PTO TRAINING OCTOBER 5, 11:00 AM Call Instructions: Please Mute - PowerPoint PPT Presentation

PTO TRAINING OCTOBER 5, 11:00 AM Call Instructions: Please • Mute your phone, microphone, and speakers on your computer/device • Turn off the zoom video feature • Enter your name/organization in the chat box feature for attendance • Submit questions via the chat box feature • Questions will be answered following the presentation • Time to ask questions via audio will be offered for those on the phone 1

CQM WEBINAR THURS DA Y , OCOTOBER 5 11:00 AM – 12:00 PM

AGENDA TCPI and ENSW updates Conflict of Interest Forms Q2 CQM data report 3 Q3 CQM reporting requirements HIT Assessment Summary Q&A

TCPI UPDATE TCPi: Please submit all Clinical Quality Measures by 10/ 25/ 17 https:/ / ucdenver.co1.qualtrics.com/ j fe/ form/ S V_eS ccPhX7pT40Fbn TCPi CHITA Field Note https:/ / ucdenver.co1.qualtrics.com/ j fe/ form/ S V_6PS duWbmzgZWWEJ NQF PQRS Description Weight assessment and counseling for nut rition and NQF 0024 physical act ivit y for children PQRS 239 and adolescent s. Body Mass Index (BMI) NQF 0421 screening and follow-up. PQRS 128 Tobacco use assessment and NQF 0028 t obacco cessat ion int ervention. PQRS 226 Blood pressure cont rol. NQF 0018 PQRS 236 HbA1c cont rol for pat ient s NQF 0059 wit h diabetes. PQRS 001 S creening for clinical NQF 0418 depression and follow-up plan. PQRS 134 Development al screening in NQF 1448 t he first 3 years of life. PQRS n/ a 4

TCPI NATIONAL QUALITY MEASURE COLLECTION TOOL We will be reporting Quality measures like we have in the past for this Quarter. Beginning in Quarter 4 (reporting in January 2018) we will be using the new national TCPi Reporting tool We have asked all CHITAs in TCPi to document which measures practices will be reporting. We will preload the tool with this information so when you login at the practice level you will only see measures that you are planning to report on. Please submit this survey by October 13 th . 5

ENSW UPDATE ▪ Please ensure all measures are reported by October 31st, 2017 ▪ 12 month and 15 month CQMs. Please work with practices to collect and submit 12 month and 15 month CQMs 6

SIM Q2 CQM DATA

Percentage of active primary care practice sites reporting CQMs each quarter 100.0% 98.9% 90.2% 93.0% 98.0% 100.0% 92.4% 80.0% 1 or more 97.0% CMQs 90.0% 75.0% 77.2% Required number of 64.0% 64.0% CQMs 50.0% 25.0% 0.0% 2016 Q1 (optional) 2016 Q2 2016 Q3 2016 Q4 2017 Q1 2017 Q2

SIM cohort-1 primary care practices progress over time for Depression Screening, Diabetes A1c Poor Control, and Developmental Screening Clinical Quality Measures 100.00% 93.70% 90.00% 84.90% 80.00% 72.20% 76.50% 73.50% 70.00% Depression S creening 60.00% 48.80% Diabet es A1c Poor 49.20% Control* 50.00% 48.80% 38.90% 34.30% 40.00% Development al 33.80% S creening 33.20% 38.80% 30.00% 34.50% 20.00% 10.00% 0.00% 2016 Q2 2016 Q3 2016 Q4 2017 Q1 2017 Q2 *For Diabetes A1c measure we want to see the values for this measure decrease over time 9

SIM Q2 CQM DATA REPORT ▪ Q2 CQM Reporting Breakdown ▪ 53 Adult 94% Req 100% at least 1 ▪ 22 Pediat ric 82% Req 100% at least 1 ▪ 17 Adult CPC+ 100% Req 100% at Least 1 92 Total Practices 10

Number SIM primary care practice sites that reported on each CQM in Q2 of 2017 Depression S creening and Follow-up 82 Hypertension 69 Diabetes: A1c 69 S UD: Tobacco Use 66 Adult Obesity S creen 55 Fall S afety 47 Asthma Medication Management 38 Adolescent Obesity S creen (Diet) 26 Adolescent Obesity S creen (Activity) 26 Adolescent Obesity S creen 26 Maternal Depression S creening 16 Developmental S creening 15 Depression Remission at 12 months* 12 S UD: Alcohol and Other Drug Dependence 10 S UD: Alcohol 1 0 10 20 30 40 50 60 70 80 90 **This measure is only available for practices that are in both S IM and CPC+

Aggregate values of CQMs reported on by S IM primary care practice sites in Q2 of 2017 90.00% 84.85% 81.86% 80.37% 79.28% 80.00% 75.24% 69.34% 70.00% 62.59% 60.03% 59.22% 60.00% 47.11% 48.85% 50.00% 45.29% 43.83% 40.00% 33.20% 30.00% 20.00% 10.00% 0.00% 0.00% 12

CPC+ reporting group (N=17 practice sites) 80.00% 75.87% 70.86% 69.55% 70.00% 63.82% 61.19% 55.56% 56.94% 60.00% 52.46% 50.00% 42.53% 39.07% 37.75% 40.00% 30.00% 26.44% 20.00% 10.00% 0.00%

Pediatric reporting group (N= 22 practice sites) 90.00% 84.85% 81.12% 80.00% 74.96% 70.00% 60.08% 60.00% 47.05% 46.54% 50.00% 43.57% 40.00% 27.27% 30.00% 20.00% 10.00% 0.00% Depression Obesit y Adult Ast hma Med Mat ernal Development al Obesit y Obesit y Obesit y S creening (S IM): S creening: Management : Depression: S creening: Adolescent Adolescent Adolencest Act ivity: Weight : Nut rition:

Adult reporting group (N= 53 practice sites) 100.00% 86.73% 88.94% 90.00% 80.69% 80.69% 80.00% 69.27% 70.00% 64.56% 56.90% 60.00% 45.83% 47.99% 46.01% 45.68% 50.00% 44.60% 42.19% 40.00% 34.70% 30.00% 20.00% 10.00% 0.00% 0.00%

CQMS WITH DOCUMENTED ISSUES IN Q2 Number of practie sites that reported difficulties with different CQMs S UD: Alcholo and other Depression S creening, 1 drugs, 1 Asthma: Medication S UD: Tobacco, 1 Management, 1 Adult Obesity , 1 Maternal Depression S creening, 1 Adolescent Obesity , 2 Represents 6 practice sites that documented their issues with specific CQMs 16

Q2 DATA FLAGS ▪ Focus on Practices that didn’ t report all measures Less than required Adult:10 Peds:4 CPC+:0 Reported 0 Adult:0 Peds:0 CPC+:0 17

PRACTICES THAT DON T SUBMIT REQUIRED CQMS ▪ We are making a concerted effort to identify why practices are not able to submit the required number of CQMs ▪ S urvey sent to CHITAs with three questions: ▪ Please explain why the practice did not report the required number of measures? (check all that apply) (Vendor, Workflow or other issue) ▪ Please explain why the practice did not report the required number of measures? (check all that apply) ▪ Please explain why the practice did not report the required number of measures? (check all that apply) 18

Q3 2017 SIM CQM REPORTING REQUIREMENTS

Q3 REPORTING REQUIREMENTS AND SCHEDULE SIM Q3 2017 CQM reporting requirements ▪ Practice sites choose: trailing 12 months or year-to-date ▪ Trailing year approach is preferred ▪ Q3 report due October 31 st 2017 ▪ CQM reporting will be through Qualtrics 20

REPORTING SCHEDULE: ADULTS 2016 Q1 (Jan-Mar 16) 2016 Q2 (Apr-Jun 16) 2016 Q3 (Jul-Sep 16) 2016 Q4 (Oct-Dec 16) Test period, practice sites report whatever Choose 3 core CQMs: Choose 3 core CQMs (same as Q2) Report 4 core CQMs (non-Mathematica): • • they can Asthma Asthma • • Influenza Influenza • • Depression OR Maternal Depression Depression OR Maternal Depression • • Obesity: Adult Obesity: Adult and 1 non-core CQM (non-Mathematica): • Diabetes: Hemoglobin A1c • Fall Safety • Hypertension = 5 total CQMs 2017 Q1 (Jan-Mar 17) 2017 Q2 (Apr-Jun 17) 2017 Q3 (Jul-Sep 17) 2017 Q4 (Oct-Dec 17) Choose 5 primary CQMs: Report all 6 primary CQMs: Same as Y2Q2 Same as Y2Q2 • • • • Depression Screening Depression Screening Phase in additional secondary CQMs Phase in additional secondary CQMs • • Diabetes: Hemoglobin A1c Diabetes: Hemoglobin A1c as appropriate as appropriate • • Hypertension Hypertension = 6 total CQMs required = 6 total CQMs required • • Obesity: Adult Obesity: Adult • • SUD: Alcohol & Other Drug SUD: Alcohol & Other Drug Dependence Dependence • • SUD: Tobacco SUD: Tobacco Secondary CQMs (if needed): Secondary CQMs (if needed): • • Asthma (new) Asthma (new) • • Fall Safety Fall Safety • • Maternal Depression Screening Maternal Depression Screening • • SUD: Alcohol SUD: Alcohol = 5 total CQMs required = 6 total CQMs required Cohort 1 SIM CQM Reporting Schedules: http://www.practiceinnovationco.org/wp-content/uploads/2017/02/SIM-Clinical-Quality-Measures-CQM-Reporting-Schedules-Cohort-1.pdf 21

REPORTING SCHEDULE: PEDS 2016 Q1 (Jan-Mar 16) 2016 Q2 (Apr-Jun 16) 2016 Q3 (Jul-Sep 16) 2016 Q4 (Oct-Dec 16) Test period, practice sites report whatever choose 3 core CQMs: choose 3 core CQMs (same as Q2) Report 5 core CQMs (non-Mathematica): • • they can Asthma Asthma • • Depression Depression • • Influenza Influenza • • Maternal Depression Maternal Depression • • Obesity: Adolescent Obesity: Adolescent 2017 Q1 (Jan-Mar 17) 2017 Q2 (Apr-Jun 17) 2017 Q3 (Jul-Sep 17) 2017 Q4 (Oct-Dec 17) Report all 4 primary CQMs: Same as Y2Q1 Same as Y2Q1 Same as Y2Q1 • • • • Depression Screening Phase in additional secondary CQMs Phase in additional secondary CQMs Phase in additional secondary CQMs • Developmental Screening as appropriate as appropriate as appropriate • Maternal Depression Screening = 4 total CQMs required = 4 total CQMs required = 4 total CQMs required • Obesity: Adolescent Secondary CQMs (if needed): • Asthma (new) = 4 total CQMs required Cohort 1 SIM CQM Reporting Schedules: http://www.practiceinnovationco.org/wp-content/uploads/2017/02/SIM-Clinical-Quality-Measures-CQM-Reporting-Schedules-Cohort-1.pdf 22