SIM CQM & ASSESSMENT UPDATES WEBINAR TUESDAY, FEBRUARY 28 11:00 - PowerPoint PPT Presentation

SIM CQM & ASSESSMENT UPDATES WEBINAR TUESDAY, FEBRUARY 28 11:00 – 12:00

AGENDA Welcome & Intros Conflict of Interest Forms SIM CQM Measure Simplification 2 Revised CQM Reporting Schedules Discussion: How are CHITAs working with practices on data quality? SPLIT Assessments Cohort 2 RFA Release

CQM SIMPLIFICATION: ADULTS Measure Condition SIM Metric Title Citation CPC+ QPP Primary CQMs Depression Preventive Care and Screening: Screening for Clinical NQF 0418 Depression Remission at 12 Months  Depression and Follow-up Plan CMS 2v6 Diabetes: Hemoglobin A1c Diabetes: Hemoglobin A1c Poor Control NQF 0059   CMS 122v5 Hypertension Controlling High Blood Pressure NQF 0018   CMS 165v5 Obesity: Adult Preventive Care and Screening: Body Mass Index (BMI) NQF 0421 No obesity measure (not required for  Screening and Follow-up Plan CMS 69v5 SIM if in CPC+) Substance Use Disorder: Alcohol and Initiation & Engagement of Alcohol & Other Drug NQF 0004   Other Drug Dependence Dependence Treatment CMS 137v5 Substance Use Disorder: Tobacco Preventive Care and Screening: Tobacco Use: Screening and NQF 0028   Cessation Intervention CMS 138v5 Secondary CQM Asthma Medication Management for People with Asthma (replaced NQF 1799 No asthma measure  to align with QPP) CMS n/a Fall Safety Falls: Screening for Future Fall Risk NQF 0101   CMS 139v5 Maternal Depression Maternal Depression Screening NQF 1401 No maternal depression measure  CMS 82v4 Substance Use Disorder: Alcohol Preventive Care and Screening: Unhealthy Alcohol Use: NQF 2152 Alcohol & Other Drug Dependence  Screening & Brief Counseling CMS n/a measure (above) Measures reported via APCD claims data automatically Breast Cancer Breast Cancer Screening NQF 2372  (clinical)  (clinical) CMS 125v5 Colorectal Cancer Colorectal Cancer Screening NQF 0034  (clinical)  (clinical) CMS 130v5 3

CQM SIMPLIFICATION: PEDIATRICS Measure Condition Metric Title Citation QPP Primary CQMs Depression Preventive Care and Screening: Screening for Clinical NQF 0418  Depression and Follow-up Plan CMS 2v6 Development Screening Developmental Screening in the First Three Years of NQF 1448 No developmental Life (developed by Mathematica) CMS – under development screening measure Maternal Depression Maternal Depression Screening NQF 1401  CMS 82v4 Obesity: Adolescent Weight Assessment and Counseling for Nutrition and NQF 0024  Physical Activity for Children and Adolescents CMS 155v5 Secondary CQM Asthma Medication Management for People with Asthma NQF 1799  (replaced to align with QPP) CMS n/a CQM Reporting Requirements Summary: http://www.practiceinnovationco.org/wp-content/uploads/2017/02/SIM-Clinical- Quality-Measures-CQM-Reporting-Requirements-Summary.pdf Updated CQM Guidebook: http://www.practiceinnovationco.org/wp-content/uploads/vfb/2016/06/FINAL_SIM-CQM- GUIDEBOOK_20160609.pdf 4

CQM SIMPLIFICATION: CHANGES CQMs removed from reporting requirements Measure Condition Metric Title Citation Anxiety Anxiety Screening (developed by Mathematica) No endorsed measures NQF 0061 Diabetes: Blood Pressure Diabetes: Blood Pressure Management (developed by CMS – N/A Management Mathematica) Influenza Preventive Care and Screening: Influenza Immunization NQF 0041 CMS 147v5 CQMs replaced Measure Condition Original Metric Title Original Citation New Metric Title New Citation Medication Management for People with Asthma Use of Appropriate Medications NQF 0036 NQF 1799 Asthma (replaced to align with QPP) CMS 126v4 CMS n/a for Asthma Initiation & Engagement of Alcohol & Other NQF 0004 Drug Dependence Treatment CMS 137v5 NQF 2597 Substance Use Screening Preventive Care and Screening: Tobacco NQF 0028 Substance Use CMS - in testing phase Composite (tobacco, alcohol, Use: Screening and Cessation Intervention CMS 138v5 Disorder (developed by illicit drug use) Preventive Care and Screening: Unhealthy Mathematica) NQF 2152 Alcohol Use: Screening & Brief Counseling CMS n/a 5

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 6

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 7

REPORTING SCHEDULE: CPC+ 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 8

DISCUSSION How are CHITAs working with practices on data quality? 9

SPLIT ASSESSMENTS ▪ SIM Baseline Assessment Reports were sent to practices to review ▪ Practices will be given six weeks to complete these assessments ▪ Practices are required to complete the following assessments: 1. Integrated Practice Assessment Tool (IPAT) 2. Medical Home Practice Monitor (Monitor) 3. Data Quality Assessment (DQA) 4. Milestone Activity Inventory (Inventory) ▪ Due date of April 7, 2017 10

SPLIT ASSESSMENTS ▪ SIM Baseline Assessment Reports should be reviewed between Practice Facilitator and Practice QI Team ▪ Focus on identifying Practice’s: ▪ Areas of strength ▪ Progress made over the last year ▪ Opportunities for improvement ▪ SIM 12 month assessments being completed outside of SPLIT ▪ Intent to minimize technical accessibility issues ▪ Links, Access Codes, and Instructions were emailed ▪ Contact PracticeTransformation@ucdenver.edu with any questions 11