Series 1: Meaningful Use for Behavioral Health Providers 9/2013 From the CIHS Video Series “Ten Minutes at a Time” Module 5: Clinical Quality Measures and Behavioral Health

Module 7 Outline Core Objective #10 “Report Ambulatory Clinical Quality Measures to CMS” How Clinical Quality Measures are Defined How Clinical Quality Measures are Gathered and Reported The Clinical Quality Measures for Behavioral Health use/core-measures/clinical-quality-measures

Core Objective #10: Clinical Quality Measures (CQMs) Objective 10 Report ambulatory clinical quality measures to CMS Measure For 2011, provide aggregate numerator, denominator, and exclusions through attestation. For 2012, electronically submit the clinical quality measures Stage 1 focus – ABILITY to report on CQMs measures/clinical-quality-measures

Three Core CQMs NQF 0013 Hypertension – Blood Pressure Measurement Percent of patient visits for patients 18+ with a diagnosis of hypertension who have been seen for at least 2 office visits with blood pressure recorded NQF 0028 Preventative Care and Screening Measure Pair A) Tobacco assessment – percent of patients 18+ who have been seen for at least 2 office visits who were queried about tobacco use one or more times within 24 months B) Tobacco cessation intervention– percent of patients 18+ identified as tobacco users within the past 24 months who received cessation intervention NQF 0421 Adult Weight Screening and Follow Up Percent of patients 18+ with a calculated BMI in the past 6 months or during the current visit documented in the medical record AND if the most recent BMI is outside parameters, a follow up plan is documented

Three Alternate CQMs NQF 0024 Weight Assessment and Counseling for Children and Adolescents The percentage of patients 2-17 years of age who had an outpatient visit with a PCP or OB/GYN and who had evidence of BMI percentile documentation, counseling for nutrition and counseling for physical activity during the measurement year. NQF 0038 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); two H influenza type B (HiB); three hepatitis B (Hep B); one chicken pox (VZV); four pneumococcal conjugate (PCV); two hepatitis A (Hep A); two or three rotavirus (RV); and two influenza (flu) vaccines by their second birthday. The measure calculates a rate for each vaccine and nine separate combination rates. NQF 0041 Preventive Care and Screening: Influenza Immunization for Patients > 50 Years Old Percent of patients 50 years and older who received an influenza immunization during the flu season (September – February)

Attesting/Reporting on Core/Alternate Core CQMs Required to report – but you can report a “0” denominator Core CQMs EPs must report on 3 Required Core CQMs. But if the denominator of 1 or more of the required Core CQMs is 0, then EPs are required to report results for up to three Alternate Core CQMs If any or all of the Core CQMs don’t apply to the EPs scope of practice, the EHRS must still be able to calculate all three Core CQMs and demonstrate that the denominator is 0 Alternate Core CQMs If Alternate Core CQMs don’t apply and the EP can’t report a number in order to meet the required three Core/Alternate Core CQMs, then the EPs are required to report the measures with a 0 denominator for all three Alternate Core CQMs Would mean reporting on a total of 6 Core/Alternate Core CQMs

Three Additional CQMs Must Be Selected Select 3 from a list of 44 Additional CQMs Complete EHRS Certification (Ambulatory Outpatient) requires ability to report on 6 Core/Alternate Core CQMs and at least 3 Additional CQMs that are specific to the scope of practice they serve If you do not have data for one or more of the three Additional CQMs, you must report “0” in the denominator for those Additional CQMs If the EHR does not calculate CQMs that the provider wants to report on, the provider is not required to report on those CQMs, and may select any CQM and report “0” in the denomonator.

Behavioral Health, Menu Set, CQM NQF 0004 NQF 0004 Initiation and Engagement of Alcohol and Other Drug Dependence Treatment (a) Initiation, (b) Engagement “ Percent of adolescent and adult patients with a new episode of alcohol and other drug (AOD) dependence who initiate treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter or partial hospitalization within 14 days of the diagnosis and who initiated treatment and who had two or more additional services with an AOD diagnosis within 30 days of the initiation visit.” (APA explication of NQF 0004)

Behavioral Health, Menu Set, CQM NQF 0105 NQF 0105 Anti-depressant medication management: (a) Effective Acute Phase Treatment, (b) Effective Continuation Phase Treatment “The percent of male and female patients 18 years of age and older who were diagnosed with a new episode of major depression, treated with antidepressant medication, and who remained on an antidepressant medication treatment.” (APA explication of NQF 0105)

Behavioral Health, Menu Set, CQM NQF 0027 NQF-0027 Smoking and Tobacco Use Cessation, Medical assistance: a) Advising Smokers and Tobacco Users to Quit, b) Discussing Smoking and Tobacco Use Cessation Medications, c) Discussing Smoking and Tobacco Use Cessation Strategies “Percentage of patients 18 years of age and older who were current smokers or tobacco users, who were seen by a practitioner during the measurement year and who received advice to quit smoking or tobacco use or whose practitioner recommended or discussed smoking or tobacco use cessation medications, methods or strategies” (APA explication of NQF 0027)

Guidance on Core and Alternate Core Clinical Quality Measures, Additional Measures Guidance from CMS on all of the Stage 1 NQF Clinical Quality Measures can be found here: Guidance/Legislation/EHRIncentivePrograms/Downloads/CQM_E Ps_2012_02_02.pdf Guidance from American Psychiatric Association on Meaningful Use and Clinical Quality Measures practice/electronic-health-records/medicare-and-medicaid- electronic-health-record-ehr-incentive-payment-programs

Summary of Key Points The CQM reporting requirement tests the ability to report on Core/Alternate Core and Additional CQMs – it does not require actual numbers of patients if these are not available. Reports on CQMs can have “0” as the denominator The Certified Complete EHR captures data on all six Core/Alternate Core CQMs and at least three Menu CQMs relevant to the scope of practice they serve.

We Have Solutions for Integrating Primary and Behavioral Healthcare Contact CIHS for all types of primary and behavioral health care integration technical assistance and training needs 1701 K Street NW, Ste 400 Washington DC Web: Phone: Prepared and presented by Colleen O’Donnell, MSW, PMP, CHTS-IM for the Center for Integrated Health Solutions