PTO TRAINING JANUARY 8TH, 11:00 AM Call Instructions: Please Mute - PowerPoint PPT Presentation

PTO TRAINING JANUARY 8TH, 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 MONDAY, JANUARY 8 11:00 AM – 12:00 PM

AGENDA TCPI and ENSW updates Conflict of Interest Forms Q3 CQM data report 3 Q4 CQM reporting requirements HIT Assessment Summary Q&A

TCPI UPDATE TCPi: Please submit all Clinical Quality Measures by 01/26/18 All CQMs will be submitted through the Healthcare Communities tool TCPi CHITA Field Note https://ucdenver.co1.qualtrics.com/jfe/form/SV_6PSduWbmzgZWWEJ NQF PQRS Description Weight assessment and counseling for nutrition and NQF 0024 physical activity for children and adolescents. PQRS 239 Body Mass Index (BMI) NQF 0421 screening and follow-up. PQRS 128 Tobacco use assessment and tobacco cessation NQF 0028 intervention. PQRS 226 Blood pressure control. NQF 0018 PQRS 236 HbA1c control for patients NQF 0059 with diabetes. PQRS 001 Screening for clinical NQF 0418 depression and follow-up plan. PQRS 134 Developmental screening in NQF 1448 the first 3 years of life. PQRS n/a 4

TCPI NATIONAL QUALITY MEASURE COLLECTION TOOL We will be using the TCPi National CQM collection tool this Quarter All CHITAs are being asked to submit CQMs on behalf of their practices All CHITAs should have created their own login to the Healthcare Community website and requested access to the TCPi Community. Once Logged in please select the TCPi community and Outcomes Sharing on the left side of the screen to access the CQM reporting page. 5

ENSW UPDATE ▪ Please ensure all measures are reported by January 31st, 2018 ▪ 12 month and 15 month CQMs. Please work with practices to collect and submit 12 month and 15 month CQMs 6

SIM Q3 CQM DATA

* Q3 of 2017 was an optional reporting period for cohort-2

*For Diabetes A1c measure we want to see the values for this measure decrease over time 9

SIM Q3 CQM DATA REPORT ▪ Q3 Cohort 1 CQM Reporting Breakdown ▪ 47 Adult (6) 35 Req ▪ 23 Pediatric (4) 19 Req ▪ 13 Adult CPC+ (5) 12 Req ▪ 92 Total Practices 10

SIM Q2 CQM DATA REPORT ▪ Q3 Cohort 2 CQM Reporting Breakdown ▪ 84 Adult (6) 52 Req ▪ 36 Pediatric (4) 10 Req ▪ 16 Adult CPC+ (5) 13 Req ▪ 155 Total Practices 11

**This measure is only available for practices that are in both SIM and CPC+

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CQMS WITH DOCUMENTED ISSUES IN Q3 Some practices reported on multiple issues related to CQM reporting 15

Q4 2017 SIM CQM REPORTING REQUIREMENTS

Q4 REPORTING REQUIREMENTS AND SCHEDULE SIM Q4 2017 CQM reporting requirements ▪ Practice sites choose: trailing 12 months or year-to-date ▪ Q4 report due January 31 st , 2018 ▪ CQM reporting will be through Split login (still the same Qualtrics survey just different way to access it.) ▪ https://split.practiceinnovationco.org/#/login 17

REPORTING SCHEDULE: ADULTS COHORT 1 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 18

REPORTING SCHEDULE: PEDS COHORT 1 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 19

REPORTING SCHEDULE: CPC+ COHORT 1 2016 Q1 (Jan-Mar 16) 2016 Q2 (Apr-Jun 16) 2016 Q3 (Jul-Sep 16) 2016 Q4 (Oct-Dec 16) Same as Cohort 1 SIM Only (see above) Same as Cohort 1 SIM Only (see above) Same as Cohort 1 SIM Only (see above) Same as Cohort 1 SIM Only (see above) 2017 Q1 (Jan-Mar 17) 2017 Q2 (Apr-Jun 17) 2017 Q3 (Jul-Sep 17) 2017 Q4 (Oct-Dec 17) Choose 4 primary CQMs: Report all 5 primary CQMs: Same as Y2Q2 Same as Y2Q2     Depression: Depression: Phase in additional secondary CQMs Phase in additional secondary CQMs a) Depression Screening (SIM/QPP) OR a) Depression Screening OR as appropriate as appropriate b) Depression Remission at 12 months b) Depression Remission at 12 months = 5 total CQMs required = 5 total CQMs required  (CPC+ group 1) Diabetes: Hemoglobin A1c   Diabetes: Hemoglobin A1c (CPC+ Hypertension  group 1 & SIM/QPP) SUD: Alcohol & Other Drug  Hypertension (CPC+ group 1 & Dependence  SIM/QPP) SUD: Tobacco  SUD: Alcohol & Other Drug Secondary CQMs (if needed):  Dependence (CPC+ group 2 & Asthma  SIM/QPP) Fall Safety   SUD: Tobacco (CPC+ group 3 & Maternal Depression Screening  SIM/QPP) SUD: Alcohol Secondary CQMs (if needed): = 5 total CQMs required  Asthma (SIM/QPP)  Fall Safety (CPC+ group 2 & SIM/QPP)  Maternal Depression Screening (SIM/QPP)  SUD: Alcohol (SIM/QPP) = 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 20

REPORTING SCHEDULE: ADULTS COHORT 2 21

REPORTING SCHEDULE: PEDS COHORT 2 22

REPORTING SCHEDULE: CPC+ COHORT 2 23

FIELD NOTE FEEDBACK OCTOBER AND NOVEMBER 2018

OCTOBER COHORT 1 DATA AGGREGATION October Stratus 10 QRUR Reports 3 Milliman Reports 9 Other 32 Unknown/NA 59 Not Used 57 25

NOVEMBER COHORT 1 DATA AGGREGATION November Stratus 11 QRUR Reports 2 Milliman Reports 5 Other 26 Unknown/NA 37 Not Used 70 26

OCTOBER COHORT 1 CQMS WORKED ON October Depression 33 Practices Improving data entry 17 Practices Clinical Workflows 11 Practices Diabetes HgbA1c 17 Practices Improving data entry 9 Practices Clinical Workflows 7 Practices None 40 Practices 27

NOVEMBER COHORT 1 CQMS WORKED ON November Depression 27 Practices Improving data entry 8 Practices Clinical Workflows 20 Practices Diabetes HgbA1c 17 Practices Improving data entry 2 Practices Clinical Workflows 14 Practices None 41 Practices 28

OCTOBER COHORT 2 DATA AGGREGATION October Stratus 17 QRUR Reports 4 Milliman Reports 17 Other 78 Unknown/NA 63 Not Used 116 29

NOVEMBER COHORT 2 DATA AGGREGATION November Stratus 10 QRUR Reports 0 Milliman Reports 16 Other 67 Unknown/NA 75 Not Used 94 30

OCTOBER COHORT 2 CQMS WORKED ON October Depression 29 Practices Improving data entry 12 Practices Clinical Workflows 11 Practices Diabetes HgbA1c 33 Practices Improving data entry 17 Practices Validating CQM 15 Practices None 92 Practices 31

NOVEMBER COHORT 2 CQMS WORKED ON November Depression 36 Practices Improving data entry 13 Practices Clinical Workflows 18 Practices Diabetes HgbA1c 19 Practices Clinical Workflows 9 Practices Validating CQM 12 Practices None 73 Practices 32