1. Behavioral Health Clinic Quality Measures(BHCQMs)
0028 Preventive Care and Screening: Tobacco Use: Screening and Cessation intervention ( TSC)
Time to initial evaluation (I-eval)
March 2, 2017

2. 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

3. BHCQM Summary Measure Specifics Omit Where Documented Who Documents
Numerator
Denominator
Frequency
Comments
0028 Preventive Care &
Screening: Tobacco
Use: Screening &
Cessation Intervention
(TSC)
Percentage of individuals aged 18 years and older screened for tobacco use one or more times within 24 months AND who received cessation counseling intervention if identified as a tobacco user.
Individuals with no Tobacco Screening and documentation that Tobacco Screening was not Performed due to one of the following reasons: Medical, not otherwise specified OR individuals screened for tobacco use and identified as tobacco users, but did not receive a tobacco cessation intervention, reason not otherwise specified.
Medical record. Means to extract and aggregate data needed. Can be Electronic health records (including billing records), paper health records, or registry
Documented by Care Coordinator, Direct Care Staff, LVN, MA, Prescribers, RN, or LPHA ~ Licensed Clinical Social Worker ( LCSW), Licensed Professional Counselor ( LPC), Licensed Marriage and Family Therapist (LMFT)
Patients who were screened for tobacco use at least once within 24 months AND who received tobacco cessation intervention if identified as a tobacco user. If not a user are counted in numerator.
Patients aged ≥ 18 years on date of encounter with at least one encounter during the reporting period (see cpt/hcpcs codes).
Denominator is the measurement year and, for the numerator, is the measurement year and the prior year
Tobacco Use – Includes use of any type of tobacco. Tobacco Cessation Intervention – Includes brief counseling (3 minutes or less), and/or pharmacotherapy
Time to Initial
Evaluation (I-Eval)
The percent of new individuals with initial evaluation provided within 10 business days of first contact, and the mean number of days until initial evaluation for new individuals. Data is to be stratified by age (12-17; 18 and older).
Those seeking or requiring urgent or emergent care. (Only routine care is counted in this measure).
Medical record. Means to extract data and aggregate needed.
No requirements.
1. Number of new individuals seeking services who received an initial evaluation within 10 business days of the first contact with the center. 2. The total number of days between the first contact and initial evaluation for all members of the eligible population seen at the center during the measurement period.
Number of new individuals seeking non-urgent or emergency services.
Once for each new individual.

4. 0028 Preventive Care and Screening: Tobacco Use: Screening and Cessation intervention ( TSC)
What outcome is being measured?
Percentage of consumers aged 18 years and older who were screened for tobacco use one or more times within a year AND who received cessation counseling intervention if identified as a tobacco user.
Purpose/Benefit?
Record the quality of services provided for preventive screening for tobacco use
Screen at first contact and on a regular basis as tobacco use and motivation to quit changes. Increased types and number of interventions produces better outcomes.
Tobacco kills more than AIDS, heroin, cocaine, alcohol, car accidents, fire and homicide – COMBINED. MI population accounts for ½ of all smoking deaths.
Heavy smokers report substantially greater symptom burden and more functional disability compared to nonsmoking people seeking mental health treatment
(TSC)

5. What needs to be collected ? Tracked ?
Age (18+) at time of encounter
Any Type of Tobacco Use Screening by Anyone: Identify Users and Not Users. If multiple screenings are completed during reporting period and one of them identifies individual as a User, that screening should be used in the report so you get credit for providing intervention.
Cessation counseling intervention: Brief counseling and/or pharmacotherapy if individual is User
Pay Source
(TSC)

6. What needs to be collected ? Eligible population
Eligible encounter at the provider entity during the measurement year (encounter code table follows)
Aged 18 years and older on the date of service during the measurement year
Pay Source: Medicaid, dual eligible Medicaid & Medicare, and Other
Exclude individuals with documentation of no tobacco screening performed because of limited life expectancy or other medical reason
(TSC)

7. Code
Description
90791
Psych Diag Eval NO Medical
90792
Psych Diag Eval WITH Medical
90832
Psychotherapy minutes
90834
Psychotherapy minutes
90837
Psychotherapy Over 53 minutes
90845
Psychoanalysis
96150
Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires)
96151
Health and behavior assessment (eg, health-focused clinical interview, behavioral observations, psychophysiological monitoring, health-oriented questionnaires) re-assessment
96152
Health and behavior intervention, each 15 minutes, face-to-face; individual
97003
OT Initial Evaluation
97004
Occupational Therapy Re-Eval
99201
New PT Visit Level 1
99202
New PT Visit Level 2
99203
New PT Visit Level 3
99204
New PT Visit Level 4
99205
New Patient Exam Level 5
99212
Established PT Level 2
99213
Established PT Level 3
99214
Established PT Level 4
99406
Smoking and tobacco use cessation counseling visit; intermediate, 3-10 minutes
99407
Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes
G0438
Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit
G0439
Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit

8. Performance Parameters & Interpretation
Numerator/Performance Met: Consumer screened for tobacco use AND received tobacco cessation intervention (counseling, pharmacotherapy, or both), if identified as a tobacco user OR
Numerator/Performance Met: Consumer screened for tobacco use and identified as a non-user of tobacco
Performance Not Met: Tobacco screening OR tobacco cessation intervention not performed, reason not otherwise specified
Interpretation of score: Better performance = Higher percentage
(TSC)

9. Where to Record the information?
Medical records:
Electronic Health Record (including billing records)
Paper Health Records
Registry
Excel spreadsheet
Database
Helpful for records to be stored in shared drive or chart
(TSC)

10. Each BHC will need to determine the following: Screening and Tobacco Cessation Intervention
When does the tobacco screening/s take place?
What tobacco cessation service/s was provided within 6 months of individual being identified as Tobacco User?
Who will collect and document?
Encounter documented by clinician
Tobacco Screening can be provided by any staff
Intervention can be provided by staff trained to provide brief cessation counseling and appropriate referrals for internal and external support and nicotine replacement pharmacotherapies.
(TSC)

11. Process change: Workflow: What changes are needed?
Who and how will tobacco use and interventions be documented, tracked and monitored?
2. Procedures/policies:
Map out process detail including who is responsible to do what when
Develop or revise existing procedures
Identify changes in documentation process needed to capture this data
Train staff early just before implementation
Reports – track to see if you are meeting the measure
3. Example:
Test the system! See if what is planned works, or will there need to be changes
PDSA cycles!
TSC

12. What it will take to be successful.
Train staff prior to implementation. Give them tobacco assessment tool, cessation resources, and develop tracking mechanism for referrals, cessation products, and tobacco cessation services.
Determine how you will identify pay source
Determine the way you will get the data in the required reporting template
For further details, see pages of BHCQMeasuresVol 1(508)1 & pages of BHCQMAppendicesVol 2(508)2
(TSC)

13. Texas Behavioral Health Resources for Tobacco Cessation www
Texas Behavioral Health Resources for Tobacco Cessation   – Videos, posters, quit plans, handouts, and links to other websites   877-YES-QUIT – - Free telephone and online quit tobacco resources for Texans.  Eligible participants may receive two weeks of NRT. Online referral form for clinicians to refer people: 

14. Time to Initial Evaluation (I-Eval)
What outcome is being measured?
The percent of new consumers with initial evaluation provided within 10 business days of first contact, and the mean number of days until initial evaluation for new consumers.
This is for people with “routine” non-emergent needs.
Purpose/Benefit?
Provides for better engagement of people with “glancing blows” to our system
(I-EVAL)

15. What needs to be collected ? Tracked ?
First contact date (phone call or face to face)
Initial evaluation provided by date (for the CCBHC)
Provided: this means the initial evaluation was received
10 Business days: M-F excluding state and federal holidays
For those seeking routine services
Age
New consumers: those not seen in the past 6 months
Once for each consumer
Payer
(I-EVAL)

16. What needs to be collected ? Eligible population – Age Stratification
Two age stratifications and a total rate:
12-17 years as of the end of the measurement year
18 years and older as of the end of the measurement year
Total ( both age groups)
(I-EVAL)

17. What needs to be collected ? Eligible population – Event/diagnosis
Two steps:
Step 1: All new consumers seeking services during the first 11 months of the measurement year
Step 2: Aged 12 years and older as of the end of the measurement year
(I-EVAL)

18. Two part Measure – Calculation One
Medical record Metric specification #1: The percentage of New consumers with initial evaluation provided within 10 business days of the 1st contact
Denominator: Number in eligible population
Denominator Measurement Period (MP): The measurement year excluding the last 30 days of the measurement year and including the 6 months preceding the measurement year
Numerator: Number receiving initial evaluation within 10 business days of the 1st contact during the measurement year
Numerator MP: The measurement year
Why? To assure initial evaluation in 10 days
(I-EVAL)

19. Two part Measure – Calculation Two
Medical record Metric specification #2: The mean (average number of days) until initial evaluation for new consumers
Denominator: Number in eligible population
Denominator Measurement Period: The measurement year excluding the last 30 days of the measurement year and including the 6 months preceding the measurement year
Numerator: Total number of days between first contact and initial evaluation for all in the eligible population seen at the provider in the measurement year
Numerator MP: The measurement year.
Why? To assure initial evaluation in 10 days
(I-EVAL)

20. Interpretation of Scores – Why do this?
Percentage of new consumers with initial evaluation provided within 10 business days:
Better performance = Higher score
Mean number of days until initial evaluation for new consumers:
Better performance = Lower number
(I-EVAL)

21. Recognized limitation of I-EVAL
It is likely some new consumers will not have an appointment within 10 days because of their own schedules and non-urgent need.
This situation is a recognized limitation of this measure that will affect all clinics.
Trying to adjust for non-consumers who are offered but do not accept an appointment within 10 business days complicates the calculation unnecessarily.
(I-EVAL)

22. Where to Record the information?
Medical records. Potential sources:
Electronic Health Record (including billing records)
Paper Health Records
Excel spread sheet
Database
Registry
Electronic Scheduling system: separate from the medical record, but used to schedule and monitor appointments and time frames
(I-EVAL)

23. I-EVAL Open Access Question from SAMHSA
If a program has, where clients can come in where ever they want during certain hours, but they happen to call first to determine when open access hours are, if that call considered first contact?
No, a call to determine when open access hours are held is not first contact unless that call is accompanied by the preliminary screening and risk assessment, and collection of basic data about the person, including insurance information, In general, however, if a person calls just to find out what hours you are open that is not an initial contact. That is an attempt to come in and find out when they can have an initial contact.
If a consumer calls seeking an evaluation and we provide them with our own open access and they never show, is that counted in the denominator?
Yes, assuming your provided the preliminary screening and risk assessment to ascertain level of acuity when they called.
(I-EVAL)

24. Each BHC will need to determine the following: Initial Contact
When does the initial contact take place?
A phone call
Registration
Clinic visit
MCOT
Who will collect and document ?
No requirements/restrictions as to who completes the initial contact
First contact is simply the first contact
Need to determine where you want it documented so you can pull the data
(I-EVAL)

25. Each BHC will need to determine the following: Initial Evaluation
When does the initial evaluation take place?
The initial evaluation is the one meeting standards for CCBHC
Clinic visit
Access to care
Who will collect and document ?
Initial evaluation is done by an LPHA, a prescriber or a QMHP in conjunction with the LPHA or Prescriber’s evaluation
Need to determine where you want it documented so you can pull the data
(I-EVAL)

26. Process change: Workflow: Will it have to change?
Ways you document, track and monitor – do they need to change
2. Procedures/policies:
Think of all the steps in the process. Is there an actual procedure documenting this?
Will you need to amend the documentation process to capture this data
Reports – track to see if you are meeting the measure
3. Example:
Test the system! See if what is planned works, or will there need to be changes
PDSA cycles!
(I-EVAL)

27. Appendix for I-eval
Metrics and Quality Measures for Behavioral Health Clinics: Technical Specifications and Resource Manual – Volume Two
Review pages for detailed examples of I-Eval
(I-EVAL)

28. What it will take to be successful.
Designate a staff team responsible to get the process done
Protocols and procedures facilitate a consistent process
Train staff – Test the plan! This is about your documentation system being able to track and stratify the particulars of the measure.
Staff are having an initial contact now – How do you document and track when that occurs?
Staff are providing an initial evaluation now – What is the best way to link that initial contact to the initial evaluation and track it?
(I-EVAL)

29. Revised Webinar Schedule Webinars: Will send out revised registration

30. Remember… Start planning assessment and collection methods now.
Baseline period begins 7/1/17 (aligns with proposed DSRIP baseline)
Data reporting for measurement year 1/1/18
Resources: Texas Council Website (BHCQM volume 1 and 2, FAQs, template, webinars)
ccbhc/