Measuring Performance

Alliance is creating a platform for partners across the care continuum to work together and improve health outcomes. Partners have been organized into Performance Teams to focus on a select group of measures. Each team will solve problems together, ultimately improving partner performance and patient health. This guide was developed to clarify details for each measure, since this is how the State measures our performance.

Performance Team & Measure Categories Avoidable Hospital Utilization

Asthma

Patient Activation (PAM)

Behavioral Health

Palliative Care

Preventive Health

October 2017, Version 2

The major measure stewards for measures used in DSRIP are: • National Committee for Quality Assurance (NCQA) which developed the Healthcare Effectiveness Data and Information Set (HEDIS®)

• The Agency for Healthcare Research and Quality (AHRQ)

Where Do Measures Come From?

which maintains the Prevention Quality Indicators (PQI and PDI) and the Consumer Assessment of Health Care Providers and Systems Survey (CAHPS)

• Quality Assurance Reporting Requirements (QARR) this dataset includes Medicaid managed care performance data from the QARR by member demographic characteristics. QARR is largely based on measures of quality developed and published by NCQA (HEDIS®)

• 3M which determines Potentially Preventable ED Visits (PPV) and Potentially Preventable Readmissions (PPR)

• Insignia Patient Activation Measure® (PAM®) • New York State specific measures which maintains measures associated with the prevention agenda

• Other data sources (BRFSS, vital statistics, UAS-NY, SPARCS, NYS HIV Surveillance System, etc) October 2017, Version 2

Measure Categories

Process

Percentage of patients w/persistent asthma (mild, moderate, severe) w/a prescription for a controller medication

Outcome

Percentage of patients who refilled their prescriptions for 50 & 75% of the 12-months following the initial filling of the prescription for the controller(s)

Access

Percent of members who visited a PCP

Utilization

Rate of potentially preventable ED visits for patients with a principle diagnosis of Asthma

Patient Experience

Percent of patients who reported that they usually or always got an appointment for care when needed

October 2017, Version 2

Numerator

Key Components of a Measure

Denominator

Rate

October 2017, Version 2

Patients who meet the criteria for the measure

Eligible population for the measure

Either expressed as a percentage or as a per 100, 1,000 or 100,000 basis or as a ratio

Key Terms

• DSRIP GLOSSARY • Procedure and Diagnosis Coding System (ICD-10PCS and ICD-10CM) • ICD-10PCS is used in hospital inpatient settings for inpatient procedure coding • ICD-10CM is the code set for diagnosis coding and is used for all healthcare settings in the United States. • CPT® codes are used by insurers to help determine the amount of reimbursement that a practitioner will receive for services provided. Reference: https://www.ama-assn.org/practicemanagement/cpt-category-ii-codes • Measurement Year July 1 of the prior year through June 30 of the measurement year. • IPSD: Index Prescription Start Date • Measure stewards refers to the primary (and secondary, if applicable) party responsible for updating and maintaining a measure

October 2017, Version 2

October 2017, Version 2

Avoidable Hospital Utilization Measures October 2017, Version 2

Measure Type: 3M (revenue & diagnosis codes) Measure Definition The number of potentially avoidable emergency room visits as defined by revenue and diagnosis codes PPVs are ED visits for ambulatory care sensitive conditions that may have been avoided with adequate patient monitoring and follow-up. Eligible Population: 1 year old at start of measurement year and older In our current workflows how do we know about PPVs? • Patients with an ED visit appear in Hospital Census reports AND the HIXNY RHIO provides Admission, Discharge and Transfer alerts • ED Coding determines PPVs Examples of diagnosis data categorized as Potentially Preventable: • principal diagnosis related to mental health, alcohol, or substance abuse • principal diagnosis of dental conditions • principal diagnosis of asthma • menstrual & other Female diagnoses • principal diagnosis of Dental & Oral Diseases • How can we work to impact this outcome? • How can we be proactive?

October 2017, Version 2

Measure Type: AHRQ

Measure Definition The number of admissions which the reason for admission corresponds to an adult prevention quality indicator. Quality indicators found by clicking resource link Resource link Eligible Population: 18 years old at start of measurement year and older In our current workflows how do we know about Potentially Preventable Admissions? • Patients with a Hospital admission appear in Hospital inpatient Census reports AND the HIXNY RHIO provides Admission, Discharge and Transfer alerts • Hospital inpatient discharge data is used to identify quality of care for ambulatory care sensitive conditions: • diabetes with short-term complications, diabetes with long-term complications, uncontrolled diabetes without complications, diabetes with lower-extremity amputation, chronic obstructive pulmonary disease, asthma, hypertension, heart failure, dehydration, bacterial pneumonia, or urinary tract infection. • How can we work to impact this outcome? • How can we be proactive? October 2017, Version 2

Measure Type: AHRQ

Measure Definition The number of admissions which the reason for admission corresponds to a child prevention quality indicator. Quality indicators found by clicking resource link Resource link Eligible Population: 6 - 17 years old at start of measurement year In our current workflows how do we know about Potentially Preventable Admissions? • Patients with a Hospital admission appear in Hospital inpatient Census reports AND the HIXNY RHIO provides Admission, Discharge and Transfer alerts • Hospital inpatient discharge data is used to identify quality of care for ambulatory care sensitive conditions: • asthma, diabetes with short-term complications, gastroenteritis, or urinary tract infection.

• How can we work to impact this outcome? • How can we be proactive? October 2017, Version 2

Measure Type: 3M (revenue & diagnosis codes)

Measure Definition The number of readmission chains in which an at-risk admission is followed by one or more clinically related readmission/s within 30 days of discharge. Eligible Population: All ages In our current workflows how do we know about Potentially Preventable Readmissions? • Patients with a Hospital Readmission appear in Hospital inpatient Census reports AND the HIXNY RHIO provides Admission, Discharge and Transfer alerts • ICD-10 PCS/CM

• How can we work to impact this outcome? • How can we be proactive? October 2017, Version 2

Measure Type: CMS/AHRQ/HHS Survey *Hospital Collected & Reported (non-claims)

Eligible Population: 18 years and older

H-CAHPS Measure

Definition

Care Transition (Q23) During this hospital stay, staff took my preferences and those of my family or caregiver into account in deciding what my health care needs would be when I left.

Average of hospital specific results for the Care Transition composite using Strongly Agree and Agree responses

Care Transition (Q24) When I left the hospital, I had a good understanding of the things I was responsible for in managing my health.

Average of hospital specific results for the Care Transition composite using Strongly Agree and Agree responses

Care Transition (Q25) When I left the hospital, I clearly understood the purpose for taking each of my medications.

Average of hospital specific results for the Care Transition composite using Strongly Agree and Agree responses October 2017, Version 2

Preventive Health Measures October 2017, Version 2

Measure Type: HEDIS (claims) Measure Definition Percentage of adults who had an ambulatory or preventive care visit during the measurement year Eligible Population: (20-44 years), (45-64 years), (65 years and older) Coding • Ambulatory or preventive/wellness care visit • Applicable Visit CPT/HCPCS Codes: 92002, 92004, 92012, 92014, 99201 – 99205, 99211, 99215, 99241 - 99245, 99304 - 99310, 99315 - 99316, 99318, 99324, 99325 - 99328, 99334 - 99337, 99341 - 99345, 99347 - 99350, 99381 - 99387, 99391 - 99397, 99401 – 99404, 99411 – 99412, 99420, 99429, G0402, G0438, G0439, G0463, S0620, S0621, T1015 • Applicable Visit CM/DX/CPT II Codes: Z00.00, Z00.01, Z000.121, Z00.129, Z00.8, Z02.0, Z02.1, Z02.5 • How can we work to impact this outcome? • How can we be proactive? • What are some example roles of Care Management, PCP and Integration? October 2017, Version 2

Measure Type: HEDIS (claims) Measure Definition Percentage of children: 12–24 months, 25 months–6 years: One or more visits with a PCP during the measurement year. Percentage of children: 7–11 years, 12–19 years: One or more visits with a PCP during the measurement year or the year prior to the measurement year Eligible Population: (12-24 months), (25 months -6 years), (7-11 years), (12-19 years) Coding • Ambulatory or preventive/wellness care visit • Applicable Visit CPT/HCPCS Codes: 99201 - 99205 99211 - 99215 99241 - 99245, 99341 99345, 99347-99350, 99381 - 99387, 99391 - 99397, 99401 – 99404, 99411 – 99412, 99420, 99429, G0402, G0438, G0439, G0463, T1015 • Applicable Visit DX/CPT II Codes: Z00.110, Z00.111, Z000.121, Z00.129, Z00.8, Z02.0, Z02.1, Z02.5 • How can we work to impact this outcome? • How can we be proactive? • What are some example roles of Care Management, Integration? OctoberPCP 2017, and Version 2

Measure Type: AHRQ (Third-Party Administered Survey (non-claims)) Eligible Population: 18 years and older

CGCAHPS Measure

Definition

Primary Care - Usual Source of Care - Q2

Percent of Reponses ‘Yes’

Primary Care – Length of Relationship – Q3

Percent of Responses at least ‘1 year’ or longer

Getting Timely Appointments, Care and information (Q6, Number responses ‘Usually’ or ‘Always’ got appt for 8, and 10) urgent care or routine care as soon as needed , and got answers the same day if called during the day Care Coordination (Q13, 17 and 20)

Number responses ‘Usually’ or ‘Always’ that provider seemed to know important history, follow-up to give results from tests, and talked about all prescription medicines October 2017, Version 2

Behavioral Health Measures October 2017, Version 2

Measure Type: 3M (revenue & CPT codes) Measure Definition: Reduce the number of potentially preventable emergency department visits (any preventable visit) for patients with a Behavioral Health diagnosis. Eligible Population: 1 year old at start of measurement year and older

Coding • ICD-10 PCS/CM • Persons included in this measure are: Individuals with a Behavioral Health primary/secondary diagnosis and individuals who have received Behavioral Health service/s from a Behavioral Health provider within the measurement year

• How can we work to impact this outcome? • How can we be proactive? October 2017, Version 2

Measure Type: HEDIS (claims)

Measure Definition The percent of people on antidepressant medication who remain on it during the entire 12-week acute treatment phase. Eligible Population: 18 years and older

Coding • Diagnosis of major depression (F32.0 – F32.4, F32.9 –F33.3, F33.41, F33.9) • Dispensed antidepressant medication, dosage and start date ___Link to medication list___ • 84 days (12 weeks) or greater of continuous treatment with antidepressant medication (based upon medication fill/refill) • Include the date the prescription was written and evidence that the prescription was filled and covered the 84 days required for the acute phase. • How can we work to impact this outcome? • How can we be proactive? • What are some example roles of Care Management, PCP and Integration? October 2017, Version 2

Measure Type: HEDIS (claims) Measure Definition Increase the percent of patients who remained on antidepressant medication for at least 6 months Eligible Population: 18 years and older Coding • Diagnosis of major depression (F32.0 – F32.4, F32.9 –F33.3, F33.41, F33.9) • Dispensed antidepressant medication, dosage and start date ___Link to medication list____ • 180 days (6 months) or greater of continuous treatment with antidepressant medication • Include the date the prescription was written and evidence that the prescription was filled and covered the 180 days required for the continuation phase. • How can we work to impact this outcome? • How can we be proactive? • What are some example roles of Care Management, PCP and Integration? October 2017, Version 2

Measure Type: HEDIS (claims)

Measure Definition The percent of patients with schizophrenia who remained on antipsychotic medication for at least 80% of their treatment period Eligible Population: 19 - 64 years Coding • Diagnosis of schizophrenia (F20.0 – F20.3, F20.5, F20.81, F20.89, F20.9, F25.0, F25.1, F25.8, F25.9) • Dispensed at least 2 antipsychotic medications during measurement year ___Link to medication list____ • Prescriptions are filled at least 80% of the time • For long-acting injectable antipsychotics reimbursed through a medical claim with no days of supply field, the days of supply was imputed from the drug label (eg, 28 days of supply were imputed for paliperidone palmitate medical claims) • How can we work to impact this outcome? • How can we be proactive? • What are some example roles of Care Management, PCP and Integration? October 2017, Version 2

Measure Type: HEDIS (claims) Measure Definition The number of patients with schizophrenia and cardiovascular disease who receive an LDL-C test during the measurement year Eligible Population: 18 - 64 years Coding • Diagnosis of schizophrenia (F20.0 – F20.3, F20.5, F20.81, F20.89, F20.9, F25.0, F25.1, F25.8, F25.9) • AND diagnosis of cardiovascular disease: Patient had AMI or CABG (Inpatient Visit only) or PCI (in any setting) during prior year. Patient had ischemic vascular disease (IVD) during both the measurement year and year prior (I20.0 – I20.9, I24.0 – I24.9, I25.10 – I25.119, I25.5 – I25.9, I63.00 – I66.9, I67.2, I70.0 –I70.92, I74.01 – I75.89) • Lab test for LDL-C test CPT Codes: 80061, 83700, 83701, 83704, 83721 CPT Category II Codes: 3048F – 3050F • Document & Review test results with Patient/family

• How can we work to impact this outcome? • How can we be proactive? • What are some example roles of Care Management, PCP and Integration? October 2017, Version 2

Measure Type: HEDIS (claims) Measure Definition Percent of patients diagnosed with both schizophrenia and diabetes who receive both an LDL-C test and a HBA1c test during the measurement year Eligible Population: 18 - 64 years Coding • Diagnosis of schizophrenia: (F20.0 – F20.3, F20.5, F20.81, F20.89, F20.9, F25.0, F25.1, F25.8, F25.9) • AND diagnosis of diabetes: (E10.10 – E10.351, E10.359, E10.36, E10.39 – E11.351, E11.359, E11.36, E11.39 – E13.351, E13.359, E13.36, E13.39 – E13.9, O24.011 – O24.33, O24.811 – O24.83) • Lab test for both a LDL-C test and a HbA1c test during the measurement year • LDL-C Test CPT Codes: 80061, 83700, 83701, 83704, 83721 / CPT Category II Codes: 3048F – 3050F • HbA1c Test CPT Codes: 83036, 83037 / CPT Category II Codes: 3044F – 3046F

• How can we work to impact this outcome? • How can we be proactive? • What are some example roles of Care Management, PCP and Integration? October 2017, Version 2

Measure Type: HEDIS (claims) Measure Definition Percent of patients diagnosed with schizophrenia or bipolar disorder who are using antipsychotic medication who receive a glucose test or HBA1c test during the measurement year Eligible Population: 18 - 64 years Coding • Diagnosis of schizophrenia (F20.0 – F20.3, F20.5, F20.81, F20.89, F20.9, F25.0, F25.1, F25.8, F25.9) • OR diagnosis of bipolar disorder (F30.10 – F31.9) • Lab test for glucose test OR HBA1c test Glucose Test CPT Codes: 80047, 80048, 80050, 80053, 80069, 82947, 82950, 82951 (leave it if done at office, delete if not in office) HbA1c Test CPT Codes: 83036, 83037 / CPT Category II Codes: 3048F – 3050F • Prescribed an Antipsychotic Medication ___Link to medication list____

• How can we work to impact this outcome? • How can we be proactive? • What are some example roles of Care Management, PCP and Integration? October 2017, Version 2

Measure Type: HEDIS (claims) Measure Definition: *this is 2 measures follow-up within 7 days and follow-up within 30 days post discharge Increase the number of ambulatory follow-up visits occurring within 7 days or 30 days of discharge for a behavioral health reason. *A visit within 7 days fulfills both 7 and 30 day measure/s

Eligible Population: 6 years and older Coding • Follow-up visit within 7 or 30 days to a mental health practitioner CPT/HCPCS Codes: 90791, 90792, 90832 – 90845, 90847 – 90853, 90867 – 90876, 98960 – 98962, 99078, 99201 – 99220, 99241 – 99245, 99341 – 99350, 99383 – 99387, 99393 – 99404, 99411, 99412, 99495 (this code only for 30-day indicator), 99496, 99510, G0155, G0176, G0177, G0409 – G0411, G0463, H0002, H0004, H0031, H0034 – H0037, H0039, H0040, H2000, H2001, H2010 – H2020, M0064, S0201, S9480, S9484, S9485, T1015 ___link to MH practitioner list____ Resource link • Follow-up visits identified by these codes must be with a mental health practitioner or eligible non-mental health provider that bills a mental health diagnosis: UB Rev- 0510, 0515-0517, 0519-0523, 0526-0529, 0982, 0983 • Acute inpatient discharge (F20.0 – F39, F42 – F43.9, F44.89, F53, F60.0 – F63.9, F68.10 – F68.8, F84.0 – F84.9, F90.0 – F94.9)

• How can we work to impact this outcome? • How can we be proactive? October 2017, Version 2 • What are some example roles of Care Management, PCP and Integration?

Measure Type: HEDIS (claims) Measure Definition: Increase the number of children with an ambulatory prescription dispensed for ADHD medication, who receive one follow-up visit within 30 days with practitioner w/prescribing authority . Patients qualify for measure denominator is “newly” dispensed ADHD medication for the first time, prescribed a “new” medication OR 120+ day gap in refill Eligible Population: 6 -12 years old Coding • Index visit resulting w/ADHD diagnosis and ADHD medication prescribed ___Link to Medication list___ • One follow-up visit w/in 30 days post Index Visit CPT/HCPCS Codes: 90791 – 90792, 90801 – 90829, 90832 – 90840, 90845, 90847, 90849, 90853, 90857, 90862, 90875, 90876, 96150 – 96154, 98960 – 98962, 99078, 9920199205, 99211 – 99215, 99217 – 99223, 99231 – 99233, 99238 – 99239, 99241 – 99245, 99251 – 99255, 99341 99350, 33891 – 99394, 99401 – 99404, 99411 – 99412, 99510

• How can we work to impact this outcome? • How can we be proactive? • What are some example roles of Care Management, PCP and Integration? October 2017, Version 2

Measure Type: HEDIS (claims) Measure Definition: Increase the number of children who receive continued follow-up care after starting an ADHD medication. Continued is defined as; at least 2 follow-up visits in the 9- month period after the initiation phase ended. Eligible Population: 6 -12 years old Coding • Index visit resulting w/ADHD diagnosis and ADHD medication prescribed ___Link to Medication list___ • Two follow-up visits after initiation phase and w/in 270 days • Follow-up Visit CPT/HCPCS Codes: 90791 – 90792, 90801 – 90829, 90832 – 90840, 90845, 90847, • 90849, 90853, 90857, 90862, 90875, 90876, 96150 – 96154, 98960 – 98962, 99078, 99201-99205, 99211 – 99215, 99217 – 99223, 99231 – 99233, 99238 – 99239, 99241 – 99245, 99251 – 99255, 99341 – 99350, 33891 – 99394, 99401 – 99404, 99411 – 99412, 98966 – 98968, 99441 – 99443, 99510, G0155, G0176, G0177, G0409 – G0411, G0463, H0002, H0004, H0031, H0034 – H0037, H0039, H0040, H2000, H2001, H2010 – H2020, M0064, S0201, S9480, S9484, S9485, T1015

• How can we work to impact this outcome? • How can we be proactive? • What are some example roles of Care Management, PCP and Integration? October 2017, Version 2

Measure Type: HEDIS (claims) Measure Definition: Increase the number of people who initiated treatment through an inpatient AOD admission, outpatient visit, intensive outpatient encounter, or partial hospitalization within 14 days of the index episode

Eligible Population: 13 years and older Coding • Index episode (IE) resulting with AOD diagnosis (F10.10 – F10.20, F10.220 – F11.20, F11.220 – F13.20, F13.220 – F14.20, F14.220 – F15.20, F15.220 – F16.20, F16.220 – F16.99, F18.10 – F18.20, F18.220 – F19.20, F19.220 –F19.99) • One follow-up visits within 14 days of index episode CPT/HCPCS Codes: 90791, 90792, 90832 – 90845, 90847 – 90853, 90875, 90876, 98960 – 98962, 99078, 99201 – 99220, 99241 – 99245, 99341 – 99350, 99384 – 99387, 99394 – 99404, 99408 – 99412, 99510, G0155, G0176, G0177, G0396, G0397, G0409 - G0411, G0443, G0463, H0001, H0002, H0004, H0005, H0007, H0015, H0016, H0020, H0022, H0031, H0034 –H0037, H0039, H0040, H2000, H2001, H2010 – H2020, H2035, H2036, M0064, S0201, S9480, S9484, S9485, T1006, T1012, T1015

• Applicable Follow-up Visit CPT Codes (for only these service locations: Psychiatric Facility-Partial Hospitalization/Community Mental Health Center): 99221 – 99223, 99231 – 99233, 99238, 99239, 99251 - 99255 *Index episode may be established in detox, ED, outpatient, partial hospitalization, inpatient or intensive outpatient • How can we work to impact this outcome? • What are some example roles of Care Management, Integration? OctoberPCP 2017, and Version 2

Measure Type: HEDIS (claims) Measure Definition: Increase the number of people who initiated treatment AND who had two or more additional services with a diagnosis of AOD within 30 days of the initiation visit Eligible Population: 13 years and older Coding

• Index episode (IE) resulting with AOD diagnosis (F10.10 – F10.20, F10.220 – F11.20, F11.220 – F13.20, F13.220 – F14.20, F14.220 – F15.20, F15.220 – F16.20, F16.220 – F16.99, F18.10 – F18.20, F18.220 – F19.20, F19.220 –F19.99) • Two follow-up visits w/in 30 days of the initiation visit Applicable Follow-up Visit CPT/HCPCS Codes: 90791, 90792, 90832 – 90845, 90847 – 90853, 90875, 90876, 98960 – 98962, 99078, 99201 – 99220, 99241 – 99245, 99341 – 99350, 99384 – 99387, 99394 – 99404, 99408 – 99412, 99510, G0155, G0176, G0177, G0396, G0397, G0409 - G0411, G0443, G0463, H0001, H0002, H0004, H0005, H0007, H0015, H0016, H0020, H0022, H0031, H0034 – H0037, H0039, H0040, H2000, H2001, H2010 – H2020, H2035, H2036, M0064, S0201, S9480, S9484, S9485, T1006, T1012, T1015

• Applicable Follow-up Visit CPT Codes (for only these service locations: Psychiatric Facility-Partial Hospitalization/Community Mental Health Center): 99221 – 99223, 99231 – 99233, 99238, 99239, 99251 – 99255 • How can we work to impact this outcome? • How can we be proactive? October 2017, Version 2 • What are some example roles of Care Management, PCP and Integration?

Measure Type: HEDIS (medical record abstraction) Measure Definition: Increase the number of people screened for clinical depression using a standardized depression screening tool, and if positive, with follow up within 30 days Eligible Population: 18 years and older Coding • Completed standardized depression screening tool w/positive result __Measure Reference__ • Documentation of one or more of the following in a follow-up visits w/in 30 days of positive screen: recommend/prescribe antidepressant meds: 1. recommend/refer to Behavioral Health provider 2. recommend/schedule follow-up outpatient visit 3. further assessment same day pos screen indicating depression negative 4. referral to crisis services 5. referral to inpatient facility (same day as pos depression screen) • Applicable Initial Outpatient Visit CPT/HCPCS Codes: - 96150, 96151, 99201, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, G0402, G0438, G0439, G0444 • Applicable Screening HCPCS Codes: G8431 (Screening for clinical depression is positive & follow up plan is documented), G8510 (Screening for clinical depression is negative; a follow up plan is not required)

• How can we work to impact this outcome? • How can we be proactive? October 2017, Version 2 • What are some example roles of Care Management, PCP and Integration?

Asthma Measures October 2017, Version 2

Measure Type: AHRQ Measure Definition: Reduce the number of potentially preventable hospital admissions for patients 2 to 39 years with Asthma. *Admissions with a principle diagnosis of Asthma Eligible Population: 2 years old at start of measurement year - 39 years old Coding • Applicable ICD-10 CM Diagnosis of Asthma J45.20—J45.22, J45.30-J45.32, J45.40-J45.42, J45.50-J45.52, J45.901, J45.902,J45.909, J45.990, J45.991, J45.998 • Root cause analysis • RHIO alerts/Census rosters • Patient ED use and principle admission diagnosis PQI 15 Resource Link PDI 14 Resource Link

• How can we work to impact this outcome? • How can we be proactive? October 2017, Version 2 • What are some example roles of Care Management, PCP and Integration?

Measure Type: HEDIS (claims) Measure Definition: Increase the number of people with a ratio of controller medications to total Asthma medications of 0.50 or greater during the measurement year Eligible Population: 5-64 years old

Coding • Diagnosis of Asthma J45.20—J45.22, J45.30-J45.32, J45.40-J45.42, J45.50-J45.52, J45.901, J45.902,J45.909, J45.990, J45.991, J45.998 • Documented Asthma Action Plan Code: LOINC 69981-9 • Documented Asthma Control Test: LOINC 82674-3 • Dispensed asthma reliver medication __Link to medication list__ • Dispensed asthma controller medication __Link to medication list__

• How can we work to impact this outcome? • How can we be proactive? • What are some example roles of Care Management, PCP and Integration? October 2017, Version 2

Measure Type: HEDIS (claims) Measure Definition: Increase the number of people who filled prescriptions for Asthma controller medications during at least 50% of their treatment period Eligible Population: 5-64 years old Coding • Diagnosis of Asthma J45.20—J45.22, J45.30-J45.32, J45.40-J45.42, J45.50-J45.52, J45.901, J45.902,J45.909, J45.990, J45.991, J45.998 • Documented Asthma Action Plan Code: LOINC 69981-9 • Documented Asthma Control Test: LOINC 82674-3 • Dispensed asthma controller medication __Link to medication list__ • Prescriptions filled at least 50% of the time (eg: if a person’s treatment period is 180 days (6 months) and a prescription covers 30 days (1 month) the person would have to fill their prescription 3 times) • How can we work to impact this outcome? • How can we be proactive? OctoberPCP 2017,and Version 2 • What are some example roles of Care Management, Integration?

Measure Type: HEDIS (claims) Measure Definition: Increase the number of people who filled prescriptions for Asthma controller medications during at least 75% of their treatment period

Eligible Population: 5-64 years old Coding • Diagnosis of Asthma J45.20—J45.22, J45.30-J45.32, J45.40-J45.42, J45.50-J45.52, J45.901, J45.902,J45.909, J45.990, J45.991, J45.998 • Documented Asthma Action Plan Code: LOINC 69981-9 • Documented Asthma Control Test: LOINC 82674-3 • Dispensed asthma controller medication __Link to medication list__ • Prescriptions filled at least 75% of the time (eg: if a person’s treatment period is 180 days (6 months) and a prescription covers 30 days (1 month) the person would have to fill their prescription 5 times) • How can we work to impact this outcome? • How can we be proactive? OctoberPCP 2017,and Version 2 • What are some example roles of Care Management, Integration?

Palliative Care Measures October 2017, Version 2

Measure Type: Survey (non-claims) Eligible Population: All Ages

Palliative Care Measure

Definition

Q2. Below is a list of symptoms, which you may or may Number of patients offered or provided an intervention for not have experienced. For each symptom, please tick the question Number of patients with responses 2, 3, or 4 one box that best describes how it has affected you for the question (Sometimes, Most of the time, Always) over the past week: Q5. Have you been feeling depressed? (refers to past week)

Number of patients offered or provided an intervention for the question Number of patients with responses 2, 3, or 4 for the question (Sometimes, Most of the time, Always)

Q6. Have you felt at peace? (refers to past week)

Number of patients offered or provided an intervention for the question Number of patients with responses 2, 3, or 4 for the question (Sometimes, Occasionally, Not at all)

Q10. Check all advance directives known to have been completed:

Number of patients offered or provided an intervention for the question Number of patients with response 4 (None)

October 2017, Version 2

Patient Activation Measures October 2017, Version 2

Measure Type: PPS Administered Survey (non-claims) Measure Definition: Increase the number of people who’s PAM scores reflected that patients are better able to manage their own health as compared to initial survey results (Patient Population: Uninsured, low utilizing, non-utilizers) Eligible Population: All ages

Coding • PAM Survey (Flourish System) • Follow-up PAM Survey (if PAM’ed within same measurement year) • Insignia Health’s Patient Activation Measure (PAM®) survey is being used to assess project beneficiaries’ levels of activation, by assigning an activation score and level derived from survey results. Knowing a person’s PAM® activation level allows providers to tailor their interactions and interventions to meet the patient’s individual needs, increasing the probability of positive health and wellness outcomes. PAM® scores are also predictive of relevant health care outcomes, such as costs, hospital readmissions, and utilization of primary and preventative care services • How can we work to impact this outcome? • How can we be proactive? October 2017, Version 2 • What are some example roles of Care Management, PCP and Integration?

Measure Type: HEDIS (claims)

Measure Definition Reduce the percentage of Medicaid members with no claims history for primary and preventive care services in the measurement year Eligible Population: All Medicaid members Coding • Primary care well visit and/or preventive service/s CPT code (See Child & Adult access codes) • New patient/Initial Exams CPT Codes: 99201- 99205, T1016 TR

• How can we work to impact this outcome? • How can we be proactive? • What are some example roles of Care Management, PCP and Integration? October 2017, Version 2

Measure Type: Claims (CPT/ICD-10 codes)

Measure Definition Reduce the number of ED visits for self-pay per 100 ED visits Eligible Population: 1 year old at start of measurement year and older Coding • Hospital discharge data • ICD-10 PCS/CM

• How can we work to impact this outcome? • How can we be proactive? October 2017, Version 2

Medication Lists October 2017, Version 2

Asthma Medication List To determine the treatment period, calculate the number of days from the Index Prescription Start Date (IPSD) to the end of the measurement period. The IPSD is the earliest dispensing event for any asthma controller medication during the measurement year. Generic Aclidinium**

Albuterol

Trade Tudorza

Type LAMA

Generic Cromolyn

Trade Intal

ProAir/ Respiclick Proventil Ventolin

SABA

Flunisolide

Aerospan ICS

Beclomethasone Beclovent Qvar

ICS

Glycopyrrolate/ Bevespi LABA/LAMA Formoterol Aerosphere Fumarate Budesonide

Pulmicort

ICS

Budesonide/For Symbicort moterol

ICS/LABA

Ciclesonide**

ICS

Alvesco

Fluticasone Propionate

Flovent

Fluticasone P/salmeterol

Advair

Fluticasone Furoate

Arnuity

Fluticasone Furoate /Vilanterol

Breo

Formoterol

Foradil

Type NSAID

Generic Indacaterol**

Trade Arcapta Neohaler

Type LABA

Ipratropium

Atrovent

LAMA

Levalbuterol

Xopenex

SABA

Mepolizumab

Nucala

Immunomodulator

Mometasone

Asmanex

ICS

ICS

ICS/LABA

ICS ** COPD only

Glycopyrrolate

ICS/LABA

SABA – Short acting beta-agonist (rescue or reliver)

LABA

LABA – Long acting beta-agonist LTRA – Leukotriene Receptor Antagonist NSAID – Non-steroidal anti-inflammatory ICS – Inhaled corticosteroid LAMA - Anti-cholinergic (Long acting muscarinic antagonist)

Seebri LAMA Neohaler

October 2017, Version 2

Asthma Medication List To determine the treatment period, calculate the number of days from the Index Prescription Start Date (IPSD) to the end of the measurement period. The IPSD is the earliest dispensing event for any asthma controller medication during the measurement year. Generic Mometasone/ Formoterol

Trade Dulera

Type ICS/LABA

Generic Trade Umeclidinium / Anoro Vilaterol**

Montelukast

Singulair

LTRA

Indacaterol/ glycopyrrolate

Utibron LABA/LAMA Neohaler

Olodaterol

Striverdi

LABA Accolate

LTRA

Xolair

Immunomodulator

Zafirlukast

Omalizumab

Zileuton

Zyflo

LTRA

Prednisone

Type LAMA/ LABA

Prednisone Oral steroid

Prednisilone

Oral steroid

Salmeterol

Serevent

LABA

Tiotropium bromide / Olodaterol**

Stiolto

LAMA/ LABA

Umeclidinium** Incruse

LAMA

** COPD only SABA – Short acting beta-agonist (rescue or reliver)

October 2017, Version 2

LABA – Long acting beta-agonist LTRA – Leukotriene Receptor Antagonist NSAID – Non-steroidal anti-inflammatory ICS – Inhaled corticosteroid LAMA - Anti-cholinergic (Long acting muscarinic antagonist)

Medication List Measure Antidepressant Medication Management – Effective Acute Phase Treatment & Effective Continuation Phase Treatment

Antipsychotic Medication Adherence

Child ADHD Medication Follow-up Diabetes Screening for People with Schizophrenia or Bipolar Disease who are Using Antipsychotic Medication

Medication List Bupropion, Vilazodone, Vortioxetinem, Isocarboxazid, Phenelzine, Selegiline , Tranylcypromine, Nefazodone, Trazodone, Amitriptyline-chlordiazepoxide, Amitriptyline Perphenazine, Fluoxetine-olanzapine, Desvenlafaxine, Duloxetine, Levomilnacipran, Venlafaxine, Citalopram, Escitalopram, Fluoxetine, Fluvoxamine, Paroxetine , Sertraline, Maprotiline, Mirtazapine, Amitriptyline, Amoxapine, Clomipramine, Desipramine, Doxepin (>6 mg), Imipramine, Nortriptyline, Protriptyline, Trimipramine Aripiprazole, Asenapine, Clozapine, Haloperidol, Iloperidone, Loxapine, Lurisadone, Molindone, Olanzapine, Paliperidone, Pimozide, Quetiapine, Quetiapine fumarate, Risperidone, Ziprasidone, Chlorpromazine, Fluphenazine, Perphenazine, Perphenazine-amitriptyline, Prochlorperazine, Thioridazine, Trifluoperazine, Fluoxetine-olanzapine, Aripiprazole, Fluphenazine decanoate, Haloperidol decanoate, Paliperidone palmitate Amphetamine-dextroamphetamine, Dexmethylphenidate, Dextroamphetamine, Lisdexamfetamine, Methylphenidate, Methamphetamine, Clonidine, Guanfacine, Atomoxetine Aripiprazole, Asenapine, Clozapine, Haloperidol, Iloperidone, Loxapine, Lurisadone, Molindone, Olanzapine, Paliperidone, Pimozide, Quetiapine, Quetiapine fumarate, Risperidone, Ziprasidone, Chlorpromazine, Fluphenazine, Perphenazine, Perphenazineamitriptyline, Prochlorperazine, Thioridazine, Trifluoperazine, Fluoxetine-olanzapine, Thiothixene, Fluphenazine decanoate, Haloperidol decanoate, Paliperidone palmitate October 2017, Version 2

Measure Reference October 2017, Version 2

Measure References Follow-up after Hospitalization for Mental Illness Measure: Follow-up after Hospitalization for Mental Illness (7 days & 30 days) Back to Measure Mental Health Practitioner: •

An MD or DO who is certified as a psychiatrist or child psychiatrist by the American Medical Specialties Board of Psychiatry and Neurology or by the American Osteopathic Board of Neurology and Psychiatry; or, if not certified, who successfully completed an accredited program of graduate medical or osteopathic education in psychiatry or child psychiatry and is licensed to practice patient care psychiatry or child psychiatry, if required by the state of practice.

•

An individual who is licensed as a psychologist in his/her state of practice, if required by the state of practice.

•

An individual who is certified in clinical social work by the American Board of Examiners; who is listed on the National Association of Social Worker’s Clinical Register; or who has a master’s degree in social work and is licensed or certified to practice as a social worker, if required by the state of practice.

•

A registered nurse (RN) who is certified by the American Nurses Credentialing Center (a subsidiary of the American Nurses Association) as a psychiatric nurse or mental health clinical nurse specialist, or who has a master’s degree in nursing with a specialization in psychiatric/mental health and two years of supervised clinical experience and is licensed to practice as a psychiatric or mental health nurse, if required by the state of practice.

•

An individual (normally with a master’s or a doctoral degree in marital and family therapy and at least two years of supervised clinical experience) who is practicing as a marital and family therapist and is licensed or a certified counselor by the state of practice, or if licensure or certification is not required by the state of practice, who is eligible for clinical membership in the American Association for Marriage and Family Therapy. October 2017, Version 2

Measure References Adult Standardized Depression Screening tool • • • • • • • • • • • • •

Patient Health Questionnaire [PHQ-9] Beck Depression inventory [BDI or BDI-II] Mood Feeling Questionnaire [MFQ] Center for Epidemiologic Studies Depression Scale [CES-D] Depression Scale [DEPS] Duke Anxiety-Depression Scale [DADS] Geriatric Depression Scale [GDS] Hopkins Symptom Checklist [HSCL] Zung Self-Rating Depression Scale [SDS] Cornell Scale Screening PRIME MD-PHQ-2 Edinburgh Postnatal Depression Scale [EPDS]) **Assessment tools may be named or a complete tool may be embedded in the medical record and not named

October 2017, Version 2

DSRIP Glossary Click icon to open

October 2017, Version 2