Behavioral Health Clinic Quality Measures(BHCQMs) 0418 Screening for Clinical Depression and Follow- Up Plan (CDF-BH) 0710 Depression Remission at 12 Months March 2, 2017

Objectives of this webinar The participants will be able to - Describe what needs to be collected in these measures Plan how to gather and record data for the measures Identify process changes which will need to occur at each Center

Purpose and Benefits Nationally, 15.7% of people report a physician telling them they have depression in their lifetime Individuals with a current diagnosis of depression or anxiety were more likely to have cardiovascular disease, diabetes, asthma and obesity. Were more likely to be a current smoker, be physically inactive or drink heavily Major depression is a leading cause of disability in the US for persons aged 15-44. Source: ICSI Guideline for Major Depression in Adults in Primary Care 16th edition September 2013 ISCI Guideline for Major Depression in Adults in Primary Care Guideline Web PDF

0418 Screening for Clinical Depression and Follow-Up Plan (CDF-BH) What outcome is being measured? The percentage of consumers aged 12 and older screened for clinical depression on the date of the encounter using an age- appropriate standardized depression screening tool, and if positive, a follow-up plan is documented on the date of the positive screen Screen, then make a plan

Who is eligible? Consumers flagged as having had an outpatient visit at the provider entity at least once during the measurement year and who are 12 years old or older on the date of the encounter. Very broad….. So nearly everyone

There are exclusions: Consumer has an active diagnosis of Depression or Bipolar Disorder Consumer refuses to participate Consumer is in an urgent or emergent situation where time is of the essence and to delay treatment would jeopardize the consumer’s health status Situations where the consumer’s functional capacity or motivation to improve may impact the accuracy of results of nationally recognized standardized depression assessment tools (for example, certain court-appointed cases or cases of delirium). …..but

Depression Screening Tool: Normalized and validated for the population in which it is being utilized. The name of the age-appropriate standardized depression screening tool utilized must be documented in the medical record. Some depression screening tools are: Patient Health Questionnaire (PHQ-9); Beck Depression Inventory (BDI or BDI-II); Center for Epidemiologic Studies Depression Scale (CES-D); Depression Scale (DEPS); Duke Anxiety-Depression Scale (DADS); Geriatric Depression Scale (GDS); Hopkins Symptom Checklist (HSCL); The Zung Self-Rating Depression Scale (SDS), and Cornell Scale Screening and PRIME MD-PHQ2.

Depression Screening Tool: PHQ-9 PHQ-9 recommended by the Behavioral Health Advisory Committee to HHSC Used with many DSRIP measures We are going to use this Adult and Adolescent versions available Self administered – brief scores each of the 9 DSM-IV criteria as “0” (not at all) to “3”

Follow Up Plan: Proposed outline of treatment to be conducted as a result of screening. Follow-up for a positive depression screening must include one (1) or more of the following: Additional evaluation Suicide risk assessment Referral to a practitioner who is qualified to diagnose and treat depression Pharmacological interventions Other interventions or follow-up for the diagnosis or treatment of depression The documented follow-up plan must be related to a positive depression screening, for example: “Patient referred for psychiatric evaluation due to positive depression screening.” How can you build your plan? Can you make it a database with elements that can be capitalized and used for other measures? Is there opportunity for overlap?

How to calculate the percentage: Numerator: The number of consumers who were screened for clinical depression using a standardized tool AND, if positive, a follow-up plan is documented on the date of the positive screen Denominator: The number of consumers in the eligible population with an outpatient visit during the measurement year Consumers flagged as having had an outpatient visit at the provider entity at least once during the measurement year and who are 12 years old or older on the date of the encounter.

Reporting: Stratified by whether the consumer is a Medicaid beneficiary, LIOU, and Other (as of the date of the visit). Stratified by age group (ages 12 to 17, ages 18 to 64, and age 65 and older). Web-based reporting on the Texas Council site

Example: How to calculate the denominator -Stratified by Payor Source Steps Medicaid LIOU Other Total Age and outpatient encounter-eligible consumers seen during MY 250 100 50 400 Exclusions 45 15 10 70 Denominator 205 85 40 330 MY = Measurement Year Consumer has an active diagnosis of Depression or Bipolar Disorder Consumer refuses to participate Consumer is in an urgent or emergent situation

Example: How to calculate the numerator -Stratified by Payor Source Steps Medicaid LIOU Other Total Consumers screened for clinical depression with positive screen 100 55 5 160 Consumers with positive screen who had a follow-up plan documented on the same day 90 30 3 123 Numerator

Example: Example: Stratified Total - Payor Medicaid: 90/205 = .44 or 44% LIOU: 30/85 = .35 or 35% Other: 3/40 = .08 or 8% Total: 123/330 = .37 or 37%

Example: How to calculate the denominator -Stratified by age group Steps Aged 12-17 years Aged 18-64 years Aged 65 or older Total Age and outpatient encounter-eligible consumers seen during MY 100 225 75 400 Exclusions 20 40 10 70 Denominator 80 185 65 330

Example: How to calculate the numerator -Stratified by age group Steps Aged 12-17 years Aged 18-64 years Age 65 or older Total Consumers screened for clinical depression with positive screen 65 170 35 270 Consumers with positive screen who had a follow-up plan documented on the same day 40 63 20 123 Numerator

Example: Example: Stratified Total – age group Aged 12-17: 40/80 = .50 or 50% Aged 18-64: 63/185 = .34 or 34% Aged 65 and older: 20/65 = .31 or 31% Total: 123/330 = .37 or 37%

Concerns / Lessons Learned: “It is just one more thing to do” Process Changes Data collection / Report Making Outcome Improvement Who will do the screening? QMHP? How much time will it take? Follow-up Plan = Opportunity for Recovery Planning options Team approach Build then verify Verify then improve Related outcome strategies Housing, Employment Relationships to Smoking and Drinking

0710 Depression Remission at 12 months What outcome is being measured? The percentage of adults years 18 and older with Major Depression or Dysthymia who reached remission +/- 30 days after an index visit. Applies to individuals with new and existing diagnoses with a current PHQ-9 score greater than (9) nine. Index Event: Anyone who has an existing or new diagnosis of Major Depression or Diagnosis or Dysthymia with a PHQ-9 with a score above 9. Remission: tracked +/-30 days (11-13 months from index event) with a PHQ-9 Score of 5 or less. Denominator: Eligible population: Individuals (1) seen at least 1x in measurement year with (2) a diagnosis of Dysthymia or depression during an encounter in the measurement year. (3) Must have an index date PHQ-9 score greater than 9 documented during the 12 month denominator identification period and are (4) 18 years or older at the index date. Numerator: The number of individuals who achieve remission with a PHQ-9 result less than 5, 12 months (+/- 30 days) after index visit. Exclusions: Active diagnosis of Bipolar or Personality Disorder; additional optional exclusions: died, went into hospice care or permanent nursing home resident For behavioral health providers, the Depression or dysthymia diagnosis codes must be listed as the primary diagnosis. This excludes patients with other psychiatric diagnoses with a secondary component of Depression. If the provider is primary care, the diagnosis codes can be in any position (this might occur if the patient was diagnosed by a primary care provider and subsequently seen by the BHC). This distinction between behavioral health providers and other providers is only meaningful for BHCs that include non-behavioral health healthcare providers who may screen for depression as a part of providing general health care.

What needs to be collected? Tracked? Individuals seen during Measurement Year (not excluded) Whose PHQ-9 score was greater than 9 (at the index date) during MY Active Diagnosis of MDD or Dysthymia at the time of index event (F32-F33, F34 codes) Those age 18 or older at the time of the index event. Subsequent PHQ-9 scores administered 11-13 months post index event with a score of 5 or less (deemed remission). Pay source (to stratify, Medicaid, Low-income, uninsured) Exclusions: Died, were in hospice, became permanent Nursing home resident, had diagnosis of Bipolar (F31 codes)* or Personality Disorder (F60)* during Measurement Year *indicates a required exclusion

Denominator Data Criteria Example: 200 individuals were seen in Measurement Year -10 died -5 were in Hospice -45 changed diagnosis to either Bipolar or Personality Disorder 160 non-excluded persons Denominator computes: Number of persons in the eligible population (minus exclusions): Of those, the number of persons with a PHQ-9 score above 9 on index date Index date = ALL of the following: PHQ-9 greater than 9 Active Diagnosis of Major Depression or Dysthymia NOT seen in a prior index period Index period BEGINS with Above defined Index date and is up to 13 months in duration. Of those, who have a diagnosis of major depression or Dysthymia on the index date Who are 18 years of age or older at the time of the index event Steps Medicaid Medicare/ Medicaid Other Total Non excluded 100 20 140 PHQ 9 <9 75 10 105 Active Dx 55 5 80 Ages 18 and < 40 15 60 Denominator:

Numerator Criteria Data Number of persons who achieve remission by scoring less than 5 on a PHQ-9 twelve (12) months after the index date (+/- 30 days): Eligible Individuals after exclusions Minus those not administered PHQ-9 during 60 day window of twelve months Or those tested during the 60 day window, but scored a 5 or higher on the PHQ-9 Because of the Reporting Period, there will be limitations regarding what can be reported and when. Continuing Example: Steps Medicaid Medicare/Medicaid Other Total Eligible 40 15 5 60 Not admin PHA-9 4 2 1 7 Scored 5 or higher 3 11 Numerator 40-11=29 15-5=10 5-2=3 60-18=42 Reason for +/- 30 days is for the re-assessment

Performance Interpretation Better Quality = Higher Score. Based on the Example above: Quality Measure, percentage with 12-month depression remission: Medicaid: 29/40 = .725 = .73 or 73% Medicare and Medicaid: 10/15 = .666 = .67 or 67% Neither: 3/5 = .60 = .60 or 60% Total: 42/60 = .70 = .70 or 70%

Reporting Considerations: Keep in mind you can’t include anyone in the Numerator who has not had a PHQ-9 11-13 months from the index event. You will have low or preliminary numbers that you report in the first reporting period. You will have individuals that have an index event within the reporting period WITHOUT second assessment within the reporting period, these would be reported in a subsequent period. For example: If you were reporting this for DSRIP and started collecting in October 2017, for reporting the following October 2018 you would only be able to report individuals with an index event October 2017 or November 2017 (preliminary numbers). Full reporting of this measure would be October 2019 to accommodate all index dates in the first year.

0710 Depression Remission at 12 months What outcome is being measured? The percentage of adults years 18 and older with Major Depression or Dysthymia who reached remission +/- 30 days after an index visit. Applies to individuals with new and existing diagnoses with a current PHQ-9 score greater than (9) nine. Index Event: Anyone who has an existing or new diagnosis of Major Depression or Diagnosis or Dysthymia with a PHQ-9 with a score above 9. Remission: tracked +/-30 days (11-13 months from index event) with a PHQ-9 Score of 5 or less. Denominator: Eligible population: Individuals (1) seen at least 1x in measurement year with (2) a diagnosis of Dysthymia or depression during an encounter in the measurement year. (3) Must have an index date PHQ-9 score greater than 9 documented during the 12 month denominator identification period and are (4) 18 years or older at the index date. Numerator: The number of individuals who achieve remission with a PHQ-9 result less than 5, 12 months (+/- 30 days) after index visit. Exclusions: Active diagnosis of Bipolar or Personality Disorder; additional optional exclusions: died, went into hospice care or permanent nursing home resident For behavioral health providers, the Depression or dysthymia diagnosis codes must be listed as the primary diagnosis. This excludes patients with other psychiatric diagnoses with a secondary component of Depression. If the provider is primary care, the diagnosis codes can be in any position (this might occur if the patient was diagnosed by a primary care provider and subsequently seen by the BHC). This distinction between behavioral health providers and other providers is only meaningful for BHCs that include non-behavioral health healthcare providers who may screen for depression as a part of providing general health care.

What needs to be collected? Tracked? Individuals seen during Measurement Year (not excluded) Whose PHQ-9 score was greater than 9 (at the index date) during MY Active Diagnosis of MDD or Dysthymia at the time of index event (F32-F33, F34 codes) Those age 18 or older at the time of the index event. Subsequent PHQ-9 scores administered 11-13 months post index event with a score of 5 or less (deemed remission). Pay source (to stratify, Medicaid, Low-income, uninsured) Exclusions: Died, were in hospice, became permanent Nursing home resident, had diagnosis of Bipolar (F31 codes)* or Personality Disorder (F60)* during Measurement Year *indicates a required exclusion

Denominator Data Criteria Example: 200 individuals were seen in Measurement Year -10 died -5 were in Hospice -45 changed diagnosis to either Bipolar or Personality Disorder 160 non-excluded persons Denominator computes: Number of persons in the eligible population (minus exclusions): Of those, the number of persons with a PHQ-9 score above 9 on index date Index date = ALL of the following: PHQ-9 greater than 9 Active Diagnosis of Major Depression or Dysthymia NOT seen in a prior index period Index period BEGINS with Above defined Index date and is up to 13 months in duration. Of those, who have a diagnosis of major depression or Dysthymia on the index date Who are 18 years of age or older at the time of the index event Steps Medicaid Medicare/ Medicaid Other Total Non excluded 100 20 140 PHQ 9 <9 75 10 105 Active Dx 55 5 80 Ages 18 and < 40 15 60 Denominator:

Numerator Criteria Data Number of persons who achieve remission by scoring less than 5 on a PHQ-9 twelve (12) months after the index date (+/- 30 days): Eligible Individuals after exclusions Minus those not administered PHQ-9 during 60 day window of twelve months Or those tested during the 60 day window, but scored a 5 or higher on the PHQ-9 Because of the Reporting Period, there will be limitations regarding what can be reported and when. Continuing Example: Steps Medicaid Medicare/Medicaid Other Total Eligible 40 15 5 60 Not admin PHA-9 4 2 1 7 Scored 5 or higher 3 11 Numerator 40-11=29 15-5=10 5-2=3 60-18=42 Reason for +/- 30 days is for the re-assessment

Performance Interpretation Better Quality = Higher Score. Based on the Example above: Quality Measure, percentage with 12-month depression remission: Medicaid: 29/40 = .725 = .73 or 73% Medicare and Medicaid: 10/15 = .666 = .67 or 67% Neither: 3/5 = .60 = .60 or 60% Total: 42/60 = .70 = .70 or 70%

Reporting Considerations: Keep in mind you can’t include anyone in the Numerator who has not had a PHQ-9 11-13 months from the index event. You will have low or preliminary numbers that you report in the first reporting period. You will have individuals that have an index event within the reporting period WITHOUT second assessment within the reporting period, these would be reported in a subsequent period. For example: If you were reporting this for DSRIP and started collecting in October 2017, for reporting the following October 2018 you would only be able to report individuals with an index event October 2017 or November 2017 (preliminary numbers). Full reporting of this measure would be October 2019 to accommodate all index dates in the first year.