Series 1: Meaningful Use for Behavioral Health Providers 9/2013 From the CIHS Video Series “Ten...
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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
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
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
Slide 3
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
http://www.healthit.gov/providers-professionals/achieve-meaningful-
use/core-measures/clinical-quality-measures
Slide 4
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
http://www.healthit.gov/providers-professionals/achieve-meaningful-use/core-
measures/clinical-quality-measures
Slide 5
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
Slide 6
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)
Slide 7
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
dont 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 dont
apply and the EP cant 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
Slide 8
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. http://oncchpl.force.com/ehrcert/CHPLHome
Slide 9
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.
http://bit.ly/18zF1uphttp://bit.ly/18zF1up (APA explication of NQF
0004)
Slide 10
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. http://bit.ly/1570Pr3http://bit.ly/1570Pr3
(APA explication of NQF 0105)
Slide 11
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 http://bit.ly/18bZiSOhttp://bit.ly/18bZiSO (APA
explication of NQF 0027)
Slide 12
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:
http://www.cms.gov/Regulations-and-
Guidance/Legislation/EHRIncentivePrograms/Downloads/CQM_E
Ps_2012_02_02.pdf Guidance from American Psychiatric Association on
Meaningful Use and Clinical Quality Measures
http://www.psychiatry.org/practice/managing-a-
practice/electronic-health-records/medicare-and-medicaid-
electronic-health-record-ehr-incentive-payment-programs
Slide 13
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.
Slide 14
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 20006 Web:
www.integration.samhsa.govwww.integration.samhsa.gov
Email:[email protected]@thenationalcouncil.org
Phone:202-684-7457 Prepared and presented by Colleen ODonnell, MSW,
PMP, CHTS-IM for the Center for Integrated Health Solutions