2015 and 2016 and had a ≥ 50% ratio of controller medications to total asthma
medications during the 2016 measurement year.
National Committee for
Quality Assurance
Annual Monitoring for
Patients on Persistent
Medications
Percentage of patients 18 years of age and older who received at least 180 treatment
days of ambulatory medication therapy for a select therapeutic agent during the
measurement year and at least one therapeutic monitoring event for the therapeutic
agent in the measurement year. (1) ACE inhibitors or ARBs, (2) Digoxin, (3)
Diuretics, (4) Total rate.
National Committee for
Quality Assurance
PCMH Redesign, Quality Measure Review
8
OHIP Flagship Issue: Tobacco Cessation

In 2013, Oklahoma was ranked 45th in rate of smoking among adults (23.7%).

OHIP Goals:


Reduce adolescent smoking prevalence from 15.1% in 2013 to 10.0% in 2020 for high school-aged
youth and from 4.8% in 2013 to 2.0% in 2020 for middle school-aged youth.

Reduce adult smoking prevalence from 23.7% in 2013 to 18.0% in 2020.
Potential Quality Measures for Consideration:
Measure
Brief Description
Primary Steward
Tobacco Use and Help with
Quitting Among
Adolescents
The percentage of adolescents 12 to 20 years of age with a primary care visit
during the measurement year for whom tobacco use status was documented
and received help with quitting if identified as a tobacco user
National Committee for
Quality Assurance
Preventive Care and
Screening: Tobacco Use:
Screening and Cessation
Intervention
Percentage of patients aged 18 years and older who were screened for
tobacco use one or more times within 24 months AND who received
cessation counseling intervention if identified as a tobacco user
Physician Consortium for
Performance Improvement
Medical Assistance with
Smoking and Tobacco Use
Cessation
Percentage of patients aged 18 years and older who were screened for
tobacco use one or more times within 24 months AND who received
cessation counseling intervention if identified as a tobacco user
Physician Consortium for
Performance Improvement
Children who are Exposed
to Secondhand Smoke
within the Home
Percentage of children 0-17 who live with a smoker and if that smoker smokes
inside the child´s house
The Child and Adolescent
Health Measurement
Initiative
PCMH Redesign, Quality Measure Review
9
OHIP Flagship Issue: Obesity

In 2013, Oklahoma was ranked 44th in the rate of adult obesity (32.5%).

OHIP Goals:



Reduce adolescent obesity prevalence from 11.8% in 2013 to 10.6% in 2020.
Reduce adult obesity prevalence from 32.5% in 2013 to 29.5% in 2020.
Potential Quality Measures for Consideration:
Measure
Brief Description
Weight Assessment and
Counseling for Nutrition
and Physical Activity for
Children and Adolescents
Percentage of patients 3-17 years of age who had an outpatient visit with a Primary National Committee for
Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had
Quality Assurance
evidence of the following: (1) Percentage of patients with height, weight, and body
mass index (BMI) percentile documentation, (2) Percentage of patients with
counseling for nutrition, (3) Percentage of patients with counseling for physical
activity.
Preventive Care and
Screening: Body Mass
Index (BMI) Screening and
Follow-Up Plan
Percentage of patients aged 18 years and older with a BMI documented during the
current encounter or during the previous six months AND with a BMI outside of
normal parameters, a follow-up plan is documented during the encounter or
during the previous six months of the current encounter Normal Parameters:
Age 18 years and older BMI => 18.5 and < 25 kg/m2.
Centers for Medicare &
Medicaid Services
Child Overweight or
Obesity Status Based on
Parental Report of BodyMass-Index (BMI)
Age and gender specific calculation of BMI based on parent reported height and
weight of child (ages 10-17). The measure uses CDC BMI-for-age guidelines in
attributing overweight status (85th percentile up to 94th percentile) and obesity
status (95th percentile and above).
The Child and Adolescent
Health Measurement
Initiative
Preventive screening and
counseling on weight,
healthy diet and exercise
This measure assesses the average proportion of "yes" responses to three items
about whether provider(s) discussed/screened on weight, healthy diet and
exercise among young adults.
NQF
PCMH Redesign, Quality Measure Review
Primary Steward
10
OHIP Flagship Issue: Children’s Health - Maternal Health

In 2013, Oklahoma was ranked 43rdth in terms of infants per 1,000 that do not
survive to their first birthday.

OHIP Goals:


Reduce infant mortality from 6.8/K live births in 2013 to 6.4/K in 2020.

Reduce maternal mortality from 29.1/100K live births to 26.2/100K live births by 2020.
Potential Quality Measures for Consideration:
Measure
Brief Description
Maternity Care: Prenatal
and Postpartum Care
The percentage of deliveries of live births in the measurement year. Measure
National Committee for
includes: (1) The percentage of deliveries that received a prenatal care visit as a Quality Assurance
member of the organization in the first trimester or within 42 days of
enrollment in the organization; (2) The percentage of deliveries that had a
postpartum visit on or between 21 and 56 days after delivery.
Maternity Care: Frequency
of Ongoing Prenatal Care
The percentage of Medicaid deliveries in the measurement year that received
the following number of expected prenatal visits. (1) <21 percent of expected
visits, (2) 21 percent–40 percent of expected visits, (3) 41 percent–60 percent
of expected visits, (4) 61 percent–80 percent of expected visits, (5) ≥81
percent of expected visits.
National Committee for
Quality Assurance
Maternity Care: PostPartum Follow-Up and
Care Coordination
Percentage of patients, regardless of age, who gave birth during a 12-month
period who were seen for post-partum care within 8 weeks of giving birth
who received a breast feeding evaluation and education, post-partum
depression screening, post-partum glucose screening for gestational diabetes
patients, and family and contraceptive planning.
Centers for Medicare &
Medicaid Services
PCMH Redesign, Quality Measure Review
Primary Steward
11
OHIP Flagship Issue: Children’s Health - Maternal Health
(cont’d)
Measure
Brief Description
Contraceptive Care –
Postpartum
Percentage of women ages 15-44 who had a live birth and were provided a
US Office of Population
most or moderately effective method of contraception within 3 and 60 days of Affairs (New to CMCS 2017)
delivery.
Maternity Care: Live Births
Weighing Less than 2,500
grams (LBW)
Infants weighing less than 2,500 grams (5.5 pounds) at birth are considered to
be low birthweight. The low birthweight rate is the number of low
birthweight births per 100 live births for which a birthweight is known.
Centers for Disease Control
& Prevention
Maternity Care: Elective
Delivery or Early Induction
Without Medical Indication
at >= 37 and < 39 Weeks
(Overuse)
Percentage of patients, regardless of age, who gave birth during a 12-month
period who delivered a live singleton at >= 37 and < 39 weeks of gestation
completed who had elective deliveries or early inductions without medical
indication.
Centers for Medicare &
Medicaid Services
Maternity Care: Behavioral
Health Risk Assessment
(Pregnant Women)
Percentage of patients, regardless of age, who gave birth during a 12-month
period seen at least once for prenatal care who received a behavioral health
screening risk assessment that includes the following screenings at the first
prenatal visit: screening for depression, alcohol use, tobacco use, drug use, and
intimate partner violence.
AMA-convened Physician
Consortium for
Performance
Improvement® (PCPI™)
Maternal Depression
Screening
The percentage of children who turned 6 months of age during the
measurement year, who had a face-to-face visit between the clinician and the
child during child's first 6 months, and who had a maternal depression
screening for the mother at least once between 0 and 6 months of life.
National Committee for
Quality Assurance
PCMH Redesign, Quality Measure Review
Primary Steward
12
OHIP Flagship Issue: Children’s Health - Preventive
Measure
Brief Description
Primary Steward
Children's and
Adolescents' Access to
Primary Care Practitioners
Percentage of members 12 months to 19 years of age who had a visit with a
primary care practitioner (PCP). The organization reports four separate
percentages for each product line: Children 12 to 24 months and 25 months
to 6 years who had a visit with a PCP during the measurement year, and
children 7 to 11 years and adolescents 12 to 19 years who had a visit with a
PCP during the measurement year or the year prior to the measurement year.
National Committee for
Quality Assurance
Lead Screening
Assesses children 2 years of age who had one or more blood tests for lead
poisoning by their second birthday.
National Committee for
Quality Assurance
Chlamydia Screening for
Women
Percentage of women 16-24 years of age who were identified as sexually
active and who had at least one test for chlamydia during the measurement
period
National Committee for
Quality Assurance
Chlamydia Screening and
Follow Up
The percentage of female adolescents 16 years of age who had a chlamydia
screening test with proper follow-up during the measurement period
National Committee for
Quality Assurance
Non-Recommended
Cervical Cancer Screening
in Adolescent Females
The percentage of adolescent females 16-20 years of age who were screened
unnecessarily for cervical cancer
National Committee for
Quality Assurance
Audiology Evaluation
Newborns with audiology evaluation no later than 3 months of age
Centers for Disease
Control & Prevention
Appropriate Treatment for
Children with Upper
Respiratory Infection (URI)
Percentage of children 3 months-18 years of age who were diagnosed with
upper respiratory infection (URI) and were not dispensed an antibiotic
prescription on or three days after the episode
National Committee for
Quality Assurance
Appropriate Testing for
Children with Pharyngitis
Percentage of children 3-18 years of age who were diagnosed with pharyngitis,
ordered an antibiotic and received a group A streptococcus (strep) test for
the episode
National Committee for
Quality Assurance
PCMH Redesign, Quality Measure Review
13
OHIP Flagship Issue: Children’s Health – Preventive (cont’d)
Measure
Brief Description
Primary Steward
Well-Child Visits in the First
15 Months of Life
Percentage of members who turned 15 months old during the measurement
year and who had the following number of well-child visits with a PCP during
their first 15 months of life: 0-6 Visits
National Committee for
Quality Assurance
Well-Child Visits in the
3rd, 4th, 5th, 6th Years of
Life
Percentage of members 3–6 years of age who received one or more well-child
visits with a PCP during the measurement year.
National Committee for
Quality Assurance
Developmental Screening
in the First Three Years of
Life
Percentage of children screened for the risk of developmental, behavioral and
social delays using a standardized screening tool in the 12 months preceding
their 1st, 2nd and 3rd birthdays.
Oregon Health and Science
University
Childhood Immunization
Status
Percentage of children 2 years of age who had four diphtheria, tetanus and
acellular pertussis (DTaP); three polio (IPV), one measles, mumps and rubella
(MMR); three H influenza type B (HiB); three hepatitis B (Hep B); one chicken
pox (VZV); four pneumococcal conjugate (PCV); one hepatitis A (Hep A); two
or three rotavirus (RV); and two flu vaccines by their second birthday.
National Committee for
Quality Assurance
Adolescent Well-Care
Visits
Percentage of enrolled members 12–21 years of age who had at least one
comprehensive well-care visit with a PCP or an OB/GYN practitioner during
the measurement year.
National Committee for
Quality Assurance
Immunizations for
Adolescents
The percentage of adolescents 13 years of age who had the recommended
immunizations by their 13th birthday. (Adding HPV in 2017; retired separate
HPV measure)
National Committee for
Quality Assurance
Preventive Care and
Screening: Influenza
Immunization
Percentage of patients aged 6 months and older seen for a visit between
October 1 and March 31 who received an influenza immunization OR who
reported previous receipt of an influenza immunization.
Physician Consortium for
Performance Improvement
PCMH Redesign, Quality Measure Review
14
OHIP Flagship Issue: Children’s Health - Oral Health

As recognized by the American Association of Pediatrics, oral health is an integral component
of the overall health of children.

Primary care physicians and dentists have an opportunity to evaluate children for dental caries
risk and employ preventive strategies to mitigate risk.

Potential Quality Measures for Consideration:
Measure
Brief Description
Primary Steward
Annual Dental Visit
Percentage of members 2 to 20 years of age who had at least one dental visit
during the measurement year.
National Committee for
Quality Assurance
Preventive Dental Services
Percentage of children (1-17) who had one or more preventive dental visits in
the past 12 months.
The Child and Adolescent
Health Measurement
Initiative
Children Who Have Dental
Decay or Cavities
Percentage of children, age 0-20 years, who have had tooth decay or cavities
during the measurement period.
Centers for Medicare &
Medicaid Services
Primary Caries Prevention
Intervention as Offered by
PCPs, including Dentists
Percentage of children, age 0-20 years, who received a fluoride varnish
application during the measurement period.
Centers for Medicare &
Medicaid Services
Dental Sealants for 6-9
Year Old Children at
Elevated Caries Risk
Percentage of enrolled children in the age category of 6–9 years at “elevated”
risk (i.e., “moderate” or “high”) who received a sealant on a permanent first
molar tooth as a dental OR oral health service within the reporting year.
Dental Quality Alliance
Ambulatory Care Sensitive
Emergency Department
Visits for Dental Caries in
Children
Number of emergency department visits for caries-related reasons per
100,000 member months for all enrolled children.
American Dental
Association in behalf of the
Dental Quality Alliance
PCMH Redesign, Quality Measure Review
15
OHIP Flagship Issue: Behavioral Health

In 2013, Oklahoma was ranked 44th on the number of poor mental health days in
the past 30 days reported by adults (4.3 days).

OHIP Goals (on three dimensions):


Reduce the prevalence of addiction disorders from 8.8% to 7.8% by 2020.

Reduce the prevalence of untreated mental illness from an 86% treatment gap in 2013 to
76% in 2020.

Reduce suicide deaths from 22.8/100K in 2013 to 19.4/100K in 2020.
Potential Quality Measures for Consideration, are presented in three Domains:
Mental
Illness
PCMH Redesign, Quality Measure Review
Addiction
Suicide
16
OHIP Flagship Issue: BH - Mental Illness
Mental Health
Measures
Brief Description
Preventive Care and
Screening: Screening for
Clinical Depression and
Follow-Up Plan
Percentage of patients aged 12 years and older screened for depression on the Centers for Medicare &
date of the encounter using an age appropriate standardized depression
Medicaid Services
screening tool AND if positive, a follow-up plan is documented on the date of
the positive screen.
Depression: Utilization of
the PHQ-9 Tool
Patients age 18 and older with the diagnosis of major depression or dysthymia
who have a Patient Health Questionnaire (PHQ-9) tool administered at least
once during a 4-month period in which there was a qualifying visit.
Minnesota Community
Measurement
Depression: Remission at
Twelve Months
Patients age 18 and older with major depression or dysthymia and an initial
Patient Health Questionnaire (PHQ-9) score greater than nine who
demonstrate remission at twelve months (+/- 30 days after an index visit)
defined as a PHQ-9 score less than five. This measure applies to both patients
with newly diagnosed and existing depression whose current PHQ-9 score
indicates a need for treatment.
Minnesota Community
Measurement
Anti-Depressant Medication
Management
Percentage of patients 18 years of age and older who were treated with
antidepressant medication, had a diagnosis of major depression, and who
remained on an antidepressant medication treatment, for (1) for at least 84
days (12 weeks), and for at least 180 days (6 months).
National Committee for
Quality Assurance
Follow-Up Care for
Children Prescribed
AttentionDeficit/Hyperactivity
Disorder (ADHD)
Medication
Percentage of children 6-12 years of age and newly dispensed a medication for
attention-deficit/hyperactivity disorder (ADHD) who had appropriate followup care. Two rates are reported. a. Percentage of children who had one
follow-up visit with a practitioner with prescribing authority during the 30-Day
Initiation Phase. b. Percentage of children who remained on ADHD
medication for at least 210 days and who, in addition to the visit in the
Initiation Phase, had at least two additional follow-up visits with a practitioner
within 270 days (9 months) after the Initiation Phase ended.
National Committee for
Quality Assurance
PCMH Redesign, Quality Measure Review
Primary Steward
17
OHIP Flagship Issue: BH - Mental Illness (cont’d)
Mental Health
Measures
Brief Description
Follow-Up After Emergency
Department for Mental
Illness
Percentage of emergency department (ED) visits for members 6 years of age
National Committee for
and older with a primary diagnosis of mental illness, who had an outpatient
Quality Assurance (First Year
visit, an intensive outpatient encounter or a partial hospitalization for mental
HEDIS Measure)
illness. Two rates reported: follow-up within 7 days of the visit, and the follow
up within 30 days of the visit.
Follow-Up After
Emergency Department for
Alcohol and Other Drug
Dependence
Percentage of ED visits for members 13 years of age and older with a primary
diagnosis of alcohol and other drug (AOD) dependence, who had an
outpatient visit, an intensive outpatient encounter or a partial hospitalization
for AOD. Two rates are reported for each measure: The percentage of ED
visits for which the member received
follow-up within 7 days of the visit and the percentage of ED visits for which
the member received follow-up.
National Committee for
Quality Assurance (First
Year HEDIS Measure)
Follow-Up After Discharge
from Emergency
Department for Mental
Illness or Alcohol and
Other Drug Dependence
Percentage of ED discharges for patients 18 years of age and older who had a
visit to the emergency department with a primary diagnosis of mental health
or alcohol or other drug dependence during the measurement year, who had
a follow-up visit with any provider with a corresponding primary diagnosis of
mental health or alcohol or other drug dependence within 7 and 30 days of
discharge.
National Committee for
Quality Assurance (New to
CMCS in 2017)
Follow-Up After
Hospitalization for Mental
Illness (FUH)
Percentage of discharges for patients 6 years of age and older who were
hospitalized for treatment of selected mental illness diagnoses and who had an
outpatient visit, an intensive outpatient encounter or partial hospitalization
with a mental health practitioner. Two rates reported: follow-up within 7 days
of the visit, and the follow up within 30 days of the visit.
National Committee for
Quality Assurance
Diabetes Monitoring for
People with Diabetes and
Schizophrenia
Percentage of members 18 to 64 years of age with schizophrenia and diabetes
who had both a low-density lipoprotein cholesterol (LDL-C) test and a
hemoglobin A1c (HbA1c) test during the measurement year.
National Committee for
Quality Assurance
PCMH Redesign, Quality Measure Review
Primary Steward
18
OHIP Flagship Issue: BH - Mental Illness (cont’d)
Mental Health
Measures
Brief Description
Primary Steward
Diabetes Screening for
People with Schizophrenia
or Bipolar Disorder Using
Antipsychotic Meds
Percentage of members 18 to 64 years of age with schizophrenia or bipolar
disorder who were dispensed an antipsychotic medication and had a diabetes
screening test during the measurement year.
National Committee for
Quality Assurance
Adherence to
Antipsychotic Medications
For Individuals with
Schizophrenia
Percentage of individuals at least 18 years of age as of the beginning of the
measurement period with schizophrenia or schizoaffective disorder who had
at least two prescriptions filled for any antipsychotic medication and who had
a Proportion of Days Covered (PDC) of at least 0.8 for antipsychotic
medications during the measurement period (12 consecutive months)
Health Services Advisory
Group
Use of Multiple Concurrent
Antipsychotics in Children
and Adolescents
This measure is used to assess the percentage of children and adolescents 1 to AHRQ, CMS
17 years of age who were on two or more concurrent antipsychotic
medications.
Use of First-Line
Psychosocial Care for
Children and Adolescents
on Antipsychotics
Percentage of children and adolescents 1 to 17 years of age who had a new
prescription for an antipsychotic medication and had documentation of
psychosocial care as first-line treatment.
National Committee for
Quality Assurance (New to
CMCS in 2017)
Metabolic Monitoring for
Children and Adolescents
on Antipsychotics
This measure is used to assess the percentage of children and adolescents 1 to
17 years of age who had two or more antipsychotic prescriptions and had
metabolic testing.
National Committee for
Quality Assurance
PCMH Redesign, Quality Measure Review
19
OHIP Flagship Issue: BH - Addiction
Addiction Measures
Brief Description
Initiation and Engagement of
Alcohol and Other Drug
Dependence Treatment
Percentage of patients 13 years of age and older with a new episode of alcohol National Committee for
and other drug (AOD) dependence. (1) Percentage of patients who initiated
Quality Assurance
treatment within 14 days of the diagnosis. (2) Percentage of patients who
initiated treatment and who had two or more additional services with an AOD
diagnosis within 30 days of the initiation visit.
Preventive Care and
Screening: Unhealthy
Alcohol Use: Screening &
Brief Counseling
Percentage of patients aged 18 years and older who were screened for
unhealthy alcohol use using a systematic screening method at least once within
the last 24 months AND who received brief counseling if identified as an
unhealthy alcohol user.
Physician Consortium for
Performance Improvement
Bipolar Disorder and Major
Depression: Appraisal for
alcohol or chemical
substance use.
Percentage of patients with depression or bipolar disorder with evidence of an
initial assessment that includes an appraisal for alcohol or chemical substance
use.
Center for Quality
Assessment and
Improvement in Mental
Health
Evaluation or Interview for
Risk of Opioid Misuse
All patients 18 and older prescribed opiates for longer than six weeks duration American Academy of
evaluated for risk of opioid misuse using a brief validated instrument (e.g.
Neurology
Opioid Risk Tool, SOAPP-R) or patient interview documented at least once
during Opioid Therapy in the medical record.
Opioid Therapy Follow-up
Evaluation
All patients 18 and older prescribed opiates for longer than six weeks
duration who had a follow-up evaluation conducted at least every three
months during Opioid Therapy documented in the medical record.
American Academy of
Neurology
Use of Opioids at High
Dosage (in Persons
without Cancer)
The proportion of individuals without cancer who are receiving very high daily
dosages for an extended period of time.
Pharmacy Quality Alliance
Documentation of Signed
Opioid Treatment
Agreement
All patients 18 and older prescribed opiates for longer than six weeks
duration who signed an opioid treatment agreement at least once during
Opioid Therapy documented in the medical record.
American Academy of
Neurology
PCMH Redesign, Quality Measure Review
Primary Steward
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OHIP Flagship Issue: BH - Suicide
Addiction Measures
Brief Description
Primary Steward
Child and Adolescent Major
Depressive Disorder
(MDD): Suicide Risk
Assessment
Percentage of patient visits for those patients aged 6 through 17 years with a
diagnosis of major depressive disorder with an assessment for suicide risk.
Physician Consortium for
Performance Improvement
Bipolar disorder Suicide
Risk Assessment
This measure is used to assess the percentage of patients diagnosed with
bipolar disorder who receive an initial assessment that considers the risk of
suicide.
STABLE Project National
Coordinating Council
Preventive Screening and
Counseling on Emotional
Health and Relationship
Issues
This measure assesses the average proportion of "yes" responses to six items
about whether provider(s) discussed/screened for feeling sad or depressed,
school performance, friends, suicide and sexual orientation among young
adults.
Child and Adolescent
Health Measurement
Initiative
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Utilization, Efficiency & Coordination Measures
Measure
Brief Description
Ambulatory
Care/Emergency
Department Visits
For members 18 years of age and older, the number of emergency department National Committee for
(ED) visits during the measurement year (observed) and the predicted
Quality Assurance
probability of ED visits (expected).
Inpatient Utilization
Summary of utilization of acute inpatient care and services in the following
categories: Total Inpatient, Maternity, Surgery, and Medicine.
National Committee for
Quality Assurance
All-cause Hospital
Readmission
The 30-day All-Cause Hospital Readmission measure is a risk-standardized
readmission rate for beneficiaries age 65 or older who were hospitalized at a
short-stay acute care hospital and experienced an unplanned readmission for
any cause to an acute care hospital within 30 days of discharge.
Yale University
Unplanned Hospital
Readmission w/in 30 Days
of Principal Procedure
Percentage of patients aged 18 years and older who had an unplanned hospital
readmission within 30 days of principal procedure
American College of
Surgeons
Closing the Referral Loop:
Receipt of Specialist Report
Percentage of patients with referrals, regardless of age, for which the referring
provider receives a report from the provider to whom the patient was
referred
Centers for Medicare &
Medicaid Services
Documentation of Current
Medications in the Medical
Record
Percentage of visits for patients aged 18 years and older for which the eligible
professional attests to documenting a list of current medications using all
immediate resources available on the date of the encounter. This list must
include ALL known prescriptions, over-the-counters, herbals, and
vitamin/mineral/dietary (nutritional) supplements AND must contain the
medications' name, dosage, frequency and route of administration.
Centers for Medicare &
Medicaid Services
PCMH Redesign, Quality Measure Review
Primary Steward
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Utilization, Efficiency & Coordination Measures (cont’d)
Measure
Brief Description
Primary Steward
Medication Reconciliation
Post-Discharge
The percentage of discharges from any IP facility for patients 18 years + seen
within 30 days following discharge in the office by the physician, prescribing
practitioner, RN, or clinical pharmacist providing on-going care for whom the
discharge medication list was reconciled with the current medication list in the
outpatient medical record. Reporting Criteria 1): 18-64 years of age; 2): 65
years and older; 3)Total Rate: All patients 18 years of age and older.
National Committee for
Quality Assurance
Use of Imaging Studies for
Low Back Pain
Percentage of patients 18-50 years of age with a diagnosis of low back pain
who did not have an imaging study (plain X-ray, MRI, CT scan) within 28 days
of the diagnosis.
National Committee for
Quality Assurance
PCMH Redesign, Quality Measure Review
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Patient Experience
Measure
Brief Description
Primary Steward
CAHPS for PQRS
Clinician/Group Survey
Getting timely care, appointments, and information; How well providers
Communicate; Patient's Rating of Provider; Access to Specialists; Health
Promotion & Education; Shared Decision Making; Health Status/Functional
Status; Courteous and Helpful Office Staff; Care Coordination; Between
Visit Communication; Helping Your to Take Medication as Directed; and
Stewardship of Patient Resources
Agency for Healthcare
Research & Quality
CAHPS 5.0 (Child Version,
Including Medicaid and
Children with Chronic
Conditions Supplemental
Items)
Above, plus Child Supplements.
AHRQ/National Committee
for Quality Assurance
CAHPS 5.0 (Adult Version)
Above, plus Adult Medicaid Supplements.
AHRQ/National Committee
for Quality Assurance
PCMH Redesign, Quality Measure Review
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Appendix: Behavioral Health Integration


Components of Integrated Model
Pediatric Screening Tools
PCMH Redesign, Quality Measure Review
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Integrated Behavioral Health Model:
Meadows Mental Health Policy Institute
IBH
Component
Definitional Overview
Integrated
Organizational
Culture
• IBH is highlighted in the organization’s vision and mission.
• Leadership actively supports IBH by promoting it in all organizational functions.
• IBH champions are identified and empowered.
Population
Health
Management
• IBH programs assess and differentiate their patients by their prevalent co-occurring conditions and utilization patterns.
• Health information technologies are used to manage outcomes across populations to apply the right interventions at
the right time, and to help ensure high quality care and optimal health and wellness outcomes.
Structured Use
of a Team
• Both physical health (PH) and BH providers are to the fullest practical extent physically located in the same space.
• A team based, shared workflow is present, through which continuous communication and collaboration occur to
carry out mutually-reinforcing and coordinated PH and BH care.
IBH Staff
Competencies
• Providers who are part of an IBH team must be able to coordinate care with external specialty providers and social
services, collaborate with colleagues, engage patients effectively, and conduct motivational interventions.
Universal
Screening for the
Most Prevalent PH
and BH
Conditions
• In primary care, regular and universally applied screening for common mental health and substance abuse conditions
that are both prevalent and associated with the costliest co-occurring illnesses ensures that BH conditions are
detected and incorporated into treatment plans.
• IBH programs located in BH settings must incorporate screens for common and costly PH conditions.
Integrated
Person Centered
Treatment Plans
• Each person should have a single treatment plan that incorporates all PH and BH conditions, relevant
treatment/recovery goals, and intervention plans.
• The plan should be person-centered/directed, incorporating pertinent values, lifestyles and social contexts.
Systematic Use
of Evidenced
Based Clinical
Models
• Successful programs use systematic clinical approach that target specific conditions prioritized for care in that setting.
• All providers use well-developed and shared clinical pathways for co-occurring conditions that are rooted in practice
guidelines and evidence-based practice.
• Evidence-based health/wellness programming is readily accessible to patients.
PCMH Redesign, Quality Measure Review
http://texasstateofmind.org/wp-content/uploads/2016/09/Meadows_IBHreport_FINAL_9.8.16.pdf
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Pediatric Screening Tools for Mental
Health and Substance Abuse



Pediatric Symptom Checklist (PSC-35 and PSC-Youth (11+)): Bright Futures

The Pediatric Symptom Checklist is a psychosocial screen designed to facilitate the recognition of cognitive, emotional,
and behavioral problems so that appropriate interventions can be initiated as early as possible. Included here are two
versions, the parent-completed version (PSC) and the youth self-report (Y-PSC). The Y-PSC can be administered to
adolescents ages 11 and up.

https://www.brightfutures.org/mentalhealth/pdf/professionals/ped_sympton_chklst.pdf
CRAFFT: From The Center for Adolescent Substance Abuse Research

The CRAFFT is a behavioral health screening tool for use with children under the age of 21 and is recommended by the
American Academy of Pediatrics' Committee on Substance Abuse for use with adolescents. It consists of a series of 6
questions developed to screen adolescents for high risk alcohol and other drug use disorders simultaneously. It is a short,
effective screening tool meant to assess whether a longer conversation about the context of use, frequency, and other
risks and consequences of alcohol and other drug use is warranted.

http://www.ceasar-boston.org/CRAFFT/index.php
Personal Health Questionnaire-9 (PHQ-9):

The Patient Health Questionnaire (PHQ) is a self-administered version of the PRIME-MD diagnostic instrument for
common mental disorders. The PHQ-9 is a multi-purpose instrument for screening, diagnosing, monitoring and
measuring the severity of depression. It rates the frequency of the symptoms which factor into the scoring severity
index, and Question 9 specifically screens for the presence and duration of suicide ideation. A non-scored question
weights the degree to which depressive problems have affected the patient’s level of function.

http://www.agencymeddirectors.wa.gov/files/AssessmentTools/14-PHQ-9%20overview.pdf
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