1. SOONERCARE PCMH REDESIGN Quality Measure Review
THE PACIFIC HEALTH POLICY GROUP
December 19, 2016

2. 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

3. 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+ measures selected in OK are appropriately geared toward adults and therefore only partially align with Oklahoma Health Improvement Plan priorities.
PCMH Redesign, Dec 2016

4. CPC+ Selected Measure Set: Oklahoma
Domain
Measure(s)
Primary Measure Steward
Communication & Care Coordination
Closing the Referral Loop: Receipt of Specialist Report
CMS
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
Effective Clinical Care
Breast Cancer Screening
Cervical Cancer Screening
Colorectal Cancer Screening
Controlling High Blood Pressure
Diabetes: Eye Exam
Diabetes: Hemoglobin A1c (>9%)
NCQA
Use of Imaging Studies for Low Back Pain
Efficiency & Cost Reduction
NCQA
Patient Safety
Documentation of Current Meds in Medical Record
Falls: Screening for Future Fall Risk
Use of High-Risk Meds in the Elderly
CMS
NCQA
Person & Caregiver Centered Experience & Outcomes
CAHPS for PQRS Clinical/Group Survey
AHRQ
PCMH Redesign, Dec 2016

5. Methodology for Measure Inventory
CPC+
As Baseline
Incremental
HEDIS
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

6. Adult Preventive Screening
Measure
Brief Description
Primary Steward
Breast Cancer Screening
Percentage of women years of age who had a mammogram to screen for breast cancer.
National Committee for Quality Assurance
Cervical Cancer Screening
Percentage of women years of age who were screened for cervical cancer using either of the following criteria: * Women age who had cervical cytology performed every 3 years * Women age who had cervical cytology/human papillomavirus (HPV) co-testing performed every 5 years.
Colorectal Cancer Screening
Percentage of adults years of age who had appropriate screening for colorectal cancer.
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

7. Chronic Health Issues - Child, Adolescent & Adult
Measure
Brief Description
Primary Steward
Diabetes: Comprehensive Care
HbA1c testing (most recent date and result from 2015) − HbA1c < 8.0 % = control − HbA1c > 9.0 % = poor control 2. Retinal eye exam (most recent date 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
National Committee for Quality Assurance
Diabetes: Medical Attention for Nephropathy
Percentage of patients years of age with diabetes who had a nephropathy screening test or evidence of nephropathy during the measurement period.
Diabetes: Hemoglobin A1c (HbA1c) Poor Control (>9%)
Percentage of patients years of age with diabetes who had hemoglobin A1c > 9.0% during the measurement period
Diabetes: Foot Exam
Percentage of patients 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
Diabetes: Eye Exam
Percentage of patients 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
Diabetes Care for People with Serious Mental Illness Hemoglobin (HbA1c) Poor Control (>9.0%)
Percentage of patients 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

8. Chronic Health Issues - Child, Adolescent & Adult (cont’d)
Measure
Brief Description
Primary Steward
Controlling High Blood Pressure
Percentage of patients 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 years of age with a diagnosis of hypertension whose blood pressure improved during the measurement period.
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.
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.
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.
PCMH Redesign, Quality Measure Review

9. 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
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

10. 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
Primary Steward
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 Care Physician (PCP) or Obstetrician/Gynecologist (OB/GYN) and who had 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.
National Committee for Quality Assurance
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 Body-Mass-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

11. 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
Primary Steward
Maternity Care: Prenatal and Postpartum Care
The percentage of deliveries of live births in the measurement year. Measure includes: (1) The percentage of deliveries that received a prenatal care visit as a 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.
National Committee for Quality Assurance
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.
Maternity Care: Post-Partum 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

12. OHIP Flagship Issue: Children’s Health - Maternal Health (cont’d)
Measure
Brief Description
Primary Steward
Contraceptive Care – Postpartum
Percentage of women ages who had a live birth and were provided a most or moderately effective method of contraception within 3 and 60 days of delivery.
US Office of Population Affairs (New to CMCS 2017)
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

13. 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. 
Chlamydia Screening for Women
Percentage of women years of age who were identified as sexually active and who had at least one test for chlamydia during the measurement period
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
Non-Recommended Cervical Cancer Screening in Adolescent Females
The percentage of adolescent females years of age who were screened unnecessarily for cervical cancer
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
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
PCMH Redesign, Quality Measure Review

14. 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.
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.
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.
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)
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

15. 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.
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

16. 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
Addiction
Suicide
PCMH Redesign, Quality Measure Review

17. OHIP Flagship Issue: BH - Mental Illness
Mental Health Measures
Brief Description
Primary Steward
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 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.
Centers for Medicare & Medicaid Services
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.
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 Attention-Deficit/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 follow-up 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.
PCMH Redesign, Quality Measure Review

18. OHIP Flagship Issue: BH - Mental Illness (cont’d)
Mental Health Measures
Brief Description
Primary Steward
Follow-Up After Emergency Department for Mental Illness
Percentage of emergency department (ED) visits for members 6 years of age and older with a primary diagnosis of mental illness, who had an outpatient visit, an intensive outpatient encounter or a partial hospitalization for mental illness. 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 (First Year HEDIS Measure)
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.
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.
PCMH Redesign, Quality Measure Review

19. 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 17 years of age who were on two or more concurrent antipsychotic medications.
AHRQ, CMS
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.
PCMH Redesign, Quality Measure Review

20. OHIP Flagship Issue: BH - Addiction
Addiction Measures
Brief Description
Primary Steward
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 and other drug (AOD) dependence. (1) Percentage of patients who initiated 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.
National Committee for Quality Assurance
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 evaluated for risk of opioid misuse using a brief validated instrument (e.g. Opioid Risk Tool, SOAPP-R) or patient interview documented at least once during Opioid Therapy in the medical record.
American Academy of Neurology
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.
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.
PCMH Redesign, Quality Measure Review

21. 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
PCMH Redesign, Quality Measure Review

22. Utilization, Efficiency & Coordination Measures
Brief Description
Primary Steward
Ambulatory Care/Emergency Department Visits
For members 18 years of age and older, the number of emergency department (ED) visits during the measurement year (observed) and the predicted probability of ED visits (expected).
National Committee for Quality Assurance
Inpatient Utilization
Summary of utilization of acute inpatient care and services in the following categories: Total Inpatient, Maternity, Surgery, and Medicine.
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.
PCMH Redesign, Quality Measure Review

23. Utilization, Efficiency & Coordination Measures (cont’d)
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): 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 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.
PCMH Redesign, Quality Measure Review

24. Patient Experience PCMH Redesign, Quality Measure Review 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.
PCMH Redesign, Quality Measure Review

25. Appendix: Behavioral Health Integration
Components of Integrated Model
Pediatric Screening Tools
PCMH Redesign, Quality Measure Review

26. 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

27. 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.
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.
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.
PCMH Redesign, Quality Measure Review