Clinical Quality Metrics Toolkit

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

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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

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 (4UH3CA188640-02). 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

Table of Contents Clinical Quality Metrics Background...1 Clinical Quality Metrics Timeline...1 2015 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... 16 Clinic Readiness Guidance... 17 Controlling High Blood Pressure (NQF 0018)... 23 Technical Specifications... 23 Care Team Specifications... 24 Diabetes Management: Kidney Disease Monitoring... 25 Technical Specifications... 25 Care Team Specifications... 26 Diabetes Management: Eye Exam... 27 Technical Specifications... 27 Care Team Specifications... 28 Diabetes Management: Controlling Blood Sugar /HbA1c Poor Control... 29 Technical Specifications... 29 Care Team Specifications... 30 Diabetes Management: Medication Adherence... 31 Medication Therapy Management... 31 Rheumatoid Arthritis... 33 Technical Specifications... 33 Care Team Specifications... 34 iv

Child and Adolescent Health... 35 Adolescent Well Care Visits... 35 Technical Specifications... 35 Care Team Specifications... 36 Frequently Asked Questions... 37 Sample Workflow... 38 Assessments for Children in DHS Custody... 41 Technical Specifications... 41 Care Team Specifications... 42 Dental Sealants on Permanent Molars for Children... 43 Technical Specifications... 43 Care Team Specifications... 44 Developmental Screening... 45 Technical Specifications... 45 Care Team Specifications... 46 Frequently Asked Questions... 47 Sample Workflows... 48 Mental Health... 51 Alcohol or Other Substance Misuse (SBIRT)... 51 Technical Specifications... 51 Care Team Specifications... 52 Frequently Asked Questions... 53 Sample Workflows... 55 Depression Screening and Follow-Up Plan (NQF 0418)... 57 Technical Specifications... 57 Care Team Specifications... 58 Follow-Up after Hospitalization for Mental Illness (NQF 0576)... 59 Technical Specifications... 59 Care Team Specifications... 60 Women s Health... 61 Breast Cancer Screening... 61 Technical Specifications... 61 Care Team Specifications... 62 v

Effective Contraceptive Use... 63 Technical Specifications... 63 Care Team Specifications... 64 Osteoporosis Management... 65 Technical Specifications... 65 Care Team Specifications... 66 Timeliness of Prenatal Care... 67 Technical Specifications... 67 Care Team Specifications... 68 Care for Older Adults... 69 Functional Status Assessment... 69 Technical Specifications... 69 Care Team Specifications... 70 Medication Review... 71 Technical Specifications... 71 Care Team Specifications... 72 Pain Screening... 73 Technical Specifications... 73 Care Team Specifications... 74 High Risk Medication Management... 75 Emergency Care... 77 All Cause Readmission... 77 Technical Specifications... 77 Ambulatory Care: Emergency Department Utilization... 78 Technical Specifications... 78 System Transformation... 79 Patient-Centered Primary Care Home (PCPCH) Enrollment... 79 Electronic Health Record (EHR) Adoption... 79 Member Surveys... 81 CAHPS Composite: Consumer Assessment of Health Plan Survey... 81 HOS: Health Outcomes Survey... 83 vi

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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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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 18-50 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 12-17 added to the measure Measure: Patients ages 18-75 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 18-85 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

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

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 1-1-1941 and 12-31-1997 are included in the measure Members in the denominator who had an outpatient visit and had their BMI documented in 2014 or 2015. 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 2015. 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, 2015 93% 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, 630-679 5

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 1-1-1941 and 12-31-1997 are included in the measure Members in the denominator who had an outpatient visit and had their BMI documented in 2014 or 2015. 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 2015. 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

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 1-1-1940 and 12-31-1964 Numerator Exclusions Members in the denominator who received at least one of the following screenings for colorectal cancer: - Fecal occult blood test (FOBT) in 2015 - Flexible sigmoidoscopy since 2011 - 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, 2015 47.0% 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: 2335-8, 12503-9, 12504-7, 14563-1, 14564-9, 14565-6, 27396-1, 27401-9, 2925-7, 27926-5, 29771-3, 56490-6, 56491-4, 57905-2, 58453-2 Flexible Sigmoidoscopy: 45330-45335, 45337-45342, 45345, G0104 Colonoscopy: 44388-44394, 44397, 45355, 45378-45387, 45391, 45392, G0105, G0121 Flexible Sigmoidoscopy: 45.24 Colonoscopy: 45.22, 45.23, 45.25, 45.42, 45.43 44150-44153,44155-44158, 44210-44212, G0215, G0231 ICD 9: V10.05, V10.06, 45.81-45.83, 153, 154.0-154.3, 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

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 1-1-1940 and 12-31-1964 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 2015 - Flexible sigmoidoscopy since 2011 - 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: 2335-8, 12503-9, 12504-7, 14563-1, 14564-9, 14565-6, 27396-1, 27401-9, 2925-7, 27926-5, 29771-3, 56490-6, 56491-4, 57905-2, 58453-2 Flex sigmoidoscopy: 45330-45335, 45337-45342, 45345, G0104, 45.24 Colonoscopy: 44388-44394, 44397, 45355, 45378-45387, 45392, G0105, G0121, 45.22, 45.23, 45.25, 45.42, 45.42, 45.43 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

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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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 =

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

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

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

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

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. http://www.cancer.org/acs/groups/content/@editorial/documents/document/acspc- 033144.pdf Accessed March 2015. iiii Excerpted from American Cancer Society. Steps for Increasing Colorectal Cancer Screening Rates: A Manual for Community Health Centers. http://nccrt.org/wp-content/uploads/0305.60-colorectal-cancer- Manual_FULFILL.pdf Accessed March 2015. 21

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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 1-1-1930 and 12-31-1997 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 60 85 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, 2015 64.0% 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: 99201-99205, 99212-99215, 99341-99350, 99385-99387, 99395-99397, G0438, G0439 2.16.840.1.113883.3.526.3.353 (End Stage Renal Disease) 2.16.840.1.113883.3.464.1003.109.12.1014 (ESRD Monthly Outpatient Services) 2.16.840.1.113883.3.526.3.1002 (Chronic Kidney Disease Stage 5) 2.16.840.1.113883.3.464.1003.109.12.1011 (Vascular Access for Dialysis) 2.16.840.1.113883.3.464.1003.109.12.1012 (Kidney Transplant) 2.16.840.1.113883.3.464.1003.109.12.1013 (Dialysis Services) 2.16.840.1.113883.3.464.1003.109.12.1015 (Other Services Related to Dialysis) 2.16.840.1.113883.3.464.1003.109.12.1016 (Dialysis Education) 2015 only 2.16.840.1.113883.3.526.3.378 (Pregnancy) *Value sets can be accessed through the Value Set Authority Center (VSAC) at the National Library of Medicine: https://vsac.nlm.nih.gov/. Value sets include CPT, HCPC, ICD-9, ICD-10, SNOMED, and RXNORM codes. 23

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 1-1-1930 and 12-31-1997 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 60-85 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: 99201-99205, 99212-99215, 99341-99350, 99385-99387, 99395-99397, G0438, G0439 What documentation is required? Date when blood pressure was measured and result 24

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 1-1-1940 and 12-31- 1997 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, 2015 94.0% 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) 256.4 25

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 1-1-1940 and 12-31-1997 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

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 1-1-1940 and 1-1- 1997 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, 2015 81.0% 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 2014 67028, 67030, 67031, 67036, 67039-67043, 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, 92225-92228, 92230, 92235, 92240, 92250, 92260, 99203-99205, 99213-99215, 99242-99245, S0620, S0621, S0625, S3000, 2022F, 2024F, 2026F, 3072F Exclusion Value Set HCPC/CPT Exclusion Value Set ICD-9 (optional) 256.4 27

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 1-1-1940 and 12-31-1997 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, 67039-67043, 67101, 67105, 67107, 67108, 67110, 67112, 67113, 67121, 67141, 67145, 67208, 67210, 67218, 67220, 67221, 67227, 67228, 92002, 92004, 92012, 92014, 92018, 92019, 92134, 92225-92228, 92230, 92235, 92240, 92250, 92260, 99203-99205, 99213-99215, 99242-99245, 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 2014 28

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 1-1-1940 and 12-31-1997 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, 2015 34.0% (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: 99201-99205, 99212-99215, 99341-99350, 99385-99387, 99395-99397, G0438, G0439 29

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 1-1-1940 and 12-31-1997 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: 99201-99205, 99212-99215, 99341-99350, 99385-99387, 99395-99397, G0438, G0439 Date when HbA1c test was performed and the result 30

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 2015 31

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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 12-31-1997 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, 2015 88.0% ; 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, J9310 714.0, 714.1, 714.2, 714.81 HIV: 042, V08 Pregnancy: Value Set 2.16.840.1.113883.3.464.1004.1219 33

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 12-31-1997 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 2015. 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, J9310 714.0, 714.1, 714.2, 714.81 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 No required chart documenttaion for this measure. Providers should provide sufficient documentation to support codes reported for visit. 34

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 1-1-1994 and 12-31-2003 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, 2015 62.0% Health & development history, physical exam, and health education/ anticipatory guidance 99383-99385, 99393-99395, 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, Z02.9 - not on prioritized list] 35

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 1-1-1994 and 12-31-2003 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? 99383-99385, 99393-99395, 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, Z02.9 - not on prioritized list] Health & development history, physical exam, and health education/anticipatory guidance 36

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

Adolescent Well Care Visits Sample Workflow 1. MA/team member scrubs for upcoming visits (next day/day of) to identify adolescents com ing in between the ages of 12-21, check for recent well visit, immunizations, and CRAFFT. OR 1. Team member scrubs chart from report of those who have not been in for a well visit and outreaches to family to bring adolescent in for AWC. 5. Add AWC, Immies, and/or CRAFFT to appointment notes, if not already there. 4. MA/Provider huddle regarding plan for visit. 3. MA rooms patient as per protocol and administers immunizations, enters CRAFFT results into EHR. 2. Provider sees patient as per protocol and uses HEEADSS assessment w/dot phrase (see following page). 8. Provider codes exam AWC by age/new vs established visit 99383-99395, including code for CRAFFT if done. 6. Provider reviews assessment and provides intervention as necessary; warm handoff to Behavioral Health Consultant if available (as necessary). 38

Adolescent/Young Adult.HEEADDSS Dotphrase (EXAMPLE QUESTIONS) Home: Lives with: *** Eats meals with: *** Quality of relationship with parents/guardians: *** Has family member/adult to turn to for help? *** Education/future plans: School details: *** Future plans: *** Usual grade ranges: *** Behavioral/attention issues: *** Eating Eats regular meals: *** Source and content of meals: *** Usual beverage choice: *** Concerns about body or appearance? *** Activities: Close friends? *** At least 1 hour of physical activity per day? *** Screen time (except homework) less than 2 hours/day? *** Has interest/participates in community activities/volunteer? *** Drugs/EtOH (NOTE: THESE QUESTIONS ALSO PART OF THE CRAFFT, SO MAY BE REDUNDANT) ETOH: *** Tobacco: *** Substance use: *** Depression/suicide/abuse: Has ways to cope with stress: *** Has problems with sleep: *** Gets depressed, anxious, or irritable/has mood swings: *** Has thought about hurting self or considered suicide: *** History of cutting: *** Prior suicide attempts: *** History of physical/sexual or verbal abuse: *** Safety: Use of safety belts/safety equipment: *** Home is free of violence: *** Has peer relationships free of violence: *** Concerns about guns, bullying, dating violence, passenger safety: *** Sexuality: Attracted to: *** Sexually active with: *** Practices: *** Prior STDs: *** Contraception: *** Condoms: *** 39

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Assessments for Children in DHS Custody Technical Specifications (for the data folks) Overview: CCO Incentive measure Percentage of children/adolescents receiving physical, mental, and dental assessments within 60 days of entering DHS custody Denominator Numerator Exclusions Continuous Enrollment Measurement Period 2015 OHA Benchmark Changes from 2014 All identified children/adolescents under 18 years old on the date the CCO was notified who remained in DHS custody for at least 60 days Members in the denominator who have received a physical health, mental health, and dental assessment between 30 days prior to and 60 days after notification Under age 4: exempt from the mental health assessment Under age 1: : exempt from the dental health assessment If the child: did not remain in DHS custody for at least 60 days following CCO notification, was placed in a Oregon Youth Authority 24/7 lockdown facility, was in run-away status, had trial reunification, or was not enrolled in the CCO; or if the CCO did not receive notification of the child entering foster care 60 days after date of the CCO is notified January 1 December 31, 2015 Notification date: January 1 October 31, 2015 90.0% Added dental assessment Chart Documentation Value Set HCPC/CPT Value Set ICD-9 Exclusion Value Set HCPC/CPT Exclusion Value Set ICD-9 ; sufficient documentation to support the codes billed for the visit Physical health assessment: 99201-99205, 99212-99215, 99381-99384, 99391-99394, G0439, or G0439; and Mental health assessment: 90791-90792, 96101-96102, H0031, H1001, H2000-TG, H0019, H2013, or H0037; and Dental health assessment: D0100-D0199 Under age 4: 90791-90792, 96101-96102, H0031, H1001, H2000-TG, H0019, H2013, or H0037 Under age 1: D0100-D0199 41

Assessments for Children in DHS Custody Care Team Specifications (for the non-data folks) Overview: CCO Incentive measure Percentage of children/adolescents receiving physical, mental, and dental assessments within 60 days of entering DHS custody Denominator Numerator Exclusions Is there continuous enrollment criteria? What is the timeline to meet our goal? All children/adolescents under 18 years old on the date the CCO was notified that they entered DHS custody Members in the denominator who received a physical health, mental health, and dental assessment between 30 days prior to and 60 days after the notification date Under age 4: exempt from mental health assessment Under age 1: exempt from dental health assessment If the child remains in DHS custody for less than 60 days, had trial reunification; or if the CCO was not notified 60 days after the date the CCO is notified By December 31, 2015 What is the OHA benchmark? 90.0% How is it being measured? Using claims data based on coding for the visits Physical health assessment: 99201-99205, 99212-99215, 99381-99384, 99391-99394, G0439, or G0439; and What codes count? What documentation is required? Mental health assessment: 90791-90792, 96101-96102, H0031, H1001, H2000-TG, H0019, H2013, or H0037; and Dental health assessment: D0100-D0199 No required chart documentation for this measure. Providers should provide sufficient documentation to support the codes reported for visit 42

Dental Sealants on Permanent Molars for Children Technical Specifications (for the data folks) Overview: CCO Incentive measure Percentage of children between the ages of 6 and 14 who received a sealant on a permanent molar tooth Denominator Numerator Exclusions Continuous Enrollment Measurement Period 2015 OHA Benchmark Changes from 2014 Chart Documentation Value Set HCPC/CPT Value Set ICD-9 Exclusion Value Set HCPC/CPT Exclusion Value Set ICD-9 All children born between 1-1-2001 and 12-31-2009 are included in the measure Children in the denominator who have received a sealant on a permanent molar, placed by any dental professional working in their scope of practice in 2015 January 1 - December 31, 2015 with one gap in enrollment of 45 days or less January 1 December 31, 2015 20.0% This is the first year of measurement ; sufficient documentation to support the codes billed for the visit D1351 43

Dental Sealants on Permanent Molars for Children Care Team Specifications (for the non-data folks) Overview: CCO Incentive measure Percentage of children between the ages of 6 and 14 who received a sealant on a permanent molar tooth in 2015 Denominator Numerator Exclusions All children born between 1-1-2001 and 12-31-2009 are included in the measure Children in the denominator who have received a sealant on a permanent molar, placed by any dental professional working in their scope of practice in 2015 Is there continuous enrollment criteria? 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 OHA benchmark? 20.0% How is it being measured? Using claims data based on coding for the visit What codes count? What documentation is required? D1351 No required chart documentation for this measure. Dental providers should provide sufficient documentation to support the codes reported for visit 44

Developmental Screening Technical Specifications (for the data folks) Overview: CCO Incentive measure Percentage of members who received at least one developmental screening prior to turning ages 1, 2, or 3 Denominator All members born between 1-1-2012 and 12-31-2014 Numerator Exclusions All members in the denominator who received a developmental screening in the 12 months prior to their birthday in 2015 Continuous Enrollment 12 months prior to the member s birthday in 2015 with one gap in enrollment of 45 days or less Measurement Period January 1 December 31, 2015 2015 OHA Benchmark Changes from 2014 Chart Documentation Value Set HCPC/CPT Value Set ICD-9 Exclusion Value Set HCPC/CPT Exclusion Value Set ICD-9 50.0% Results of screen, reviewed with parent/guardian, and provider records what action was taken (including no action taken for normal results) 96110 45

Developmental Screening Care Team Specifications (for the non-data folks) Overview: CCO Incentive measure Percentage of members who received at least one developmental screening in the year prior to turning ages 1, 2, or 3 Denominator Numerator Exclusions All members born between 1-1-2012 and 12-31-2014 are included in the measure All members in the denominator who received at least one developmental screening in the 12 months prior to their birthday in 2015 None Is there continuous enrollment criteria? What is the timeline to meet our goal? 12 months prior to the member s birthday in 2015, with one gap in enrollment of 45 days or less By December 31, 2015 What is the OHA benchmark? 50.0% How is it being measured? Using claims data based on coding for the visit What codes count? 96110 What documentation is required? ASQ or PEDS completed by parent, reviewed by provider, and provider records what action was taken (including no action taken for normal results) 46

Developmental Screening Frequently Asked Questions Q: Can my MA add ASQ answers to the medical record after the visit is completed? It can be entered in an addendum once the encounter has been closed; however it MUST be added on the day of service. Best practice: Have the MA enter in results into the medical record after the parent fills it out but before the provider enters the room. The provider can auto-populate results into the chart note, review with parent, and document action taken. Q: Does my organization have to use the Ages & Stages Questionnaire? No, OHA also accepts the Parents Evaluation of Developmental Status (PEDS), with or without the Developmental Milestones (DM). Q: Where can my organization purchase these screening tools? Ages & Stages Questionnaire: http://www.brookespublishing.com/resourcecenter/screening-and-assessment/asq/ Parents Evaluation of Developmental Status: http://www.pedstest.com/default.aspx Q: Can I screen a kiddo during a sick visit, or only during a Well Child Check? You can administer the screening at any time you see that the patient is due, even if they are not there for a well-child check. Q: Who gives the screening tool to the parent/guardian? It depends on what works best for your clinic. A lot of clinics have found it helpful to give the screening to the parent/guardian at check-in giving them time to fill it out before being called back. The MA can then score the tool in the room and enter it into the EHR. The provider will review the results with the parent/guardian. Q: Will the patient/parent/guardian be billed for the screening? What if it s done more than once in a year? The screening is covered by insurance regardless of the frequency of screening. Q: What happens if we get an abnormal result? The provider should review the results first. If they determine the child is not developing typically a referral should be made. The uniform Oregon referral form for early intervention can be located online. Note: parent/guardian signature is required. http://public.health.oregon.gov/healthypeoplefamilies/babies/healthscreening/abcd/d ocuments/ei-ecsereferral.pdf 47

Developmental Screening Sample Workflows 1. MA/team member scrubs charts for children coming in for Well Child Visits. Identifies children ages 0-3yrs that are due for an ASQ. 2. MA/Provider huddle to plan for patient visits; identify which ASQ is needed for WCCs. 3. MA puts ASQ - *** month in appointment notes for those who need it. Places appropriate ASQ at front desk with patient label on it. 4. Front Offices gives ASQ to parent/guardian at check in with brief explanation. 5. Parent/Guardian fills out form. MA can give assistance as needed. 6. MA rooms patient as per protocol, scores ASQ, enters results in the flowsheets, orders ASQ 96110, and leaves document in exam room for provider to review. 7. Provider reviews results with parent/guardian, decides if intervention is needed, and documents plan of action if needed. 8. If referral to Early Intervention is needed, MA fills out referral form, gets parent/ guardian signature, fills out contact info, and faxes referral form w/asq to EI program. 48

Developmental Screening 49

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Mental Health Alcohol or Other Substance Misuse (SBIRT) Technical Specifications (for the data folks) Overview: CCO Incentive measure Percentage of members age 12 and older who have received a full SBIRT screening Denominator Numerator Exclusions All members born before 12-31-2003 who have received an outpatient service in 2015 are included in the measure Members in the denominator who received screened positive in the brief screen and received at leastone full length SBIRT screening None 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-9 & 10 January 1 December 31, 2015 12.0% Adolescents ages 12 17 have been added to the measure. Additional outpatient utilization codes have been added to the denominator to incorporate adolescent outpatient visits. Additional outpatient utilization codes have been added to the denominator to incorporate changes between HEDIS 2013 and HEDIS 2015. Screening tool used and responses If brief intervention is given: documentation supporting the intervention or referral If using a time based code: Start/stop time or total face-to-face time with patient 99408, 99409, G0442, G0443, G0396, G0397 ICD-9: V79.1; V82.9 with CPT 99420 ICD-10: Z13.9; Z13.89 with CPT 99420 51

Alcohol or Other Drug Misuse (SBIRT) Care Team Specifications (for the non-data folks) Overview: CCO Incentive measure Percentage of members 12 or older who have received a full SBIRT screening Denominator Numerator All members born before 12-31-2003 who have received an outpatient service in 2015 are included in the measure Members in the denominator screened positive in the brief screen and received at least one full length SBIRT screening Exclusions Is there continuous enrollment criteria? What is the timeline to meet our goal? By December 31, 2015 What is the OHA benchmark? 12.0% How is it being measured? Using claims data based on coding for the visit What codes count? What documentation is required? 99408, 99409, G0442, G0443, G0396, G0397, V79.1, V82.9 with 99420, Z13.9, Z13.89 with 99420 Screening tool used and responses If brief intervention is given: documentation supporting the intervention or referral If using a time based code: Start/stop time or total face-to-face time with patient 52

Alcohol or Other Drug Misuse (SBIRT) Frequently Asked Questions Q: What is SBIRT? Screening, Brief Intervention, and Referral to Treatment (SBIRT) is an evidenced-based practice used to identify, reduce, and prevent the problematic use, abuse, and dependence on alcohol and drugs. Research shows that SBIRT has reduced healthcare costs, the severity of drug use, the severity of alcohol use, as well as the risk of trauma. Q: What approved evidence based screening tools can be used? Adults Alcohol Use Disorders Inventory Test (AUDIT), the Drug Abuse Screening Test (DAST) Alcohol Smoking and Substance Involvement Screening Test (ASSIST) Adolescents Care, Relax, Alone, Forget, Family & Friends, and Trouble (CRAFFT) A full list is available at: http://www.oregon.gov/oha/amh/pages/eb-tools.aspx Q: What is the difference between a brief screen and a full screen? A brief screen only includes one validated Alcohol, Drug and Mood question that identifies clients who require further screening. A full screen measures the severity of substance use to indicate if intervention or referral is needed. Q: How can SBIRT services be delivered? One person can screen, deliver brief intervention, and/or refer to treatment or it can be done by multiple people. A large number of organizations have different staff deliver one or more parts of the SBIRT service. If a multi-person intervention is decided on, please consider the additional coordination of hand offs between staff. Q: How can the brief annual screen be administered and interpreted? It can be administered written, orally, mailed or using various technologies. Since it is not a reimbursable service, it can be done by clerical, administrative, or other professionals. Q: Why are brief screens not reimbursable? The brief screen does not measure the severity of substance use to indicate if intervention or referral is needed. It only identifies those who need further screening. Q: Who can deliver and interpret a full screen? A licensed provider or an ancillary provider working under a licensed provider s general supervision can deliver and interpret a full screen. 53

Alcohol or Other Drug Misuse (SBIRT) Q: When does the CRAFFT count as part of the measure? If the screening results were discussed with the adolescent and education/brief intervention was facilitated, then the score and intervention should be documented/ billed, and the screening counts toward the numerator. Negative CRAFFT screens count as long as the screening results were discussed and verbal feedback was documented. Unlike AUDIT/DAST, the determining factor to differentiate the CRAFFT screening is not based on the score but on the education or brief intervention offered and facilitated by the provider. Because there is no way to differentiate if the CRAFFT was used as a brief or full screen, it must to be combined with intervention to count as part of the measure. Q: Who can bill for SBIRT? The following providers can bill independently for SBIRT -- Oregon Medicaid: Medicare: - Physicians - Physicians (MD, DO only) - Physician Assistants - Physician Assistants - Nurse Practitioners - Nurse Practitioners - Licensed Clinical Psychologists - Clinical Nurse Specialists - Licensed Clinical Social Workers - Licensed Clinical Psychologists - Licensed Clinical Social Workers Incident-to Billing - Certified Nurse Midwives Under Medicaid, any employee or contractor under the supervision of a licensed and credentialed provider may be reimbursed for screening and brief intervention services, under incident-to rules. However Incident-to billing rules may not always apply towards SBIRT, so it is best to check with your billing specialist beforehand. Q: Should a modifier be included? When billing CPT 99201-99215 and 99341-99350 with G0396 or G0397, the E&M service must have the accompanying modifier 25, indicating separately identifiable service. Please review rules for use of modifier 25 for distinct services performed during a visit. Q: Does SBIRT have to be delivered in a face-to-face encounter? Medicare does not require SBIRT to be delivered face-to-face. OHA allows for delivery via simultaneous audio and video transmission. 54 Q: Where can I find more information? Addictions and Mental Health Services: Approved Evidence Based Screening Tools (SBIRT) Medicare Learning Network: SBIRT Services SAMSHA-HRSA Center for Integrated Health Solutions: SBIRT Workflow SAMSHA-HRSA: SBIRT Opportunities for Implementation SBIRT Oregon

Alcohol or Other Drug Misuse (SBIRT) Sample Workflows 1. MA/team member scrubs for patients coming in the next day that need SBIRT. 2. Identify those who need SBIRT in appointment notes: 12 and older, no screening in the past year, etc. 3. Front Office gives SBIRT in confidential folder as patient checks in. 4. Patient fills out SBIRT while waiting, finishes in exam room. 5. MA gives f/u documents if positive results (DAST/AUDIT/PHQ9). 6. MA enters results into EHR, leaves paper results in exam room for provider, and alerts provider to abnormal results before entering exam room (as necessary). 7. Provider reviews results with patient, makes assessment, and decides action taken, if any. This is documented in EHR, with appropriate CPT and dx code used. 8. Provider gives warm hand off to Behavioral Consultant if available (as necessary). 55

Alcohol or Other Drug Misuse (SBIRT) Sample workflow for those who test positive on the full-length screening 56

Depression Screening and Follow-Up Plan (NQF 0418) Technical Specifications (for the data folks) Description: CCO Incentive measure Percentage of members age 12 and older who received a depression screening and follow-up plan* Denominator Numerator* Exclusions Continuous Enrollment Measurement Period 2015 OHA Benchmark Changes from 2014 Chart Documentation Value Set Exclusion Value Set All patients born before 12-31-2002 who have received at least one eligible encounter in 2015 Patients in the denominator screened for clinical depression and if positive, who have a documented follow-up plan on the date of the encounter Patients with a diagnosis of depression or bipolar disorder, patients who refuse to participate, or patients in an urgent or emergent situation January 1 December 31, 2015 25.0% First year of measurement ; sufficient documentation to support the codes billed for the visit Qualifying follow-up plans: 2.16.840.1.113883.3.600.537 (Referral for Depression Adolescent SNOMED-CT) 2.16.840.1.113883.3.600.538 (Referral for Depression Adult SNOMED-CT) 2.16.840.1.113886.3.600.1542 (Additional Eval. for Depression Adol. SNOMED-CT) 2.16.840.1.113886.3.600.1545 (Additional Eval. for Depression Adult SNOMED-CT) 2.16.840.1.113883.3.600.467 (Follow up for Depression Adolescent SNOMED-CT) 2.16.840.1.113883.3.600.468 (Follow up for Depression Adult SNOMED-CT) 2.16.840.1.113883.3.600.469 (Depression Medications Adolescent SNOMED-CT) 2.16.840.1.113883.3.600.470 (Depression Medications Adult SNOMED-CT) 2.16.840.1.113883.3.600.559 (Suicide Risk Assessment SNOMED-CT) Eligible encounters include: 90971, 90972, 90832, 90834, 90837, 90839, 92625, 96116, 96118, 96150, 96151, 97003, 99201-99205, 99212-99215, 99384-99387, 99394-99397, G0101, G0402, G0438, G0439, G0444 2.16.840.1.113883.3.600.145 (Depression Diagnosis Grouping) 2.16.840.1.113883.3.600.450 (Bipolar Diagnosis Grouping) 2.16.840.1.113883.3.600.791 (Patient Reason refused SNOMED-CT) 2.16.840.1.113883.3.600.792 (Medical reason contraindicated SNOMED-CT) Value sets can be accessed through the Value Set Authority Center (VSAC) at the National Library of Medicine: https://vsac.nlm.nih.gov/. Value sets include CPT, HCPC, ICD-9, ICD-10, SNOMED, and RXNORM codes. *translation: Patients age 12 and older who screen positive for possible depression diagnosis (ie: positive PHQ2) who have documented action in response to screening (ie: administration of PHQ9 to confirm diagnosis and assess severity and/or suicide risk assessment, etc.) 57

Depression Screening and Follow- Up Plan (NQF 0418) Care Team Specifications (for the non-data folks) Overview: CCO Incentive measure Percentage of members age 12 and older who received a depression screening and followup plan* Denominator Numerator* All members born before 12-31-2002 who have received at least one eligible outpatient visit in 2015 Members in the denominator screened for clinical depression on the date of the encounter and, if positive, who have a documented follow-up plan Exclusions Is there continuous enrollment criteria? What is the timeline to meet our goal? By December 31, 2015 What is the OHA benchmark? 25.0% How is it being measured? Reported directly from Electronic Health Records Screening and follow-up plans from EHR What codes count? What documentation is required? Qualifying outpatient visits include: 90971, 90972, 90832, 90834, 90837, 90839, 92625, 96116, 96118, 96150, 96151, 97003, 99201-99205, 99212-99215, 99384-99387, 99394-99397, G0101, G0402, G0438, G0439, G0444 No required chart documentation for this measure. Providers should provide sufficient documentation to support the codes reported for visit. *translation: Patients age 12 and older who screen positive for possible depression diagnosis (ie: positive PHQ2) who have documented action in response to screening (ie: administration of PHQ9 to confirm diagnosis and assess severity and/or suicide risk assessment and/or referral to behavioral health and/or pharmacological interventions and/or other interventions) 58

Follow-Up after Hospitalization for Mental Illness (NQF 0576) Technical Specifications (for the data folks) Overview: CCO Incentive measure Percentage of members hospitalized for select mental health disorders age 6 and older who had an outpatient visit within 7 days of discharge Denominator Numerator Exclusions Continuous Enrollment Measurement Period 2015 OHA Benchmark Changes from 2014 Chart Documentation Value Set HCPC/CPT All members age 6 years and older, hospitalized for select mental health disorders Members in the denominator who had any outpatient visit within 7 days of discharge Discharges followed by readmission or direct transfer to an acute facility, nonacute facility, or mental health residential services within 30 days, for both mental and non-mental health diagnoses 30 days from date of discharge January 1 December 31, 2015 70.0% Codes updated to reflect HEDIS 2015 ; sufficient documentation to support the codes billed for the visit 90846, 90791, 90792, 90832-90834, 90836-90838, 98960-98962, 99078, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99383-99387, 99393-99397, 99401-99404, 99411, 99412, 99510, G0155, G0176, G0177, G0409-G0411, G0463, H0002, H0004, H0006, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010-H2020, H2021, M0064, S0201, S9480, S9484, S9485, T1015, T1016 or 90839, 90840, 90845, 90847, 90849, 90853, 90867-90870, 90875, 90876 with POS 03, 05, 07, 09, 11, 12, 13, 14, 15, 20, 22, 24, 33, 49, 50, 52, 53, 71, 72 Value Set ICD-9 Exclusion Value Set HCPC/CPT Exclusion Value Set ICD-9 or 99221-99223, 99231-99233, 99238, 99239, 99251-99255 with POS 52, 53 295-299, 300.3, 300.4, 301, 308, 309, or 311-314 as principal diagnosis during hospitalization to enter measure Any code for an acute or non-acute facility; or mental health residential using T1020 with modifiers HK, HK & HE, or HK & TG; within 30 days of discharge 59

Follow-Up after Hospitalization of Mental Illness (NQF 0576) Care Team Specifications (for the non-data folks) Overview: CCO Incentive measure Percentage of members age 6 and older who had an outpatient visit within 7 days of discharge following hospitalization for select mental health disorders Denominator Numerator Exclusions Is there continuous enrollment criteria? What is the timeline to meet our goal? All members at least 6 years old at the time of hospitalization who were hospitalized for select mental health disorders Members in the denominator who had any outpatient visit within 7 days of discharge Discharges followed by readmission or direct transfer within 30 days, for both mental and non-mental health diagnoses 30 days from date of discharge By December 31, 2015 What is the OHA benchmark? 70.0% How is it being measured? What codes count? What documentation is required? Using claims data based on coding for the visit 90846, 90791, 90792, 90832-90834, 90836-90838, 98960-98962, 99078, 99201-99205, 99211-99215, 99217-99220, 99241-99245, 99341-99345, 99347-99350, 99383-99387, 99393-99397, 99401-99404, 99411, 99412, 99510, G0155, G0176, G0177, G0409-G0411, G0463, H0002, H0004, H0006, H0031, H0034-H0037, H0039, H0040, H2000, H2001, H2010- H2020, H2021, M0064, S0201, S9480, S9484, S9485, T1015, T1016 or 90839, 90840, 90845, 90847, 90849, 90853, 90867-90870, 90875, 90876 with POS 03, 05, 07, 09, 11, 12, 13, 14, 15, 20, 22, 24, 33, 49, 50, 52, 53, 71, 72 or 99221-99223, 99231-99233, 99238, 99239, 99251-99255 with POS 52, 53 No required chart documentation for this measure. Providers should provide sufficient documentation to support the codes reported for visit 60

Breast Cancer Screening Women s Health Technical Specifications (for the data folks) Overview: Medicare Stars measure Percentage of female members between the ages of 50 and 74 who had a mammogram Denominator Numerator All women born between 1-1-1941 and 12-31-1964 are included in the measure Members in the denominator who had one or more mammograms between 10-01- 2013 and 12-31-2015 Exclusions Bilateral mastectomy at any time prior to December 31, 2015 Continuous Enrollment Measurement Period 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 October 31, 2013 December 31, 2015 (2 years 2 months) No more than one gap in enrollment each year of 45 days or less October 31, 2013 December 31, 2015 81.0% This is the first year of measurement Date when mammogram was performed and result 77055, 77056, 77057, G0202, G0204, G0206 87.36, 87.37 At any time in medical history 85.42, 85.44, 85.46, 85.48 61

Breast Cancer Screening Care Team Specifications (for the non-data folks) Overview: Medicare Stars measure Percentage of women between the ages of 50 and 74 who had a mammogram Denominator All women born between 1-1-1941 and 12-31-1964 Numerator Members in the denominator who had a mammogram between 10-1-2013 and 12-31-2015 Exclusions Bilateral mastectomy at any time Is there continuous enrollment criteria? What is the timeline to meet our goal? October 31, 2013 December 31, 2015 (2 years 2 months) with one gap in enrollment each year 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? Using claims data based on coding for the visit, with a sample selected for HEDIS review 77055, 77056, 77057, G0202, G0204, G0206 87.36, 87.37 What documentation is required? Date when mammogram was performed and result 62

Effective Contraceptive Use Technical Specifications (for the data folks) Overview: CCO Incentive measure Percentage of women between the ages of 18 and 50 who utilize an approved effective contraceptive method in 2015 Denominator All women born between 1-1-1965 and 12-31-1997 Numerator 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 9 & ICD 10 Women in the denominator with evidence of one of the following methods of contraceptives in 2015: sterilization, IUD, implant, contraception injection, contraceptive pills, patch, ring, or diaphragm Any history of hysterectomy, bilateral oophorectomy, natural menopause, or premature menopause; or Pregnancy during the measurement year January 1 December 31, 2015 with one gap in enrollment of 45 days or less January 1 December 31, 2015 50.0% This is the first year of measurement ; sufficient documentation to support the codes billed for the visit 11981, 11983, 57170, 58300, 58565, 58600, 58605, 58611, 58615, 58670, 58671, 58340, 74740, 90772, 96372, A4264, A4266, J1050, J1051, J1055, J1056, J7300, J7302, J7303, J7304, J3706, J3707, Q0090, S4981, S4989, S4993 ICD-9: V25.01, V25.02, V25.11, V25.13, V25.2, V25.41, V25.42, V25.43, V25.49, V25.5, V25.9, V26.51, V45.51, V45.52, V45.59, 66.2x, 69.7, 996.30, 996.32, 996.65 ICD-10: Z30.41, Z30.431, Z30.42, Z30.49, Z30.018, Z30.019, Z30.40, Z30.8, Z30.9, Z30.2, Z98.51, Z30.430, Z30.014, Z31.431, Z30.433, Z97.5, T83.31xA, T83.32xA, T83.39xA, T83.59xA, T83.6xxA, Z30.013, Z30.011, Z79.3, 0U574ZZ, 0U578ZZ, 0UL74ZZ, 0UL78ZZ, 0UL74CZ, 0UL74DZ, 0UL78DZ, 0UH97HZ, 0UH98HZ, 0UHC7HZ, 0UHC8HZ At any time in medical history 58720, 58150, 58940, 58700 In 2015 only 59400, 59409, 59410, 59510, 59514, 59515, 59610, 59612, 59614, 59618, 59620, 59622, 59425, 59426 At any time in medical history V88.01, 65.5x, V49.81, 627.0-627.9, 256.2, 256.31, Z90.710, N92.4, N95.0, N95.1, N95.2, N95.8, N95.9, Z78.00, E89.40, E89.41, E28.310, E38.319, 0UT20ZZ, 0UT27ZZ, 0UT28ZZ, 0UT2FZZ, 0UT00ZZ, 0UT08ZZ, 0UT0FZZ, 0UT10ZZ, 0UT17ZZ, 0UT18ZZ, 0UT1FZZ, 0UT24ZZ,0UT04ZZ,0UT14ZZ In 2015 only V22.x, V61.7, V72.42, Z34.00, Z34.80, Z34.90, Z33.1, Z32.01, Z64.0 *NDC codes counts for the measure, independent of the codes shown above. A complete list of NDC codes is available here: http://www.oregon.gov/oha/analytics/ccodata/effective%20contraceptive%20use%20- %20NDC%20Table.xls 63

Effective Contraceptive Use Care Team Specifications (for the non-data folks) Overview: CCO Incentive measure Percentage of women between the ages of 18 and 50 who utilize an approved effective contraceptive method in 2015 Denominator Numerator Exclusions Is there continuous enrollment criteria? What is the timeline to meet our goal? What is the OHA benchmark? 50.0% How is it being measured? What codes count?* All women born between 1-1-1965 and 12-31-1997 are included in the measure Women in the denominator using one of these contraceptives in 2015: sterilization, IUD, implant, contraception injection, contraceptive pills, patch, ring, or diaphragm Any record of hysterectomy, bilateral oophorectomy, natural menopause, or premature menopause, or Pregnancy in 2015 2015, with one gap of 45 days or less By December 31, 2015 Using claims data based on coding for the visit 11981, 11983, 57170, 58300, 58565, 58600, 58605, 58611, 58615, 58670, 58671, 58340, 74740, 90772, 96372, A4264, A4266, J1050, J1051, J1055, J1056, J7300, J7302, J7303, J7304, J3706, J3707, Q0090, S4981, S4989, S4993 V25.01, V25.02 V25.11, V25.13, V25.2, V25.40, V25.41, V25.42, V25.43, V25.49, V25.5, V25.9, V26.51, V45.51, V45.52, V45.59, 66.2x, 69.7, 996.30, 996.32, 996.65 Z30.41, Z30.431, Z30.42, Z30.49, Z30.018, Z30.019, Z30.40, Z30.8, Z30.9, Z30.2, Z98.51, Z30.430, Z30.014, Z31.431, Z30.433, Z97.5, T83.31xA, T83.32xA, T83.39xA, T83.59xA, T83.6xxA, Z30.013, Z30.011, Z79.3, 0U574ZZ, 0U578ZZ, 0UL74ZZ, 0UL78ZZ, 0UL74CZ, 0UL74DZ, 0UL78DZ, 0UH97HZ, 0UH98HZ, 0UHC7HZ, 0UHC8HZ No required chart documentation for this measure. Providers What documentation is required? should provide sufficient documentation to support the CPT and ICD codes reported for visit. *NDC codes counts for the measure, independent of the codes shown above. A complete list of NDC codes is available here: http://www.oregon.gov/oha/analytics/ccodata/effective%20contraceptive%20use%20- %20NDC%20Table.xls 64

Osteoporosis Management Technical Specifications (for the data folks) Overview: Medicare Stars measure Percent of female members between the ages of 67 and 85 who broke a bone and received screening or treatment for osteoporosis within 6 months Denominator Numerator Exclusions Continuous Enrollment Measurement Period 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 All women born between 1-1-1920 and 12-31-1947 who suffered a fracture between July 1, 2014 and June 30, 2015 are included in the measure Members in the denominator who had: a bone mineral density test, osteoporosis therapy, or were dispensed a prescription to treat osteoporosis within 180 days after the IESD IESD = first service date within measurement period with diagnosis of a fracture Fractures of the finger, toe, face, and skull Members with an outpatient visit, observation visit, ED visit, nonacute inpatient encounter, or acute inpatient encounter for a fracture 60 days prior to IESD, or Members with a bone mineral density test during the 730 days prior to IESD, or Members who received a dispensed prescription to treat osteoporosis during the 365 days prior to the IESD 12 months before 6 months after IESD for the fracture, with no more than one gap in enrollment of 45 days or less July 1, 2014 December 31, 2015 for screening or treatment July 1, 2014 June 30, 2015 for fracture 62.0% Sufficient documentation to support codes billed for in visit Fractures: 2.16.840.1.113883.3.464.1004.1103 (Fractures Value Set) Bone density test: 76977, 77078, 77080, 77081, 77082 Osteoporosis medications: J0630, J0897, J1740, J3110, J3487, J3488, J3489 Fractures: 2.16.840.1.113883.3.464.1004.1103 (Fractures Value Set) Bone density test: 88.98 Fractures: same codes in 60 days prior to IESD Bone density test: same codes in 730 days prior to IESD Osteoporosis medications: same codes in 365 days prior to IESD Fractures: same codes in 60 days prior to IESD Bone density test: same codes in 730 days prior to IESD *Value sets can be accessed through the Value Set Authority Center (VSAC) at the National Library of Medicine: https://vsac.nlm.nih.gov/. Value sets include CPT, HCPC, ICD-9, ICD-10, SNOMED, and RXNORM codes. 65

Osteoporosis Management Care Team Specifications (for the non-data folks) Overview: Medicare Stars measure Percentage of women between the ages of 67 and 85 who broke a bone and received screening or treatment for osteoporosis within 6 months Denominator Numerator Exclusions Is there continuous enrollment criteria? What is the timeline to meet our goal? All women born between 1-1-1920 and 12-31-1947 who suffered a fracture between July 1, 2014 and June 30, 2015 Members in the denominator who had: a bone mineral density test, osteoporosis therapy, or were dispensed a prescription to treat osteoporosis, within 180 days after the first service date with a fracture diagnosis Fractures of the finger, toe, face, and skull are not included Members diagnosed with a fracture outside of the measurement period within 60 days of the first service date Members who had a bone mineral density test within 730 days prior to the first service date Members who had osteoporosis therapy or a prescription to treat osteoporosis within 365 days prior to first service date 12 months before 6 months after the first service date, with one gap of 45 days or less By December 31, 2015 for screening or treatment By June 30, 2015 for the fracture What is the 5 Star benchmark? 62.0% How is it being measured? What codes count?* What documentation is required? Using claims data based on coding for the visit, with a sample selected for HEDIS review Bone density test: 76977, 77078, 77080, 77081, 77082, 88.98 Osteoporosis medications: J0630, J0897, J1740, J3110, J3487, J3488, J3489 Providers should provide sufficient documentation to support the codes reported for visit. 66

Timeliness of Prenatal Care Technical Specifications (for the data folks) Overview: CCO Incentive measure Percentage of female members randomly selected for chart review who received prenatal care within the first trimester or within 42 days of enrollment on plan Denominator Women selected for chart review from all members who had live birth deliveries during the measurement period Numerator Exclusions Continuous Enrollment Measurement Period 2015 OHA Benchmark Changes from 2014 Chart Documentation Value Set HCPC/CPT Value Set ICD-9 Exclusion Value Set HCPC/CPT Exclusion Value Set ICD-9 Members in the denominator with a prenatal visit within the first trimester or within 42 days of enrollment on plan Prenatal visits that occurred before the member was enrolled 30 days from date of discharge following delivery November 6, 2014 November 5, 2015 90.0% Updated to reflect HEDIS 2015 Medical record must include the date of the visit and one of the following: - A basic physical obstetrical examination that includes: auscultation for fetal heart tone or pelvic exam with obstetric observations or measurement of fundus height - Evidence that a prenatal care procedure was formed, ex: screening test in the form of an obstetric panel or TORCH antibody panel alone or rubella antibody test with Rh incompatibility blood typing or echography of pregnant uterus - Documentation of LMP or EDD with: prenatal risk assessment and counseling/education or complete obstetrical history Visits can be to an OB/GYN, other prenatal care practitioner (ie: FP, CNM) or a PCP. For PCP visits, diagnosis of pregnancy must be present (documented in encounter and/or diagnosis codes) 67

Timeliness of Prenatal Care Care Team Specifications (for the non-data folks) Overview: CCO Incentive measure Percentage of women selected for chart review who received prenatal care within the first trimester or within 42 days of enrollment on plan Denominator Numerator Exclusions Is there continuous enrollment criteria? What is the timeline to meet our goal? Women selected for chart review from all women who had live birth deliveries during the measurement period Members in the denominator with a prenatal visit within the first trimester or within 42 days of enrollment on plan Prenatal visits that occurred before the member was enrolled 30 days from date of discharge following delivery By November 5, 2015 What is the OHA benchmark? 90.0% How is it being measured? Chart review of sample What codes count? What documentation is required? 68 Medical record must include the date of the visit and one of the following: - A basic physical obstetrical examination that includes: auscultation for fetal heart tone or pelvic exam with obstetric observations or measurement of fundus height - Evidence that a prenatal care procedure was formed such as: screening test in the form of an obstetric panel or TORCH antibody panel alone or rubella antibody test with Rh incompatibility typing or echography of pregnant uterus - Documentation of LMP or EDD with: prenatal risk assessment and counseling/education or complete obstetrical history Visits can be to an OB/GYN, other prenatal care practitioner (ie: FP, CNM) or a PCP. For PCP visits, diagnosis of pregnancy must be present (documented in encounter and/or diagnosis codes)

Care for Older Adults Care for Older Adults: Functional Status Assessment Technical Specifications (for the data folks) Overview: Medicare Stars measure for Special Needs Plans Percent of members age 66 and older who received an assessment of their functional status in 2015 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 born before 12-31-1949 are included in the measure Members in the denominator who received at least one functional status assessment in 2015 None January 1 December 31, 2015 with one gap in enrollment of 45 days or less January 1 December 31, 2015 83.0% Date when the functional status assessment was performed, and Evidence of a complete functional status assessment anywhere in the medical history section of the record including one of the following: - Notation that at least five activities of daily living were assessed, or - Notation that at least four instrumental activities of daily living were assessed or - Result of assessment using a standardized functional status assessment tool, or - 3 of 4 components of cognition, ambulation, sensory (hearing, vision and speech), and/or other functional independence /dependence 1170F 69

Care for Older Adults: Functional Status Assessment Care Team Specifications (for the non-data folks) Overview: Medicare Stars measure for Special Needs Plans Percentage of members age 66 and older who received an assessment of their functional status in 2015 Denominator All members born before 12-31-1949 Numerator Exclusions Is there continuous enrollment criteria? What is the timeline to meet our goal? Members in the denominator who received at least one functional status assessment in 2015 None 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? 83.0% How is it being measured? Chart review of sample What codes count? What documentation is required? Medical record must include the date of the visit and evidence of a complete functional status assessment, including one of the following: - Notation that activities of daily living were assessed - Instrumental activities of daily living were assessed -asdasd Result of assessment using a standardized functional status assessment tool - 3 of 4 components of cognition, ambulation, sensory (hea(ring, (hearing, vision vision and speech), and/or other functional independence The components of the functional status assessment may take place in separate visits in 2015. 70

Care for Older Adults: Medication Review Technical Specifications (for the data folks) Overview: Medicare Stars measure for Special Needs Plans Percent of members age 66 and older who received at least one medication review by a prescribing practitioner or pharmacist 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 born before 1-1-1949 are included in the measure Members in the denominator who received at least one medication review by a prescribing practitioner or clinical pharmacist and have a medication list signed and dated in their medical record in 2015. None January 1 - December 31, 2015 one gap in enrollment of 45 days or less January 1 December 31, 2015 87.0% Date when the medication review was performed and one of the following: A signed current medication list and notation of a medication review or Date and notation that the member is not taking any medication 90863, 99605, 99606, G8427, 1159F, 1160F 71

Care for Older Adults: Medication Review Care Team Specifications (for the non-data folks) Overview: Medicare Stars measure for Special Needs Plans Percentage of members age 66 and older who received at least one medication review Denominator All members born before 12-31-1949 Numerator Exclusions Is there continuous enrollment criteria? What is the timeline to meet our goal? Members in the denominator who received at least one medication review by a prescribing practitioner or pharmacist and have a medication list in their medical record in 2015 None 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? 87.0% How is it being measured? Chart review of sample What codes count? What documentation is required? 90863, 99605, 99606, G8427, 1159F, 1160F Medical record must include the date of the medication review was performed and include one of the following: - A signed current medication list and notation of a medication review, or - Date and notation that the member is not taking any medication 72

Care for Older Adults: Pain Screening Technical Specifications (for the data folks) Overview: Medicare Stars measure for Special Needs Plans Percent of members age 66 and older who received at least one pain screening in 2015 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 born before 1-1-1949 are included in the measure Members in the denominator who received at least one pain screening in 2015 None January 1 - December 31, 2015 with one gap in enrollment of 45 days or less January 1 December 31, 2015 88.0% Date when the pain assessment was performed and notations for a pain assessment that must include one of the following: Documentation that the patient was assessed for pain or Result of assessment using a standardized pain assessment tool 1125F, 1126F 73

Care for Older Adults: Pain Screening Care Team Specifications (for the non-data folks) Overview: Medicare Stars measure for Special Needs Plans Percentage of members age 66 and older who received at least one pain screening in 2015 Denominator All members born before 12-31-1949 Numerator Exclusions Is there continuous enrollment criteria? What is the timeline to meet our goal? Members in the denominator who received at least one pain screening in 2015 None 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? Chart review of sample What codes count? What documentation is required? 90863, 99605, 99606, G8427, 1159F, 1160F Medical record must include the date the pain assessment was performed and notations for the pain assessment must include one of the following: - Documentation that the patient was assessed for pain, or - Result of assessment using a standardized pain assessment tool 74

High Risk Medication Management Overview: Medicare Stars measures This is a Part D (pharmacy) measure based on the percentage of members with prescriptions for drugs with a high risk of side effects High Risk Medication Management: - Percent of members age 65 years and older who had prescriptions for certain drugs with a high risk of serious side effects when there may be safer drug choices. The 5 Star benchmark is 7.0% 75

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All Cause Readmission Emergency Care Technical Specifications (for the data folks) Overview: Medicare Stars measure Rate of acute inpatient stays for members age 18 or older that were followed by an unplanned acute readmission for any diagnosis within 30 days Denominator Total acute inpatient stays for members born after the date of discharge in 1997 Numerator Exclusions Continuous Enrollment Measurement Period 2015 CMS Benchmark (5 Star) Members in the denominator with at least one acute readmission for any diagnosis within 30 days of the index discharge date Direct transfers to another acute facility Acute inpatient discharges for death, or with a principal diagnosis of pregnancy, or with a principal diagnosis of a condition originating in the perinatal period Acute inpatient stays with principal diagnosis of maintenance chemotherapy, or principal diagnosis of rehabilitation, or an organ transplant, or a potentially planned procedure without a principal acute diagnosis 365 days prior to 30 days after hospital discharge January 1 December 31, 2015 for readmission January 1 December 1, 2015 for initial discharge 2.0% 77

Ambulatory Care: Emergency Department Utilization Technical Specifications (for the data folks) Overview: CCO Incentive measure Rate of emergency department visits per 1,000 member months Denominator 1,000 member months Numerator Emergency department visits that do not result in an inpatient encounter Exclusions Continuous Enrollment Measurement Period 2015 OHA Benchmark Changes from 2014 Chart Documentation Value Set HCPC/CPT Value Set ICD-9 Exclusion Value Set HCPC/CPT Exclusion Value Set ICD-9 Mental health and chemical dependency services January 1 December 31, 2015 39.4 / 1,000 member months Updated ED visits numerator codes and added CPT 90785, 90791, 90792 to exclusions ; sufficient documentation to support the codes billed for the visit 99281-99285 or 10030-69979 with POS 23 90785, 90791, 90792, 90801, 90802, 90804-90819, 90821-90824, 90826-90829, 90832-90834, 90836-90840, 90845-90857, 90849, 90853, 90857, 90862, 90863, 90865, 90867-90870, 90875, 90876, 90880, 90885, 90887, 90889, 90899 94.26, 94.27, 94.61-94.69, 290-316 78

System Transformation Patient-Centered Primary Care Home (PCPCH) Enrollment Overview: CCO Incentive measure CCOs are measured by a weighted formula that favors members enrolled in higher tier PCPCHs The formula is as follows: (#eeeeeeeeeeeeeeee iiii TTTTTTTT 11 PPPPPPPPPPPP 11) + (# eeeeeeeeeeeeeeee iiii TTTTTTTT 22 22) + (# eeeeeeeeeeeeeeee iiii TTTTTTTT 33 33) Total CCO enrollment 3 CCOs are graded on a sliding scale and must reach at least 60% through the formula to meet the measure. Ideally 100% of CCO members would be enrolled in a Tier 3 PCPCH Electronic Health Record (EHR) Adoption Overview: CCO Incentive measure CCOs are measured on the percentage of contracted providers who qualify for Federal Meaningful Use incentives. OHA calculates the rate of CCO-contracted providers who qualified for an incentive payment through the Medicaid, Medicare, or Medicare Advantage EHR incentive programs in 2015 Providers must be eligible for the EHR incentive program and located within the CCO service area, as determined by zip codes, to be included in the measure The benchmark is 72.0%, based on the highest performing CCO 79

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Member Surveys CAHPS Composite: Consumer Assessment of Health Plan Survey Overview: There are two CCO incentive measures and nine Medicare Stars measures which utilize CAHPS. Access to Care/Getting Needed Care and Customer Service/Satisfaction are measures for both. The additional Stars measures are: Annual Flu Vaccine, Care Coordination, Getting Care Quickly, Getting Needed Prescription Drugs, Overall Rating of Health Care Quality, Overall Rating of Plan, and Rating of Drug Plan. CAHPS: Access to Care/Getting Needed Care is based on two questions: - Got care for illness/injury/condition as soon as you/child needed - Got an appointment for routine care as soon as you thought you/child needed The CCO benchmark is 87.2% The 5 Star benchmark is 87.0% CAHPS: Customer Service/Satisfaction with Care is based on three* questions: - Health plan s customer service gave you needed information or help - Health plan s customer service staff treated you with courtesy and respect - Health plan forms were easy to fill out (*Stars only) The CCO benchmark is 89.6% The 5 Star benchmark is 91.0% CAHPS: Annual Flu Vaccine is based on one question: - Have you had a flu shot since July 1, 2014? The 5 Star benchmark is 79.0% CAHPS: Care Coordination is based on six questions: - Doctor had medical records and other information about care - Got follow-up to provide test results - Got test results quickly - Doctor spoke about prescription medicines - Got help managing care - Doctor is informed and up-to-date about specialist care The 5 Star benchmark is 87.0% CAHPS: Getting Care Quickly is based on three questions: - Got care as soon as you needed - Got an appointment at doctor s office/clinic as soon as you needed - Seen for appointment within 15 minutes of appointment time The 5 Star benchmark is 80.0% CAHPS: Getting Needed Prescription Drugs is based on three questions: - Got medicines the doctor prescribed easily - Filled prescriptions at a local pharmacy easily - Filled prescriptions by mail easily The 5 Star benchmark is 92.0% 81

CAHPS Composite: Consumer Assessment of Health Plan Survey CAHPS: Overall Rating of Health Care Quality is based on one question: - Rate your health care in the last 6 months from 0 to 10 The 5 Star benchmark is 88.0% CAHPS: Overall Rating of Plan is based on one question: - Rate your health plan from 0 to 10 The 5 Star benchmark is 88.0% CAHPS: Rating of Drug Plan is based on one question: - Rating your prescription drug plan from 0 to 10 The 5 Star benchmark is 92.0% The particular CAHPS used for the CCO measures is run by OHA The particular CAHPS used for the Medicare Stars measures is run by DSS Research 82

HOS: Health Outcomes Survey Overview: There are four Medicare Stars measures which utilize the HOS: Reducing Risk of Falling, Improving Physical Health, Improving Mental Health, and Monitoring Physical Activity HOS: Reducing Risk of Falling is based on four questions: - In the past 12 months, did your doctor or other health provider talk with you about falling or problems with balance or walking? - Did you fall in the past 12 months? - In the past 12 months have you had a problem with balance or walking? - Has your doctor or other health provider done anything to help prevent falls or treat problems with balance or walking? The 5 Star benchmark is 73.0% HOS: Improving or Maintaining Physical Health is based on six questions: - In general, would you rate your health? - Does your health now limit you in moderate activities? - Does your health now limit you in climbing several flights of stairs? - During the past 4 weeks, have you accomplished less than you would like with your work or other regular activities as a result of your physical health? - During the past 4 weeks, were you limited in the kind of work/ activities as a result of your physical health? - During the past 4 weeks, how much did pain interfere with your normal work? The 5 Star benchmark is 72.0% HOS: Improving or Maintaining Mental Health is based on six questions: - During the past 4 weeks, have you accomplished less than you would like with your work or other regular daily activities as a result of any emotional problems? - During the past 4 weeks, did you not do work or other activities as carefully as usual as a result of any emotional problems? - How much of the time during the past 4 weeks: Have you felt calm and peaceful? - How much of the time during the past 4 weeks: Did you have a lot of energy? - How much of the time during the past 4 weeks: Have you felt downhearted and blue? - During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities? The 5 Star benchmark is 82.0% HOS: Monitoring Physical Activity is based on two questions: - In the past 12 months, did you talk with a doctor or provider about your level of exercise of physical activity? - In the past 12 months, did a doctor or other health care provider advise you to Start, increase or maintain your level of exercise or physical activity? The 5 Star benchmark is 57.0% The particular HOS used for these measures is run by DSS Research. 83