Clinical Quality Metrics Toolkit

Transcription

1 2015 Clinical Quality Metrics Toolkit Last updated on: October 6, 2015

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3 Purpose The CareOregon Clinical Quality Metrics Toolkit aims to support the clinics in the CareOregon network, by making it easier to understand and implement the numerous quality measures we must meet. It is a central resource to spread and share, which we hope will facilitate communication and make all of our work just a little bit easier. To date, this toolkit contains our shared knowledge about the Oregon Health Authority s CCO Incentive Metrics and the CMS Medicare Stars Measures. It is our hope that this document will grow in partnership with the knowledge of our network, as we continue to innovate with new best practices and workflows. To this end, we welcome your feedback, in hopes that the toolkit will improve to better meet the needs of your clinic. Thank you, Quality Improvement & Clinical Innovation CareOregon ii

4 Acknowledgements CareOregon would like to thank the clinics for their tireless work in providing quality care to all patients, including CareOregon members. We would like to give thanks to the many team members that helped create this toolkit. In particular, we thank Emma Abiles, Josue Aguirre, Aurora Alonzo, Christine Castle, Cindy Fessler, Aimee Guardado, Christina Milano, Scott Zahlmann, and Jaclyn Testani for their contributions. We would also like to give a special thank you to Gloria Coronado and the Screen To Prevent Colorectal Cancer (STOP CRC) team at Kaiser Permanente s Center for Health Research, for allowing us to use their materials and findings to improve colorectal screening for our members. STOP CRC is supported by the National Cancer Institute (4UH3CA ). The Colon Cancer Screening Toolkit provides guidance for clinics to assess their current colon cancer screening processes and devise a plan for increasing their rates, and includes a guide for implementing a mailed outreach approach. For clinics interested in learning more about successful approaches to raising rates of colon cancer screening, we will provide technical assistance (e.g. provider presentations, and question and answer sessions). iii

5 Table of Contents Clinical Quality Metrics Background...1 Clinical Quality Metrics Timeline CCO New and Updated Metrics...3 CCO Metrics by Age...4 Adult Health...5 Adult BMI Assessment...5 Technical Specifications...5 Care Team Specifications...6 Colorectal Cancer Screening...7 Technical Specifications...7 Care Team Specifications...8 Clinic Needs Assessment...9 Clinic Readiness Checklist Clinic Readiness Guidance Controlling High Blood Pressure (NQF 0018) Technical Specifications Care Team Specifications Diabetes Management: Kidney Disease Monitoring Technical Specifications Care Team Specifications Diabetes Management: Eye Exam Technical Specifications Care Team Specifications Diabetes Management: Controlling Blood Sugar /HbA1c Poor Control Technical Specifications Care Team Specifications Diabetes Management: Medication Adherence Medication Therapy Management Rheumatoid Arthritis Technical Specifications Care Team Specifications iv

6 Child and Adolescent Health Adolescent Well Care Visits Technical Specifications Care Team Specifications Frequently Asked Questions Sample Workflow Assessments for Children in DHS Custody Technical Specifications Care Team Specifications Dental Sealants on Permanent Molars for Children Technical Specifications Care Team Specifications Developmental Screening Technical Specifications Care Team Specifications Frequently Asked Questions Sample Workflows Mental Health Alcohol or Other Substance Misuse (SBIRT) Technical Specifications Care Team Specifications Frequently Asked Questions Sample Workflows Depression Screening and Follow-Up Plan (NQF 0418) Technical Specifications Care Team Specifications Follow-Up after Hospitalization for Mental Illness (NQF 0576) Technical Specifications Care Team Specifications Women s Health Breast Cancer Screening Technical Specifications Care Team Specifications v

7 Effective Contraceptive Use Technical Specifications Care Team Specifications Osteoporosis Management Technical Specifications Care Team Specifications Timeliness of Prenatal Care Technical Specifications Care Team Specifications Care for Older Adults Functional Status Assessment Technical Specifications Care Team Specifications Medication Review Technical Specifications Care Team Specifications Pain Screening Technical Specifications Care Team Specifications High Risk Medication Management Emergency Care All Cause Readmission Technical Specifications Ambulatory Care: Emergency Department Utilization Technical Specifications System Transformation Patient-Centered Primary Care Home (PCPCH) Enrollment Electronic Health Record (EHR) Adoption Member Surveys CAHPS Composite: Consumer Assessment of Health Plan Survey HOS: Health Outcomes Survey vi

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9 Clinical Quality Metrics Background The Coordinated Care Organization (CCO) Incentive Measures are determined by the Oregon Metrics & Scoring Committee, which was established in 2012 by Senate Bill 1580 to create outcomes and quality measures for CCOs. The measures are negotiated with the Centers for Medicaid and Medicare Services (CMS) as part of Oregon s 1115 waiver agreement. Each CCO has individualized improvement targets that are designed to decrease the distance between current performance and the OHA established benchmark each year. CCOs must achieve at least 13 of the measures to earn back the payments withheld by the Oregon Health Authority (OHA). In 2014, OHA withheld 3% of aggregate CCO payments. The Medicare Stars Measures are determined by CMS. The Star Rating System measures the performance of Medicare Advantage and Part D plans, by comparing them against the rest of the country. There are over 40 measures which constitute the Star Rating System, with plans scored on a 5 Star scale for each. The individual measures are scored and weighted to determine a plan s overall Stars score. 5 Star plans have a special enrollment period and earn increased reimbursement from CMS. Clinical Quality Metrics Timeline CCO (Medicaid) Medicare Advantage Care is provided January December 2015 January December 2015 Measures are finalized December 2014 April 2015 HEDIS chart reviews are conducted January April 2016 February May 15, 2016 Member surveys are conducted Care is scored to determine performance Performance is announced Payout received for performance CAHPS: results in June 2016 May 2016 Data validated between CCO & OHA June 2016 OHA releases performance reports By June 30, 2016 Quality dollars to CCOs CAHPS: March June 2016 HOS: April July 2016 September 2016 Plan is scored against metric October 2017 Plan is awarded new Star rating January December 2018 On a per member per month basis 1

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11 2015 CCO New and Updated Metrics Effective Contraception Dental Sealants Assessments within 60 Days for Children in DHS Custody Alcohol and Drug Misuse (SBIRT) Diabetes: HbA1c Poor Control Depression Screening and Follow-Up Plan Controlling Hypertension New Measures for 2015 Measure: Women ages who utilize an effective contraceptive method Benchmark: 50% Baseline: 17% (rough estimate from women with Rx for contraceptives or IUD) Target for 2015: ~20% Measure: Children ages 6-14 who receive a sealant on a permanent molar tooth Benchmark: 20% Baseline: Estimated at 13% Target for 2015: ~16% Changes to Existing Measures for 2015 Benchmark set by OHA as the ultimate performance goal for each measure Baseline current CCO performance Measure: Children 0-17 who receive physical, mental, and dental assessments within 60 days of CCO notification that they entered DHS custody Benchmark: 90% Target for 2015: 3% improvement over baseline. Change from 2014: Dental health assessment added to the measure Measure: Patients ages 12 and older who receive a complete SBIRT screening Benchmark: 12% Target for 2015: 3% improvement over baseline Change from 2014: Members aged added to the measure Measure: Patients ages with diabetes whose HbA1c is <9.0% Benchmark: 34% Target for 2015: 34% - CCOs expected to achieve benchmark in first year Change from 2014: We must now show member health outcomes. Previously, performance was measured by ability to obtain data from clinic EMRs. Measure: Patients ages 12 and older who screen positive* for depression and have a documented follow-up plan *this is more clearly defined and explained in the specifications for this measure Benchmark: 25% Target for 2015: 25% - CCOs expected to achieve benchmark in first year Change from 2014: We must now show member health outcomes. Previously, performance was measured by ability to obtain data from clinic EMRs. Measure: Patients ages with a diagnosis of hypertension whose blood pressure was in control (<140/90mmHg) Benchmark: 34% Target for 2015: 34% - CCOs expected to achieve benchmark in first year Change from 2014: We must now show member health outcomes. Previously, performance was measured by ability to obtain data from clinic EMRs. 3

12 CCO Metrics by Age * 4 Incentive measure CCO is measured on performance and given the opportunity to earn back PMPM payments withheld by OHA *Core measure being watched by OHA per the federal waiver to ensure ongoing attention to comprehensive care during transformation

13 Adult BMI Assessment Adult Health Technical Specifications (for the data folks) Overview: Medicare Stars measure Percentage of members between the ages of 18 and 74 who had their body mass index (BMI) calculated and recorded in their medical records Denominator Numerator All members born between and are included in the measure Members in the denominator who had an outpatient visit and had their BMI documented in 2014 or For members younger than 19 years of age on the date of service, BMI percentile also meets criteria Exclusions Members who have a diagnosis of pregnancy in 2014 or Continuous Enrollment Measurement Period 2015 CMS Benchmark (5 Star) Chart Review Documentation Value Set HCPC/CPT Value Set ICD-9 Exclusion Value Set HCPC/CPT Exclusion Value Set ICD-9 January 1, 2014 December 31, 2015 (2 years) No more than one gap in enrollment each year of 45 days or less January 1 December 31, % Weight and BMI value, dated within 2014 or 2015 and from the same data source. For members younger than 19 years of age, BMI percentile may be documented as a distinct value or plotted on an age-growth chart. BMI: V85.0, V85.1, V85.21, V85.22, V85.23, V85.24, V85.25, V85.30, V85.31, V85.32, V85.33, V85.34, V85.35, V85.36, V85.37, V85.38, V85.39, V85.41, V85.42, V85.43, V85.44, V85.45 BMI Percentile: V85.51, V85.52, V85.53, V85.54 V22.0, V22.1, V22.2, V23.0, V23.1, V23.2, V23.3, V23.41, V23.42, V23.40,V23.5, V23.7, V23.81, V23.87, V23.89, V23.9, V28.0, V28.1, V28.2, V28.3, V28.4, V28.5, V28.6, V28.81, V28.82, V28.89, V28.9,

14 Adult BMI Assessment Care Team Specifications (for the non-data folks) Overview: Medicare Stars measure Percentage of members between the ages of 18 and 74 who had their body mass index (BMI) calculated and recorded in their medical records Denominator Numerator Exclusions Is there continuous enrollment criteria? What is the timeline to meet our goal? All members born between and are included in the measure Members in the denominator who had an outpatient visit and had their BMI documented in 2014 or For members younger than 19 years of age on the date of service, BMI percentile also meets criteria (optional) Members who have a diagnosis of pregnancy in 2014 or 2015 January 1, 2014 December 31, 2015 (2 years) with one gap in enrollment each year of 45 days or less By December 31, 2015 What is the 5 Star benchmark? 93.0% How is it being measured? What codes count? What documentation is required? Using claims data based on coding for the assessment, with a random sample selected for HEDIS review BMI: V85.0, V85.1, V85.21, V85.22, V85.23, V85.24, V85.25, V85.30, V85.31, V85.32, V85.33, V85.34, V85.35, V85.36, V85.37, V85.38, V85.39, V85.41, V85.42, V85.43, V85.44, V85.45 BMI Percentile: V85.51, V85.52, V85.53, V85.54 Weight and BMI value, dated within 2014 or Weight and BMI must be from the same data source For members younger than 19 years of age, BMI percentile may be documented as a distinct value or plotted on an age-growth chart 6

15 Colorectal Cancer Screening Technical Specifications (for the data folks) Overview: CCO Incentive and Medicare Stars measure Percentage of members between the ages of 51 and 75 who received colorectal cancer screening Denominator All members born between and Numerator Exclusions Members in the denominator who received at least one of the following screenings for colorectal cancer: - Fecal occult blood test (FOBT) in Flexible sigmoidoscopy since Colonoscopy since 2006 Any record of colorectal cancer or a total colectomy Continuous Enrollment Measurement Period 2015 OHA Benchmark 2015 CMS Benchmark (5 Star) Changes from 2014 Chart Documentation Value Set HCPC/CPT Value Set ICD-9 * Exclusion Value Set HCPC/CPT Exclusion Value Set ICD-9 & 10 January 1, 2014 December 31, 2015 (2 years) No more than one gap in enrollment each year of 45 days or less January 1 December 31, % 72.0% Add diagnosis codes 154.2, 154.3, V10.06 to colorectal cancer exclusion Date when the screening was performed Result is required unless clearly in the medical history section of the record FOBT must specify type of FOBT: guaiac (gfobt) or immunochemical (ifobt) - If type is not specified, the number of samples must be recorded and be > 3 FOBT: 82270, 82274, G0328; LOINC codes: , , , , , , , , , , , , , , Flexible Sigmoidoscopy: , , 45345, G0104 Colonoscopy: , 44397, 45355, , 45391, 45392, G0105, G0121 Flexible Sigmoidoscopy: Colonoscopy: 45.22, 45.23, 45.25, 45.42, , , , G0215, G0231 ICD 9: V10.05, V10.06, , 153, , 197.5; ICD 10: C18.0-C18.9, C19, C20, C21.2, C21.8, C78.5, Z85.038, Z85.048, 0DTE0ZZ, 0DTE4ZZ, 0DTE8ZZ *There are no ICD-10 codes that count. Qualifying screening services without adminstrative claims can be captured in chart review. 7

16 Colorectal Cancer Screening Care Team Specifications (for the non-data folks) Overview: CCO Incentive and Medicare Stars measure Percentage of members between the ages of 51 and 75 who received colorectal cancer screening Denominator Numerator Exclusions Is there continuous enrollment criteria? What is the timeline to meet our goal? All members born between and are included in the measure Members in the denominator who received at least one of the following screenings for colorectal cancer: - Fecal occult blood test (FOBT) in Flexible sigmoidoscopy since Colonoscopy since 2006 Any record of colorectal cancer or a total colectomy January 1, 2014 December 31, 2015 (2 years) with one gap in enrollment each year of 45 days or less By December 31, 2015 What is the OHA benchmark? 47.0% What is the 5 Star benchmark? 72.0% How is it being measured? What codes count? What documentation is required? Using claims data based on coding for the screening, with random samples selected for chart review and HEDIS review FOBT: 82270, 82274, G0328; LOINC codes: , , , , , , , , , , , , , , Flex sigmoidoscopy: , , 45345, G0104, Colonoscopy: , 44397, 45355, , 45392, G0105, G0121, 45.22, 45.23, 45.25, 45.42, 45.42, Date when the screening was performed Result is required unless clearly in the medical history section of the record FOBT must specify type of FOBT: guaiac (gfobt) or immunochemical (ifobt) - If type is not specified, the number of samples must be recorded and be > 3 8

17 Colorectal Cancer Screening: Clinic Needs Assessment for ramp up If your clinic is ready to ramp up CRC, please contact us for the CRC toolkit and additional resources. 9

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24 Colorectal Cancer Screening: Clinic Readiness Checklist To succeed, clinic leadership needs to be committed to CRC screening and clinics should have a clinician champion who is educated and influential. Beyond that foundation, the following activities and questions can help you check your clinic s readiness to implement STOP CRC: (note - EMR steps described are OCHIN/EPIC specific) Status Preparation Step Health Maintenance (HM) is Standard of Care (see Step 1, Preparatory Steps) o Is HM already your standard for recording patient care activities and are your providers and other medical staff using it regularly? o Are colonoscopy orders and results captured in HM? o What is your process for obtaining prior colonoscopy results, documenting them in the EMR and updating HM? o Are other CRC screening activities (ie: fecal testing, sigmoidoscopy) captured in HM? FIT Kit Selected and Providers Able to Support FIT (see Step 2, Preparatory Steps) o Are you already using a FIT or do you have to choose one? (Consider collection method, performance, how its processed, cost, and ease of use.) o Are FIT processes standardized, and are staff trained? Lab Interface for FIT Processing is Established (see Step 3, Preparatory Steps) o Will you use an internal or external lab? o How will tests arrive at the lab? How are lab orders placed and who puts in orders? o How are results returned? Are they automatically updated in the EMR, or is there a manual step to get results from lab to EMR? o Is HM updated when lab results are entered? o Is Lab interface in place and tested where applicable? Care Team Staff Offering FIT During Visit (see Step 4, Preparatory Steps) o Is a pre-visit scrub standardized and implemented? o Is your staff trained to provide FIT kits and answer questions? o Do administrative and medical staff know their responsibilities? o Who notifies patients of normal and abnormal results? Mailed Outreach Strategy Implemented (see Step 5, Preparatory Steps) o Will you mail kits to patients in addition to in-clinic recommendations? o Are roles, responsibilities and FTE assigned to perform the work? Ability to Identify Eligible Population (see Step 6, Preparatory Steps) o Is Reporting Workbench (RWB) available and are your staff members already trained in using it? o Do staff have access to the STOP CRC reports or reporting tool with ability to list patients by CRC screening status (quarterly or by month)? o Do you have other gaps in care reports? o Do you rely on manual chart scrub or health maintenance/procedure tracking tool? Activity Status: 0 = Not Planning at this time 1 = Designing 2 = Testing / Implementing 3 = Standardizing 4 = Maintaining 16 5 =

25 Colorectal Cancer Screening: Clinic Readiness Guidance All Appendices & Epic training material referenced are available upon request. Before you start, clinic leadership needs to be committed to CRC screening, including FIT, and clinics should have a clinician champion who is educated about FIT and influential. For clinics wanting to ramp up CRC screening, who may or may not transition to STOP CRC tools, the priority activities in 2015 are: 1. Standardize use of Health Maintenance (HM) 1 and clean charts What How STOP CRC or Other Resources Educate providers and MAs and learn how to oversee Health Maintenance (HM) use. HM needs to be the standard of care to track CRC screening and outreach (either in clinic or by mail). HM must be accurate when ordering screening tests or screened patients will appear as eligible. Patients will not trust that provider knows them if clinic offers FIT to patients already tested. The OCHIN Training library has an overview to using HM, but clinics will also need their own clinic-created process for tracking CRC screening in HM. Ensure CRC screening and results reliably captured in HM: Current colonoscopies, Historical colonoscopy, and Flex Sig orders and results Get a list of claims data from your Medicaid Health plan and confirm that HM screening interval reflects test results. EPIC HMA Update Training Guide * Updating EMR with Historical Colonoscopy Workflow - Appendix A Proactively manage and maintain clinical data An EMR Specialist or EMR-savvy staff member needs to know what the HM data means so the team can alert patient if gap, OR know HM is in error and needs to be updated. Standardize the pre-visit scrub and know how to update HM correctly (see Step 4 below) Standardize the HM update processes and staff to do it for both: 1. New results (historical or ordered colonoscopy) 2. Ordered and resulted tests but no result is in chart 1 Note that clinics that do not use HM can implement these steps using their own EMR system. 17

26 Colorectal Cancer Screening: Clinic Readiness Guidance 2. Select FIT kit, Ensure clinician support for FIT What How STOP CRC or Other Resources Select a FIT kit that works well for your clinic and with your lab processing. Make sure providers, nurses, MAs, and staff are comfortable with FIT. Make sure providers know what FIT is good for, its reliability, and how to pitch relative to colonoscopy. Key considerations: FITs vary in collection methods (number of samples), performance, how they are processed, where they are processed, cost, ease of use, and FDA approval. Use educational presentations at provider meetings, Grand Rounds, or team meetings. Identify an internal champion who is enthusiastic and supported by the organization s leaders. Kits Selected by STOP CRC Clinics Appendix B; their cost, positivity rates, and lab where processed Clinician s Reference FOBT and FIT, American Cancer Society i FIT Test Selection, American Cancer Society ii STOP CRC Patient Education Materials for Clinics: Clinic Posters, Handouts, Videos Clinicians Reference: FOBT for Colorectal Cancer Screening Appendix D Primary Care Clinician s Evidence-based Toolbox, Pages 19-31: An Office Policy Develop strong communication and training plan. Clearly communicate staff responsibilities for FIT processes. Train staff when you are ready to roll out the FIT. American Cancer Society Resources Ensure GI Network for followup colonoscopy. Make sure that you have the GI referral processes and sufficient capacity for colonoscopy after positive FIT tests 3. Establish Lab Interface for FIT processing What How STOP CRC or Other Resources Select lab to process FITs; choose on site or external lab processing. Select how FIT kits will be processed: Results processed on site by clinic staff or at internal central lab Results processed by external lab vendor located on site Results processed at external lab vendor located off site 18

27 Colorectal Cancer Screening: Clinic Readiness Guidance What How STOP CRC or Other Resources Develop lab interface. How is test arriving at the lab and how are results returned? If processing externally at an outside lab, test lab interface and resolve problems before FIT volume goes up. Determine the type of lab order (future or regular), the workflow for creating lab orders, and how to interface with the lab for processing. Determine if patients mail (or bring) FIT Kits to the clinic or send the kit directly to an external lab. Determine how results will be returned from the lab (i.e., an automated EMR interface, manually entered by staff into EMR, or scanned paper result). If using future orders, consider how long before the lab order expires for the lab you are using. Be sure the order will not expire before kits are returned in the mail. 2 If no automated lab interface exists, results need to be faxed to clinic. Need to develop process for how to enter and update HM. Determine how lab will receive billing information and how to handle tests in error queue because of wrong billing information. Develop a way to track the error queue. 4. Ramp up point-of-care staff offering FIT Kits during patient visits What How STOP CRC or Other Resources Create workflows for chart scrub and have team discussion about CRC screening recommendation. Ramp up opportunistic testing. Either set up a system for manual chart scrub for gaps in care or use HM procedure tracking tool. Patients are much more likely to follow through with screening after a doctor s recommendation. Establish a clear organizational structure for the screening system. Steps for Increasing Colorectal Cancer Screening: A Manual for CHCs 2 NOTE: Bulk ordering (in OCHIN clinics) uses a future order but fixes this problem. Kits returned to clinic, then the kit order released, Lab receives order and picks up tests, processes same day. 19

28 Colorectal Cancer Screening: Clinic Readiness Guidance What How Stop CRC or Other Resources Ramp up opportunistic testing (cont.) Ramp up patient education about the need for Colorectal Cancer screening Determine how patients are notified of results. Develop a screening protocol. Agree on MA and provider role in alerting patients during clinic visits. Determine how and when to offer kits in clinic. Use patient letters or materials, clinic posters, CRC fairs in addition to provider recommendations Understand patient population and design culturally appropriate messages Who notifies patients of normal and abnormal results? Medical Assistant Registered Nurse Licensed Practicing Nurse Panel Manager Provider PCP Specialist Office What is the preferred method of contact (i.e., phone, letter, follow-up visit)? 5. Decide whether and how to implement a mailed outreach strategy Primary Care Clinician s Evidence-based Toolbox STOP CRC Patient Education Materials in Spanish and English (Videos, Clinic Posters, Clinic Handouts) Patient Education Materials What How STOP CRC or Other Resources Mail a FIT or FOBT kit to eligible patients overdue for CRC screening. (Mailed kits have increased CRC screening rates in multiple studies.) Assign roles, responsibilities and staffing FTE to each step in the workflow for a mailed program. Establish strong IT and EMR expert support for a mailed program. 20 Use the STOP CRC program, which is a toolkit for mailed CRC screening designed to be adapted for CHC clinics. Staff will need to run reports of eligible patients, print the letters and reminder letters, order labs for the kits, mail the kits, and track the activities and lab results to ensure proper follow-up care. STOP CRC tools are effective and easy to use, but it s important to learn how to use the tools, and know what each report is telling you, and where the data came from. STOP CRC Program Overview Appendix E STOP CRC Intervention Materials (Letter Templates, Wordless FIT Instructions, Clinic Posters, Training Materials) See STOP CRC Program Overview and Cost Estimates Appendix F

29 Colorectal Cancer Screening: Clinic Readiness Guidance 6. Get a list of your population eligible for a mailed FIT What How STOP CRC or Other Resources For OCHIN Clinics in a Control site of the STOP CRC study, the Reporting Workbench (RWB) eligible patient lists will be available according to the research schedule. For OCHIN Clinic organizations not participating in STOP CRC, access the list of eligible patients using Reporting Workbench (RWB). In non-ochin systems, create a list of patients overdue for CRC screening. To set up the STOP CRC All Eligible report that lists patients due for CRC screening, a request must be sent to OCHIN using their JIRA process. RWB is available in all OCHIN-supported clinics. To get the STOP CRC All Eligible report that lists patients due for CRC screening, a request must be sent to OCHIN using their JIRA process. Another alternative is to create your own RWB filters using the eligibility criteria and CRC screening status. Use the eligibility criteria to program a report listing eligible patients in your EMR s patient registry or reporting tool. OCHIN JIRA Process to request access to STOP CRC reports in RWB (Coming soon.) STOP CRC criteria for eligibility used to generate the list of eligible patients Appendix G OCHIN JIRA Process to request access to STOP CRC reports in RWB (Coming soon.) STOP CRC criteria for eligibility - Appendix G; used to generate the list of eligible patients Tracking and Evaluating Success: As you implement changes, plan to track and evaluate your costs and the revenue implications of CRC screening. As the changes roll out in your clinic, you can work on lowering costs so that the program is sustainable. For example, kit manufacturers might sell or donate kits directly to clinic. The cost of mailing kits might change; some manufacturers are decreasing size of envelope, to lower mailing costs. Schedule a PDSA cycle for about 6 months after you implement the new clinic strategy to improve process and outcomes. i American Cancer Society. CLINICIAN S REFERENCE: FECAL OCCULT BLOOD TESTING (FOBT) FOR COLORECTAL CANCER SCREENING pdf Accessed March iiii Excerpted from American Cancer Society. Steps for Increasing Colorectal Cancer Screening Rates: A Manual for Community Health Centers. Manual_FULFILL.pdf Accessed March

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31 Controlling High Blood Pressure (NQF 0018) Technical Specifications (for the data folks) Overview: CCO Incentive and Medicare Stars measure Percentage of members between the ages of 18 and 85 who are diagnosed with hypertension and whose blood pressure is below 140/90 mmhg Denominator Numerator Exclusions Continuous Enrollment Measurement Period 2015 OHA Benchmark 2015 CMS Benchmark (5 Star) Changes from 2014 Chart Documentation Value Set HCPC/CPT Exclusion Value Set* All members born between and with a diagnosis of hypertension by August 1 and who received a qualifying outpatient visit in 2015 Members in the denominator whose blood pressure at the most recent visit is adequately controlled* systolic <140 mmhg, diastolic <90 mmhg *Medicare STARS only members ages without diabetes are in adequate control with systolic <150 mmhg, diastolic <90 mmhg. All others remain <140/90. Any record of end state renal disease (ESRD), chronic kidney disease stage 5, dialysis or renal transplant; or Pregnancy in 2015 January 1 December 31, % 75.0% First year of measurement Date when blood pressure was measured and result Blood pressure data reported from EHR (CCO) or HEDIS review of sample (Stars) Qualifying outpatient visits include: , , , , , G0438, G (End Stage Renal Disease) (ESRD Monthly Outpatient Services) (Chronic Kidney Disease Stage 5) (Vascular Access for Dialysis) (Kidney Transplant) (Dialysis Services) (Other Services Related to Dialysis) (Dialysis Education) 2015 only (Pregnancy) *Value sets can be accessed through the Value Set Authority Center (VSAC) at the National Library of Medicine: Value sets include CPT, HCPC, ICD-9, ICD-10, SNOMED, and RXNORM codes. 23

32 Controlling High Blood Pressure (NQF 0018) Care Team Specifications (for the non-data folks) Overview: CCO Incentive and Medicare Stars measure Percentage of members diagnosed with hypertension between the ages of 18 and 85 whose blood pressure is below 140/90 mmhg Denominator All members born between and diagnosed with hypertension by August 1 and who received a qualifying outpatient visit in 2015 Members in the denominator whose blood pressure is controlled* systolic <140 mmhg, diastolic <90 mmhg Numerator Exclusions Is there continuous enrollment criteria? *Medicare STARS only members years old without diabetes have controlled blood pressure if systolic <150 mmhg, diastolic <90 mmhg. All others remain <140/90. Any record of end state renal disease (ESRD), chronic kidney disease stage 5, dialysis, or renal transplant, or Pregnancy in 2015 What is the timeline to meet our goal? By December 31, 2015 What is the OHA benchmark? 64.0% What is the 5 Star benchmark? 75.0% How is it being measured? What codes count? CCO Reported directly from Electronic Health Records Stars HEDIS review of sample Qualifying outpatient visits include: , , , , , G0438, G0439 What documentation is required? Date when blood pressure was measured and result 24

33 Diabetes Management: Kidney Disease Monitoring Technical Specifications (for the data folks) Overview: Medicare Stars measure Percentage of members between the ages of 18 and 75 who are diagnosed with diabetes and who had kidney function testing Denominator Numerator Exclusions Continuous Enrollment Measurement Period 2015 CMS Benchmark (5 Star) Chart Review Documentation Value Set HCPC/CPT Value Set ICD-9 Exclusion Value Set HCPC/CPT Exclusion Value Set ICD-9 All members with diabetes (type 1 and type 2) born between and are included in the measure Members in the denominator who had medical attention for nephropathy in 2015: a visit to a nephrologist, at least one ACE inhibitor or ARB prescribed, or a microalbuminuria test. Members who do not have a diagnosis of diabetes and who have a diagnosis of polycystic ovaries, gestational diabetes or steroid-induced diabetes in 2014 or 2015 January 1 - December 31, 2015 with one gap in enrollment of 45 days or less January 1 December 31, % Date when the kidney function test was performed with either Result of nephropathy screening test or evidence of nephropathy Microalbuminuria test: 82042, 82043, 82044, 84156, 3060F, 3061F (optional)

34 Diabetes Management: Kidney Disease Monitoring Care Team Specifications (for the non-data folks) Overview: Medicare Stars measure Percentage of members diagnosed with diabetes between the ages of 18 and 75 who had kidney function testing Denominator Numerator Exclusions Is there continuous enrollment criteria? All members born between and with a diagnosis of diabetes (type 1 or type 2) Members in the denominator who had medical attention for nephropathy in 2015 including: a visit to a nephrologist, at least one ACE inhibitor or ARB prescribed, or a microalbuminuria test Members who do not have a diagnosis of diabetes and who have a diagnosis of polycystic ovaries, gestational diabetes, or steroid-induced diabetes in 2014 or 2015 January 1 - December 31, 2015 with one gap in enrollment of 45 days or less What is the timeline to meet our goal? By December 31, 2015 What is the 5 Star benchmark? 94.0% How is it being measured? HEDIS review of sample What codes count? What documentation is required? Microalbuminuria test: 82042, 82043, 82044, 84156, 3060F, 3061F Date when kidney function test was performed with either Result of nephropathy screening test or evidence of nephropathy 26

35 Diabetes Management: Eye Exam Technical Specifications (for the data folks) Overview: Medicare Stars measure Percentage of members between the ages of 18 and 75 who are diagnosed with diabetes and who received a retinal eye exam Denominator Numerator Exclusions Continuous Enrollment All members with diabetes (type 1 and type 2) born between and are included in the measure Members in the denominator who had a retinal eye exam to check for damage from diabetes in 2015 (optional) Members who do not have a diagnosis of diabetes and who have a diagnosis of polycystic ovaries, gestational diabetes or steroid-induced diabetes January 1 - December 31, 2015 with one gap in enrollment of 45 days or less Measurement Period 2015 CMS Benchmark (5 Star) Chart Review Documentation Value Set HCPC/CPT Value Set ICD-9 January 1 December 31, % One of the following: the date and result of an eye exam by an eye care professional, or a chart or photograph of retinal abnormalities including the date, or documentation of a negative retinal or dilated eye exam in , 67030, 67031, 67036, , 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, , 92230, 92235, 92240, 92250, 92260, , , , S0620, S0621, S0625, S3000, 2022F, 2024F, 2026F, 3072F Exclusion Value Set HCPC/CPT Exclusion Value Set ICD-9 (optional)

36 Diabetes Management: Eye Exam Care Team Specifications (for the non-data folks) Overview: Medicare Stars measure Percentage of members diagnosed with diabetes between the ages of 18 and 75 who received a retinal eye exam Denominator Numerator Exclusions Is there continuous enrollment criteria? What is the timeline to meet our goal? All members born between and with a diagnosis of diabetes (type 1 or type 2) Members in the denominator who had a retinal eye exam to check for damage from diabetes in 2015 (optional) Members who do not have a diagnosis of diabetes and who have a diagnosis of polycystic ovaries, gestational diabetes, or steroid-induced diabetes January 1 - December 31, 2015 with one gap in enrollment of 45 days or less By December 31, 2015 What is the 5 Star benchmark? 81.0% How is it being measured? What codes count? What documentation is required? HEDIS review of sample 67028, 67030, 67031, 67036, , 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, , 92230, 92235, 92240, 92250, 92260, , , , S0620, S0621, S0625, S3000, 2022F, 2024F, 2026F, 3072F One of the following: date and result of an eye exam by an eye care professional, or chart or photograph of retinal abnormalities with the date, or documentation of a negative retinal or dilated eye exam in

37 Diabetes Management: Controlling Blood Sugar/HbA1c Poor Control Technical Specifications (for the data folks) Overview: CCO Incentive and Medicare Stars measure Percentage of members between the ages of 18 and 75 who are diagnosed with diabetes and who have a HbA1c level above 9.0% (poor control) Denominator All patients born between and with a diagnosis of diabetes who have received a qualifying outpatient visit* in 2015 *Medicare STARS only members do not need to have a qualifying outpatient visit. All members with a diagnosis of diabetes are included in the measure Numerator All patients in the denominator whose HbA1c level at the most check is >9.0% Exclusions Continuous Enrollment Measurement Period 2015 OHA Benchmark 2015 CMS Benchmark (5 Star) Changes from 2014 Chart Documentation Value Set HCPC/CPT Value Set ICD-9 Exclusion Value Set HCPC/CPT Exclusion Value Set ICD-9 January 1 December 31, % (lower is better) 21.0% (lower is better) First year of measurement for CCO Incentive Metrics Date when HbA1c test was performed and the result Most recent HbA1c level is reported from EHR (CCO) or chart review (Stars) Qualifying outpatient visits for CCO measure include: , , , , , G0438, G

38 Diabetes Management: Controlling Blood Sugar/HbA1c Poor Control Care Team Specifications (for the non-data folks) Overview: CCO Incentive and Medicare Stars measure Percentage of members between the ages of 18 and 75 who are diagnosed with diabetes and who have a HbA1c level above 9.0% (poor control) Denominator Numerator All members born between and with a diagnosis of diabetes and who have had an outpatient visit* *Medicare STARS only members do not need to have a qualifying outpatient visit. All members with a diagnosis of diabetes are included in the measure Members in the denominator whose HbA1c level at the most recent check is greater than 9.0% Exclusions Is there continuous enrollment criteria? What is the timeline to meet our goal? By December 31, 2015 What is the OHA benchmark? 34.0% (lower is better) What is the 5 Star benchmark? 21.0% (lower is better) How is it being measured? What codes count? What documentation is required? CCO Reported directly from Electronic Health Records Stars HEDIS review of sample Qualifying outpatient visits for CCO measure include: , , , , , G0438, G0439 Date when HbA1c test was performed and the result 30

39 Diabetes Management: Medication Adherence Overview: Medicare Stars measures These is a Part D (pharmacy) measures that focus on the adherence of diabetic members across a range of medications Medication Adherence for Oral Diabetes Medications: - Percent of members age 18 and older that adhere to their prescribed drug therapy across classes of diabetes medications in 2015 The 5 Star benchmark is 81.0% Medication Adherence for Hypertension (RAS antagonists): - Percent of members age 18 years and older that adhere to their prescribed drug therapy for renin angiotensin system (RAS) antagonists in 2015 The 5 Star benchmark is 85.0% Medication Adherence for Cholesterol (Statins): - Percent of members age 18 years and older that adhere to their prescribed drug therapy for statin cholesterol medications in 2015 The 5 Star benchmark is 83.0% Medication Therapy Management Overview: Medicare Stars measures This is a Part D (pharmacy) measure based on the percentage of members who have a comprehensive medication review Medication Therapy Management (MTM): - Percent of members who received a written summary of a comprehensive medication review The 5 Star benchmark is undetermined this is a new measure for

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41 Rheumatoid Arthritis Technical Specifications (for the data folks) Overview: Medicare Stars measure Percentage of members age 18 and older with rheumatoid arthritis who had one or more prescriptions for an anti-rheumatic drug Denominator Numerator Exclusions Continuous Enrollment Measurement Period 2015 CMS Benchmark (5 Star) Chart Review Documentation Value Set Pharmacy data Value Set HCPC/CPT Value Set ICD-9 Exclusion Value Set HCPC/CPT Exclusion Value Set ICD-9 Members born before who were diagnosed with rheumatoid arthritis twice, in outpatient and/or inpatient settings, between January 1 and November 30, 2015 are included in the measure All members in the denominator who were dispensed at least one prescription for a disease modifying anti-rheumatic drug (optional) Members diagnosed with HIV any time before December 31, 2015 or members who have a diagnosis of pregnancy in 2015 January 1 - December 31, 2015 with one gap in enrollment of 45 days or less January 1 December 31, % ; sufficient documentation to support the codes billed for the visit 5-Aminosalicylates: Sulfasalazine Alkylating agents: Cyclophosphamide Aminoquinolines: Hydroxychloroquine Anti-rheumatics: Auranofin, Gold sodium thiomalate, Leflunomide, Methotrexate, Penicillamine Immunomodulators: Abatacept, Adalimumab. Anakinra. Certolizumab, Certolizumab pegol, Etanercept, Golimumab, Infliximab, Rituximab, Tocilizumab Immunosuppressive agents: Azathioprine, Cyclosporine, Mycophenolate Janus kinase (JAK) inhibitor: Tofacitinib Tetracyclines: Minocycline J0129, J0135, J0717, J0718, J1438, J1600, J1602, J1745, J3262, J7502, J7515, J7516, J7517, J7518, J9250, J9260, J , 714.1, 714.2, HIV: 042, V08 Pregnancy: Value Set

42 Rheumatoid Arthritis Care Team Specifications (for the non-data folks) Overview: Medicare Stars measure Percentage of members diagnosede with rheumatoid arthritis age 18 and older who had one or more prescriptions for an anti-rheumatic drug Denominator Numerator Exclusions Is there continuous enrollment criteria? What is the timeline to meet our goal? All members born before who were diagnosed with rheumatoid arthritis twice in either inpatient or outpatient settings between January 1 and November 30, 2015 All members in the denominator who were dispensed at least one prescription for a disease modifying anti-rheumatic drug (optional) Members diagnosed with HIV any time or members who have a diagnosis of pregnancy in January 1 December 31, 2015 with one gap in enrollment of 45 days or less By December 31, 2015 What is the 5 Star benchmark? 88.0% How is it being measured? What codes count? What drugs count? What documentation is required? Using claims data based on coding for the assessment, with a random sample selected for chart review J0129, J0135, J0717, J0718, J1438, J1600, J1602, J1745, J3262, J7502, J7515, J7516, J7517, J7518, J9250, J9260, J , 714.1, 714.2, Aminosalicylates: Sulfasalazine Alkylating agents: Cyclophosphamide Aminoquinolines: Hydroxychloroquine Anti-rheumatics: Auranofin, Gold sodium thiomalate, Leflunomide, Methotrexate, Penicillamine Immunomodulators: Abatacept, Adalimumab. Anakinra. Certolizumab, Certolizumab pegol, Etanercept, Golimumab, Infliximab, Rituximab, Tocilizumab Immunosuppressive agents: Azathioprine, Cyclosporine, Mycophenolate Janus kinase (JAK) inhibitor: Tofacitinib Tetracyclines: Minocycline No required chart documenttaion for this measure. Providers should provide sufficient documentation to support codes reported for visit. 34

43 Child and Adolescent Health Adolescent Well Care Visits Technical Specifications (for the data folks) Overview: CCO Incentive measure Percentage of members between the ages of 12 and 21 who received a comprehensive well care visit Denominator All members born between and are included in the measure Numerator Members who received a comprehensive well-care visit in 2015 Exclusions Continuous Enrollment Measurement Period 2015 OHA Benchmark Changes from 2014 Chart Documentation Value Set HCPC/CPT Value Set ICD-9/ICD-10 Exclusion Value Set HCPC/CPT Exclusion Value Set ICD None January 1 December 31, 2015 with one gap in enrollment of 45 days or less January 1 December 31, % Health & development history, physical exam, and health education/ anticipatory guidance , , G0438, G0439 ICD-9: V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9; ICD-10: Z00.00, Z00.01, Z00.121, Z00.129, Z00.5, [Z00.8, Z02.0, Z02.1, Z02.3, Z02.4, Z02.5, Z02.6, Z02.71, Z02.79, Z02.81, Z02.82, Z02.83, Z02.89, Z not on prioritized list] 35

44 Adolescent Well Care Visits Care Team Specifications (for the non-data folks) Overview: CCO Incentive measure Percentage of members between the ages of 12 and 21 who received a comprehensive well care visit Denominator Numerator All members born between and are included in the measure Members in the denominator who received at least one comprehensive well care visit in 2015 Exclusions None Is there continuous enrollment criteria? What is the timeline to meet our goal? January 1 December 31, 2015 with one gap in enrollment of 45 days or less By December 31, 2015 What is the OHA benchmark? 62.0% How is it being measured? Using claims data based on coding for the visit What codes count? What documentation is required? , , G0438, G0439 V20.2, V70.0, V70.3, V70.5, V70.6, V70.8, V70.9 ICD 10: Z00.00, Z00.01, Z00.121, Z00.129, Z00.5, [Z00.8, Z02.0, Z02.1, Z02.3, Z02.4, Z02.5, Z02.6, Z02.71, Z02.79, Z02.81, Z02.82, Z02.83, Z02.89, Z not on prioritized list] Health & development history, physical exam, and health education/anticipatory guidance 36

45 Adolescent Well Care Visits Frequently Asked Questions Q: What makes an office visit an Adolescent Well Care visit? There are 3 things that need to be documented to be able to bill for an AWC. 1. Health & development history (AAP/AAFP recommends HEEADDSS questionnaire) 2. Physical exam (Does not require GU exam) 3. Health education/anticipatory guidance These must be documented in the chart note to qualify as an AWC. Q: What is the difference between a Well Child Check and Adolescent Well Care visit? Some providers, clinics and parents may still refer to the visits as Well Child Checks. It is technically an adolescent well care visit when the patient is between the ages of 12 and 21. The difference is the type of exam and discussion in the visit. Young children might need more immunizations or developmental screenings but adolescents begin to receive counseling about drug/violence avoidance, sexual health and taking responsibility for their own health from providers. Q: Does the patient need to be seen by their PCP for it to count for the metric? No. The provider does not have to be the assigned PCP. Q: Does a sports physical count as an Adolescent Well Care visit? Not by itself. However, if the 3 components (health & development history, physical exam, and health education/anticipatory guidance) are included, the visit can be billed as an AWC as well as a sports physical. Q: Does a sick-visit count as an Adolescent Well Care visit? Not by itself. However, if the 3 components (health & development history, physical exam, and health education/anticipatory guidance) are included, the visit can be billed as an AWC in addition to a sick visit. Q: Does an Adolescent Well Care visit done at a School Based Health Center count toward the CCO metric? Yes. Visits to school-based health centers (SBHC) in a CCOs provider network are included in the measure if the billing/coding is submitted as a claim through the CCO. Q: Will CareOregon cover a second Adolescent Well Care visit within 12 months? Yes. CareOregon will cover as many Adolescent Well Care visits as appropriate per provider discretion within a 12 month period. 37